In-depth mapping of primary care physicians’ practices in four health districts in Benin: a mixed methods study

doi:10.21203/rs.3.rs-5217318/v1

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Research Article

In-depth mapping of primary care physicians’ practices in four health districts in Benin: a mixed methods study

https://doi.org/10.21203/rs.3.rs-5217318/v1

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Background

In Benin, the number of primary care physicians (PCPs) is increasing. This phenomenon challenges the current prevailing policy of task shifting from physicians to nurses adopted in Benin’s primary care system and raises a few questions. To date, information on PCPs and their practices remains scarce. This study aims to describe current PCP practices and propose a typology of these practices.

Methods

A fully mixed sequential equal-status design was used. Quantitative data were gathered from 155 PCPs through a survey, whereas qualitative data were obtained from in-depth interviews with 21 PCPs, 3 representatives of health authorities, and a review of policy documents.

Results

In our study, four types of PCPs were distinguished: first, private general practitioners (62.6%); second, public general practitioners (3.4%); third, Médecins généralistes communautaires (MGCs) (5.2%); and fourth, specialists working in primary care (28.4%). A comprehensive description of PCP practices is presented across four dimensions: professional identity, governance arrangements, roles and activities, and outputs and outcomes. Notably, only MGCs underwent structured professional identity-building. Most other PCPs perceive primary care as temporary, with low job satisfaction stemming from limited resources and inadequate incomes. Despite strong intrinsic motivation, governance challenges—such as the absence of a coherent national policy on PCPs’ practices, along with limited support to PCPs—significantly hinder their potential, leading to issues such as an excessive focus on curative care, urban concentration, and high costs.

Conclusions

This study is the first to provide a complete and in-depth description of PCP practices in Benin, confirming their growing presence and classifying their practices. It also highlights critical issues affecting these practices, emphasizing the need for stronger governance arrangements to improve primary care outcomes. The findings underscore the importance of developing an evidence-based policy framework to guide and support PCP practices in Benin.

Primary care physicians

Benin

typology.

Primary health care (PHC) is an approach to health that enables countries to equitably maximize the level and distribution of health and well-being by addressing people’s needs and preferences as early as possible, from health promotion and disease prevention to diagnosis, treatment, rehabilitation and palliative care, all of which are delivered as closely as possible to people’s everyday environments [1, 2]. PHC combine three components: integrated health services; multisectoral policy and action; and empowered people and communities. Primary care is part of integrated health services, and it is a care process that supports first-contact, accessible, continued, comprehensive and coordinated patient-centered care [1, 2].

In Benin, a west-African country, PHC is operationalized within the setting of health districts, which are local health systems comprising a network of public and private first-line facilities (or primary care facilities) supported by a district hospital [3]. In first-line facilities, where primary care should be offered, health care has traditionally been delivered by nonphysician clinicians, particularly nurse practitioners. These nurse practitioners are entrusted with various medical tasks and responsibilities, such as medical consultations, diagnoses, prescriptions, and even minor surgical procedures [4]. This organization is a result of a well-established task-shifting approach that Benin, like many other African countries [4], adopted after the economic crisis of the 1980s to address physician shortages and improve access to health services, especially in underserved areas. By delegating some of the physicians' responsibilities to nurse practitioners, the health system was able to cope with the scarcity of trained physicians. The latter, meanwhile, have predominantly been stationed at district hospitals or larger primary care centers. Physicians were also present in large private primary care centers, particularly in urban areas such as capital, where they serve wealthier populations.

Recently, however, the number of physicians in Benin has increased. The density of physicians in the country increased from 0.6/10,000 in 2011 to 2/10,000 in 2022 [5]. Limited state hiring opportunities and a growing middle class capable of providing physicians' services have led to an increase in the number of physicians employed in private primary care facilities. Consequently, the number of primary care physicians (PCPs) in the private sector has increased. Some public facilities have also started hiring PCPs, mainly in urban and densely populated areas.

This increase in the number of PCPs can, in theory, be beneficial, as they can potentially improve the quality of first-line care [6]. However, the growing presence of PCPs is gradually changing the landscape of the primary care workforce in Benin, potentially challenging the established task-shifting strategy. Moreover, it raises questions about whether the health system is adequately prepared to accommodate this change in terms of policy, resources, and organization. Moreover, the current training of physicians in Benin is (still) largely inspired by a biomedical, often hospital-based and technology-supported (laboratory, radiological services, etc.) approach. Hence, most current PCPs are ill prepared for their work at the primary level of care.

Importantly, before this study, very little was known about PCPs in Benin, including their activities, motivations, or even their numbers [6]. The limited existing studies have either focused on initiatives such as the one promoted by the French NGO Santé Sud, which supports the placement of young physicians in rural areas [7, 8], or analysed the quality of care provided by primary care providers (including nurse practitioners and general practitioners) for specific diseases in the frame of vertical programs [9–11]. This lack of information on PCPs is also evident in many African countries, with the exception of a few, such as South Africa and Nigeria [6].

This study aimed to fill this knowledge gap by identifying PCPs working in selected health districts in Benin, describing their practices, and proposing a typology of these practices.

The research questions are as follows:

What are the number and characteristics of PCPs in the four selected health districts in Benin?
What are the different types of PCP practices that exist in Benin?
What are the key characteristics of the practices of PCPs in Benin?

Study Design

According to the typology of mixed methods research designs proposed by Leech and Onwuegbuzie [12], this study followed a fully mixed sequential equal status design (QUAN -> QUAL). The studies were classified as fully mixed because both quantitative and qualitative research methods were integrated at several stages of the research process, especially in the sampling and data analysis phases. This is sequential because the quantitative method was employed first, followed by the qualitative method. The design has an equal status since the quantitative and the qualitative strands were given the same weight in addressing the research question.

Study settings

In Benin, health districts are the most decentralized level of the health system, where PHC is operationalized. Benin has 34 health districts, and we purposefully selected four of them for this research.

The first selection criterion was the need to achieve a sound geographical balance since northern and southern Benin are different in terms of culture and health resources. The second criterion was the urbanization status of the districts, as this was likely to influence the number of PCPs and their practices.

These two criteria led us to include four types of health districts: an urban district in the north, an urban district in the south, a rural district in the north and a rural district in the south. For each type, we selected the health districts with the highest number of primary care facilities to increase the likelihood of having a high number of PCPs. The four health districts included are as follows (see Fig. 1 in the results section): Cotonou 2–3 (Cot 2–3) and Ouidah-Kpomasse-Tori (OKT) in the south and Parakou-N’dali (PN) and Nikki-Kalalé-Pèrèrè (NKP) in the north.

Study population and sampling

The study population included all the physicians working (exclusively or not, full-time or not) at first-line facilities in the four selected health districts. We excluded physicians working exclusively in hospitals. However, we included both general and specialist physicians.

We could not access a formal list of physicians. Therefore, we used desk reviews of the health system records, discussions with local health authorities and snowballing to identify all physicians working in the four districts. We sought to include all of them in the quantitative strand (exhaustive sampling). For the qualitative strand, we purposively selected PCPs on the basis of the key results of the quantitative strand (gender, place of work, satisfaction level, and practice category). Health authorities who are well acquainted with human resources and primary healthcare issues were also selected. We sought saturation.

Definition and analytical framework

Definition of PCPs’ practices

We define the practices of physicians as the way their work is organized to deliver care to the population. It encompasses a description of the physicians’ activities, workplace, governance rules, and interactions with other stakeholders.

Analytical framework

The analytical framework was developed during a scoping review conducted by our team [6]. It was informed by existing health system and primary care frameworks [13–15], as well as insights from the literature on PCP practices in sub-Saharan Africa [6].

The framework comprises four dimensions (Table 1):

Professional identity refers to the set of attributes, values, principles, motives, and experiences that PCPs and their colleagues use to define their professional work [15];
Governance involves policy guidance for the entire health system, coordination of actors and regulation, optimal allocation of resources, and ensuring accountability to the population and all stakeholders [13];
Roles and activities pertain to the expected roles of PCPs and the activities they perform.
Outputs and outcomes include the results of PCP practices in terms of direct outputs (specifically, in this study, accessibility, coordination, and technical effectiveness), health outcomes (we did not analyse them in this study) and physician satisfaction.

Data collection

Quantitative strand

We collected quantitative data between December 2019 and January 2020 through face‒to-face interviews with PCPs via a structured questionnaire. This questionnaire explored various aspects, including the PCPs' characteristics (age, sex, postgraduate training, income, etc.), their professional activities, the type of support they received (e.g., in-service training, information sources, support from health authorities and professional organisations), their level of job satisfaction, and the organization of their workplace (e.g., services offered, working hours, team composition, payment arrangements, and functional relationships with the district management team and district hospital).

The questionnaire was inspired by the analytical framework. Additionally, a satisfaction measurement tool developed by Lepnurm et al. was incorporated into the questionnaire to assess PCPs' job satisfaction [16].

The questionnaire was pretested on a convenient sample of 10 PCPs outside the study areas. Cognitive interviews and individual debriefings were conducted with these PCPs, as well as two researchers and a ministry of health officials, to ensure that the questions and instructions were clear, that the items assessed were relevant, and that the questions followed a logical flow.

Qualitative strand

From May to July 2020, we conducted in-depth interviews with PCPs via a semistructured interview guide. The guide helped to explore the physicians' motivations for working at the primary care level, as well as the values and rules that shaped their practices. It also examined governance aspects, the added value of PCPs within their facilities and districts, the benefits and challenges of working as a PCP, their relationships with other healthcare professionals, the type of support that they received, and their expectations. The guide was iteratively adapted as the interviews progressed, and more insights were gained.

After interviewing the PCPs, we realized that it was important to gather the perspectives of health authorities, particularly regarding governance aspects and the outcomes achieved by the PCPs. Therefore, we interviewed two medical officers and a Ministry of Health representative.

In addition to the interviews, we reviewed national policy documents, guidelines, and relevant resources from the websites of the Medical Council and the Ministry of Health. References to these documents are included in the results section, where they are cited.

Data analysis

Characteristics of PCPs and their practices (research questions 1 and 3)

For the quantitative data, we employed descriptive statistics. Frequencies and percentages were used for binary and categorical variables, whereas we reported the median and interquartile range for most continuous variables since they were not normally distributed.

In the case of PCP satisfaction, each of the 16 items in the satisfaction measurement scale were scored on a scale from 1 to 6, where 1 represented "very dissatisfied" and 6 represented "very satisfied." We summed the scores for all 16 items and calculated an average satisfaction score by dividing the total score by 16. Additionally, subscores were computed for each of the four dimensions of physician satisfaction (inherent, personal, professional, or performance-related) by summing the scores of the four items within each dimension and dividing the result by 4. The satisfaction scores are expressed as the means and standard deviations since they are normally distributed.

Regarding the activities performed by the PCPs, each physician rated the frequency of engagement in various activities on a scale from 0 ("never") to 4 ("very frequently"). We used these ratings to rank the activities, identifying those that were performed most and least frequently. Additionally, we calculated the median percentage of time that PCPs reported spending on different types of activities, such as curative care, preventive care, health promotion, nonclinical health activities, and administrative tasks.

Qualitative data analysis was utilized to deepen our understanding and provide a thorough description of the PCPs' practices. All the interviews were transcribed verbatim, and the data were coded via Dedoose software. We then conducted a thematic content analysis.

Both the quantitative and qualitative results were integrated to offer a comprehensive description of PCPs' practices in Benin. This description was structured using the analytical framework outlined above, with additional themes that emerged from the data analysis incorporated into the framework (as shown in Table 1).

Table 1

Analytical framework with the key themes identified during the qualitative analysis
Dimension of the PCPs practice	Themes
Professional identity	- Postgraduate training - Values explicitly put forward - Process of building the professional identity - Motivation to be a PCP
Governance	- Policy guidance and regulation - Affiliation to a professional organization and work contract - Resource allocation - Support received - Involvement in health districts’ activities and collaboration with district managers - Accountability
Roles and activities	- Roles - Activities performed - Workload - Primary care team - Coordination with other providers and hospital
Outputs and outcomes	- Service outputs (accessibility, coordination, continuity, technical effectiveness) - Physician satisfaction

Typology of the PCPs’ practices (Research Question 2)

We produced a typology of PCP practices by employing the empirically grounded type-construction methodology proposed by Susan Kluge [17]. To apply this methodology, we integrated the quantitative and qualitative results as described in the following steps.

Selection of relevant attributes for regrouping PCP practices

The first step of Kluge’s methodology consists of choosing one or more attributes for dividing an observed field into several groups. On the basis of the scoping review conducted by our team on PCP practices in sub-Saharan Africa [6], we chose two attributes to classify the practices of the PCPs included in this study:

the type of postgraduate training the PCPs received (or not) after their undergraduate medical studies: this attribute introduces significant differences in the PCPs’ practices in terms of professional identity, activities and sometimes outcomes;
The institutional status (public or private) of the health facilities where they mainly practice: the scoping review and field observations suggest that this attribute can impact PCPs’ role and activities and their governance.

Grouping the cases and checking the relevance of the groups

We grouped the PCPs’ practices on the basis of the two abovementioned attributes via a two-by-two table. At this stage, we checked the internal homogeneity of the groups, i.e., the elements within the groups must be as similar as possible.

Analysis of the relationships between the various groups

At this stage, the groups must be analysed to ensure their plausibility and relevance in the context, meaning that the group must relate to a reality in the field studied. The groups must also be compared to ensure external heterogeneity, meaning that the differences between the groups must be as strong as possible. In our study, we used both the quantitative and the qualitative results to assess this difference. The analysis of the relationships between the various groups led to a further reduction in these groups into a few types.

Characterization of the constructed types

The main characteristics of each type are described.

The following text integrates the quantitative results with the qualitative data analysis to address the research questions. The statistics are derived from the quantitative analysis (see supplement file 1). Quotes and qualitative information originate from qualitative data analysis.

Research question 1: Number and characteristics of the PCPs

In the four selected health districts, we identified a total of 214 PCPs, with 155 of them participating in the quantitative phase, resulting in a 72.4% participation rate. Those who did not participate cited a lack of time or were absent from the districts during the data collection period. Twenty-one (21) PCPs and 3 health authorities were included in the qualitative strand.

The PCPs included in the study were predominantly male, accounting for 69.7% of the sample. The median age of the participants was 34 years (IQR: 29–40), and the median length of their work experience was 6 years (IQR: 1–10). In terms of practice settings, the vast majority (89.7%) were working in urban areas, with 92.3% employed in the private sector. Over half (55.5%) of the PCPs were practicing in the health district of Cotonou 2–3, which is located in Benin's economic capital. On average, PCPs spend 90% of their work time at first-line health facilities, with the remaining time allocated to hospital duties or nonhealth-related professional activities.

Figure 1 presents the distribution of the PCPs across the four health districts. This figure shows the concentration of the PCPs in urban areas and along the main roads.

Figure 1: Location of PCPs within the four health districts studied

Research question 2: Typology of primary care physicians

Grouping the cases and checking the relevance of the groups

The postgraduate training allowed for an initial classification of the PCPs into three groups. We labelled these groups on the basis of a previous classification our team developed in the scoping review on PCP practices in sub-Saharan Africa [6]:

"General practitioners" (GPs) for PCPs without any postgraduate training.
Médecins généralistes communautaires (MGCs) or community-based general practitioners for PCPs who completed postgraduate training in community-based general practice (see details below).
Specialists for PCPs who have completed postgraduate training in a clinical specialty (see details below) and are working in primary care settings.

By introducing the second attribute (the institutional status of the PCPs' health facilities), these groups expanded into six homogenous groups (see Table 3).

Table 3

Grouping of the PCPs on the basis of postgraduate training and institutional status
Postgraduate training Institutional status	No postgraduate training	Postgraduate training in community-based general practice	Postgraduate training in a clinical speciality
Public	Public General practitioners (n = 6)	Public "MGCs” (n = 1)	Public specialists (n = 5)
Private	Private General practitioners (n = 97)	Private "MGCs” (n = 7)	Private specialists (n = 39)

Analysis of the relationships between the various groups

The analysis of the six groups mentioned above led to several observations:

There was only one public MGC. The qualitative data revealed that he was recently hired by the government and had transferred his private practice to another MGC. His values and practices did not differ significantly from those of private MGCs. After further investigation, we found no other public MGCs, even in other health districts. As a result, we decided to merge the "public MGC" group with the "private MGC" group into a single category: MGCs.
Similarly, we found insufficient differences between public and private specialists, aside from the fact that public specialists are part of the health district management team (HDMT), whereas private specialists are not. Both groups mainly engage in activities related to their clinical specialties, support GPs (except for one public specialist who also provides general care), and have similar access to resources, primarily through their specialty professional organizations.

Characterization of the constructed types

At the end of the typology exercise, we retained four different types of PCP practices in Benin.

The private GP
The public GP
The MGCs
The specialists

In the following sections, we expand on these characteristics. The latter are summarized in Table 4.

Research question 3: Characteristics of PCP practices

The practices of PCPs are described via the four key dimensions of the analytical framework: professional identity, governance, roles and activities, and outputs and outcomes. The description covers all PCPs generally, but any specific differences between types are highlighted.

Professional identity of the PCPs in Benin

Postgraduate training

The majority of PCPs (66.4%) are GPs who have not received any postgraduate training. Among them, private GPs were predominant (62.6%), whereas public GPs constituted only 3.9% of the sample.

The MGCs represented 5.2% of the sample and had completed a postgraduate program in community-based general practice. This program, run by the University of Parakou in North Benin in collaboration with the French NGO Santé Sud, includes six weeks of theoretical and practical training. The topics covered range from the role of community-based general practices in Benin's health system to mothers’ and children’s health in rural areas, practices in isolated situations, emergencies, priority diseases, care organizations, and facility management. After completing this initial training, the participants underwent two years of mentorship by senior MGCs while actively practicing.

The remaining 28.4% of PCPs were specialists who had completed four to five years of postgraduate training in various clinical specialties. These specialties include gynecology-obstetrics, public health, pediatrics, cardiology, occupational health, general surgery, ENT (ear-nose-throat) specialists, urology, geriatrics, ophthalmology, rheumatology, and traumatology.

Values underlying the PCPs’ practices

When the values underlying their practices were asked, most PCPs emphasized the following values as crucial:

respect: including respect for colleagues and patients and respect and consideration for the culture and social behaviours of the population served;
open-mindedness: including listening to and understanding others’ viewpoints;
continuous learning, which is seen as the necessity for physicians to continuously refresh their knowledge and competencies.

Some values are embedded in the Benin Code of Medical Deontology [18], even if not explicitly labelled as such. Respect is also among these values, along with integrity, transparency, professionalism, and compassion.

The training guide for MGCs also outlines some values, specific to primary care. Respect is again part of these values, along with empathy, responsibility, and consideration of the patient's psychological and social context [19].

Building a professional identity.

Most of the PCPs interviewed in our study reported that they were rarely taught the core values guiding primary care practice during their training. A few mentioned learning these values from professors in medical school or mentors in the field, but this was not systematic.

During undergraduate medical studies in Benin, some courses emphasize the attitudes expected from physicians toward their patients and during their medical practice. For example, in the first two years, a medical anthropology course and a psychiatry course address the physician‒patient relationship. In the fourth year, the legal medicine course introduces key deontological principles. Medical students also undergo socialization during clinical rotations. However, most of these rotations take place in hospital settings, offering limited opportunities to instill values and attitudes specific to primary care practices.

At the postgraduate level, only MGCs benefit from an introduction to primary care values through a short course in community general practice. Specialists have opportunities to build their professional identity during postgraduate courses and through professional organizations related to their specialties, but these opportunities are not geared toward primary care principles. In fact, most specialists encountered during the quantitative phase explicitly stated that they did not consider themselves PCPs.

Motivation to work first-line

The qualitative data suggest that primary care practice is often seen as a temporary or fallback option for physicians when other opportunities are unavailable. This is especially the case for private GPs, but it is also the case for public GPs. Indeed, among the PCPs interviewed, two (public GPs) were assigned to public primary care centers by the government, whereas seven were working as PCPs while waiting to gather the resources or experience necessary to pursue a specialty or transition to another job. Another seven felt that they had no other viable option. Only 5 out of the 21 PCPs interviewed deliberately chose to work at the primary care level.

Moreover, many PCPs, especially GPs and MGCs, perceived that primary care practice was limiting. These PCPs felt that their career development was stunted, that they were less valued than hospital physicians or specialists were and that they were restricted in what they could offer patients due to their limited diagnostic capabilities at the primary care level. Additionally, GPs and MGCs noted that their income was relatively lower than that of specialists and hospital-based physicians.

The following quote captures the demotivation experienced by some PCPs, highlighting the internal conflict between wanting to continue their primary care practice and feeling pushed out owing to personal or professional limitations.

"I have not progressed much. I have not been able to take care of my family as I should because my work does not give me the time. Here, we are in a religious centre, and what you ask for is often not given… Many have left after three or four years of service, either to go into a specialty or to become a civil servant. However, I stayed and I try to juggle to take care of my family and myself." Private GP, OKT.

Given these problems, most PCPs indicated plans to pursue a clinical specialty (7 GPs) or find employment outside the primary care setting (3 GPs and 2 specialists). Among the 9 PCPs (7 GPs, 2 MGCs) considering staying in primary care, most expressed a desire to expand their practices into polyclinics or hospitals or to gain a clinical specialty that aligned with primary care practice, such as legal medicine.

Despite these reservations, the PCPs identified several motivating factors for working in primary care. Many appreciated the opportunity to help people and contribute to local development, citing that primary care allows them, more than hospital settings do, to see patients early and serve those with limited financial means. PCPs also reported deriving intrinsic motivation from patient satisfaction and appreciation. Some found primary care practice to be intellectually stimulating, as it offered the chance to treat a variety of cases, collaborate with different actors, and develop long-term relationships with patients. A few PCPs, particularly those who owned their facilities, were motivated by the autonomy and good income benefits that their work as PCPs provided.

Governance features of primary care physicians

Policy guidance and regulation

The oldest guiding document for physicians in Benin is the Code of Medical Deontology [18], which was enacted as law in February 1973. This code outlines physicians' responsibilities to patients and society and establishes standards for interactions with patients and other health professionals. It also provides rules and guidance for dealing with specific situations such as establishing medical certificates, dealing with minors or legal cases, and penalties for violations of the code.

In addition, Benin has a Strategic Plan for Human Resources for Health [20], which covered the period from 2009–2018. This plan provided guidelines for human resource planning, staffing needs, recruitment, skills development, and career management. However, it relies on analyses that are over a decade old. More recent policies, including the National Health Policy 2018–2030 [21] and the National Health Development Plan 2018–2022 [22], offer broad guidelines for managing healthcare human resources. These policies highlight the "medicalization" of community health, referring to the deployment of physicians at first-line facilities, as a key intervention to improve care quality, although they lack details on how to implement it. Other documents regulate the professional work of civil servants [23–27] and provide rules for health workers in the private sector [28]. There are also clinical guidelines for managing various conditions at the primary care level.

Moreover, MGCs have some guiding documents, including a charter they sign before beginning their practices and an MGC guide [19]. However, these are not documents officially recognized by the State.

Therefore, there is a notable lack of documentation specifically addressing the practices of physicians at the front line of the health system, in contrast to nurses and midwives, for whom there is a dedicated document outlining the standards for their practices [29].

Affiliation with a professional organization and work contract

Nearly all the interviewed PCPs (93.5%) were affiliated with the National Medical Council of Benin, as is required for all the physicians. However, fewer than half (47.7%) were members of any professional organization beyond the medical council. GPs had the lowest affiliation rates, with 38.1% of private GPs and 16.7% of public GPs affiliated. Almost all the MGCs were affiliated with the Benin MGC Association, and most specialists were members of a professional organization, typically those related to their specialty.

Only 67.7% of the PCPs interviewed had a formal work contract, leaving one-third in informal employment. This issue was more prevalent among private GPs.

Resource allocation

In terms of training and access to information, only 27.1% of the PCPs had received any form of continuous medical training in the 12 months prior to the survey, with no differences between the various types. Qualitative data revealed that most of the training was part of vertical health programs and projects rather than a well-structured continuous medical education plan.

While a majority of PCPs (91%) had access to national clinical guidelines for common health conditions in Benin—such as malaria, respiratory tract infections, digestive infections, and hypertension (all in the frame of disease-specific vertical programs—the top two sources they relied on for clinical case information were personal documents, including books and university lectures.

Furthermore, PCPs lack access to a digital health information system that can help them track patients and make informed decisions. Most health facilities where PCPs work rely on paper-based systems, with patient information predominantly recorded in paper registries and files.

Beyond these issues, PCPs face challenges in accessing the financial resources and equipment necessary for their practice, especially in the public sector. In the private sector, PCPs have better access to equipment, but this access is typically purchased through private funds (mainly provided by direct patient payments). The PCPs who own their health facilities reported financial difficulties in maintaining a consistent level of services, staffing, and equipment, as shown in the following quote.

"If I consider my health facility, it is with what I earn that I must try to equip it, which is what I do. I have savings that I have kept for years, to allow me to equip my facility and expand my activities progressively. However, I'm sometimes obliged to cut the savings a little to pay the other providers (working in the facility).” private GP, PN.

These resource shortages are particularly acute in rural areas, where PCPs also struggle with a lack of basic commodities, such as adequate housing, good schools for their children, and opportunities for social activities. These challenges further discourage PCPs from working in rural settings.

"Regarding the difficulties, there are also the distances separating our centers from the city, with roads and access routes that are sometimes degraded, which can sometimes complicate referrals. … personally, my family is very far from me, and I try to travel regularly." MGC, NKP

In terms of salary, the median monthly income for PCPs ranged from 200,000 FCFA to 300,000 FCFA (approximately 305 to 457 euros), with 34.2% earning less than 200,000 FCFA. Qualitative data revealed that most PCPs considered this salary insufficient. Many (10 out of 21) reported needing additional sources of income to meet their personal and family expenses. To supplement their earnings, they often work in multiple facilities or engage in nonmedical activities such as trade. This strain sometimes led to demotivation and neglect in their professional duties.

"Interviewer: “To what extent does your primary care practice enable you to support yourself and your family?”

Respondent: Let us say 60%,

Interviewer: 60%... What about the other 40%?

Respondent: The remaining 40% is... how can I explain this? It is much more the extra activities. A medical part and an extra medical part. Medical is where you have patients who want you to visit them at home. It is some kind of little contract that you have that gives you something (revenue) monthly. In addition, extra medical... personally, I'm in the charcoal business and that allows me to turn (money) a bit”. Private GP, Cot 2–3.

Support received

Most PCPs interviewed valued peer support among their colleagues, particularly for managing patients and sharing information. The MGCs also receive strong support from the MGC associations, which offer a discussion platform, periodic in-person meetings, and sometimes in-service training.

Some PCPs mentioned receiving support from health authorities and the medical council, which typically included training sessions on specific health issues and basic medical supplies, especially during the COVID-19 pandemic. In the public sector, PCPs reported receiving support mainly in the form of funding and equipment from local authorities, community organizations, and donors.

However, this support was only noted by a small number of PCPs. Many others felt that they received very limited support from health authorities, professional organizations, or other entities. Some PCPs even described feeling as though they were "struggling alone":

"We are here on our own; there is no support from the State or from specific organizations." Private GP, Cot 2–3.

This feeling of inadequate support was more prevalent among private GPs, who noted that their colleagues in the public sector appeared to receive better support.

"I mean, you truly have to distinguish between the private and public sectors. I do not know about the public sector, but in the private sector, there's no support… Well, it has to be said that recently, the medical council has been trying to do something because we're complaining a lot. They have recognized that we feel neglected and abandoned, so they are trying to propose something, but it is not there yet. When you are sick, the first person you go to is your doctor. However, doctors do not have health insurance. In the public sector, it is different. I will take the example of the pandemic; they have told us that the screening phase for first-line health workers in the private sector would come. Okay, we are here (waiting). You see? We have separated the public sector from the private sector, even though both serve the same population." Private GP, OKT.

Moreover, only 47.7% of the PCPs interviewed reported receiving a supervision visit within the 12 months prior to the survey, with no differences among the various types of PCPs. Qualitative data revealed that, in the private sector, these visits were often conducted by the Ministry of Health, primarily to assess compliance with regulations rather than to offer supportive supervision aimed at improving clinical practices or providing guidance.

Involvement in health districts’ activities and collaboration with district managers

Only 27.1% of PCPs reported being involved by district managers in district-wide public health activities, such as campaigns or monitoring health indicators. Qualitative data further indicated that contact between the PCPs and the health district management teams (HDMTs) was generally limited, except for the public GPs, who are typically part of the HDMTs, and the PCPs, who own their practices, as they must engage with authorities for administrative purposes. However, the majority of facilities where PCPs work (95.1%) maintain collaboration with HDMTs, primarily through data reporting or participation in health worker training.

Accountability

In terms of accountability, we assessed whether PCPs have clear roles and responsibilities, whether the outcomes of their practices were regularly evaluated, and whether any positive or negative sanctions were in place. Only 15.5% of the PCP facilities had a defined population of responsibility, making it challenging to set objectives and measure performance. This problem is mostly found for private GPs and specialists. Additionally, at the time of data collection, no document outlining a clear job description or the expected results for PCPs in Benin existed.

In terms of evaluation, the public GPs and some MGCs benefit from semiannual or annual assessments of the results achieved by their health facilities or the health areas for which they are responsible. This regular monitoring is mandatory in public health facilities. However, private GPs and specialists do not undergo such assessments and rarely participate in the monitoring of district health indicators.

With respect to sanctions, regulations have increasingly been established in Benin. For example, the law on health protection [30] clearly outlines the civil and criminal responsibilities of health workers. This law has been strongly enforced in recent years, with a control and inspection unit [31] regularly investigating citizens' complaints and applying sanctions when necessary. However, health workers do not receive the necessary support to help them comply with the law.

Roles and activities of primary care physicians

The surveyed PCPs engaged in a wide range of activities, although the majority focused primarily on curative care. In fact, 68.4% of PCPs reported that curative activities made up most of their work. The median percentage of time spent on curative care was 60% (IQR: 50–80). The qualitative data also confirm this insufficient investment in preventive activities from PCPs, particularly among private GPs and specialists.

The top ten activities performed by PCPs included routine curative consultations for adults and children, hypertension and diabetes care, routine health check-ups for children, minor surgeries, antenatal and postnatal care, quality improvement initiatives (e.g., clinical audits and supervision of nonphysicians), and family planning services.

The least frequently performed activities were major surgeries, vacuum deliveries, C-sections, physiotherapy, TB care, applying casts or splints, participation in community development or outreach activities, budget and planning tasks, media-based sensitization campaigns, and HIV care.

In terms of workload, the median number of weekly work hours was 48 (IQR: 36–72), whereas the median number of patients seen per day by a PCP was 8 (IQR: 5–15). This is similar for all types of PCPs.

Only 25.2% of PCPs worked alone or with nonphysician staff only (typically nurse aides), while the majority worked in primary care teams. These teams had a median of 2 physicians (IQR: 1–4) and 3 nurses or midwives (IQR: 1–5) per facility. In 33.9% of the PCP facilities, nonphysician clinicians (nurses and midwives) were also authorized to provide medical consultations.

When asked about their roles, all types of PCPs and health authorities identified three main roles: clinician (15 respondents), trainer/supervisor of nonphysicians (8 respondents), and leader of the primary care team (7 respondents). A few respondents also mentioned the roles of health educator and first-contact provider.

Outputs and outcomes of primary care physicians’ practices

The collected data did not provide detailed information on the outcomes of the PCPs' practices; however, we were able to report some outputs in this section.

We used the cost of consultations and the percentage of health facilities with full-time PCP availability as proxies to assess accessibility. The median cost of a medical consultation by the PCPs surveyed was 2000 FCFA (IQR: 1000–3000), and in 52.8% of facilities, this cost was higher than that of a consultation with a nurse practitioner. The private GPs had the same median fees, but the fees were lower for public GPs and MGCs (ranging from 500 to 1000 FCFA) and higher for specialists (3000 to 6000 FCFA). Fewer than half (47.6%) of the PCP facilities had a physician available 24/7, whereas the rest had only part-time availability.

To assess coordination, we examined the referral practices of PCPs. Just over half (57.4%) referred critical cases to the district hospital as recommended by national guidelines, whereas 41.9% referred cases to regional hospitals, bypassing the referral pathway. The qualitative data revealed that this was due to the closer proximity of regional hospitals or a lack of trust in district hospitals' ability to provide better care than what the PCPs already offered.

In terms of technical effectiveness, most stakeholders interviewed (PCPs and health authorities) perceived the added value of PCPs. Eleven out of the 21 PCPs and all three health authorities interviewed noted that PCPs were better at diagnosing and handling complex cases than nurse practitioners were. The testimonies highlighted that the presence of a PCP enhanced the quality of care, made quality healthcare more accessible to the population, and reduced reliance on alternative practitioners, particularly in rural areas. In urban areas, PCPs attract more patients to first-line facilities, meeting patients' demand for physician-led care. Additionally, the presence of PCPs improved the attitudes and clinical practices of nonphysicians. However, health authorities noted that PCPs in private GPs do not always adhere to national guidelines. The quotation below illustrates these findings.

"The first added value I see is mainly in urban areas. In a large city, the population is becoming increasingly demanding. This is bound to grow in importance, and it is a market to be conquered. In this context, it is unrealistic to limit ourselves to offering care through a system of delegated medicine, or even substandard medicine. To meet the population’s needs, we are no longer considering having health centers run by nurses in my health district. On the other hand, we have very few public health centres. Therefore, private physicians are stepping in to fill this gap. They provide the population with access to the medical care they demand without having to travel long distances.

Another added value is that physicians offer medical consultations with a diagnostic approach, whereas nurses provide paramedical consultations on the basis of clinical algorithms. Therefore, PCPs bring added value to the health district, but all of this needs to be properly regulated." District medical officer, Benin.

In terms of satisfaction, the mean career satisfaction score for PCPs, measured via the Lepnurm tool, was 4.3 (SD: 0.5) out of 6, corresponding to the ranking "somewhat satisfied". Professional satisfaction was ranked the lowest (4.1, SD: 0.7), whereas inherent satisfaction was rated the highest (4.8, SD: 0.5), reflecting PCPs' motivations. These findings were reinforced by the qualitative data, which revealed that PCPs were dissatisfied with their salary and that primary care practices did not provide the personal and professional fulfilment they had anticipated.

PCPs reported several challenges in achieving good practice outcomes, including limited resources, patients' financial constraints that hinder proper diagnosis and treatment, and systemic issues in the healthcare system. These systemic challenges included an inadequate referral system, little support for the private sector, and limited investment in primary care. Several PCPs also reported conflicts between guidelines, their training, and patient demands. For example, private GPs and MGCs noted that while they could manage certain cases, they were often unable to do so owing to resource limitations or regulatory restrictions. In the public sector, PCPs expressed frustration with top-down decisions from health authorities that did not always align with local needs. Private-sector PCPs, in particular, face additional financial and operational constraints, forcing them to focus on curative services that generate revenue rather than preventive or health promotion activities. This compromises the overall quality of care in these settings.

Table 4

Characterization of various types of PCPs in Benin
Dimensions	Private GP	Public GP	MGC	Specialists
Professional Identity	- No postgraduate training - Established spontaneously as a temporary or fallback solution - Little process for building professional identity, apart from small efforts in undergraduate school	- No postgraduate training - Hired by the State but still consider primary care practice as "a beginning" before moving to higher positions - Small efforts in undergraduate school but some opportunities to build professional identity through mentoring by district medical officers and other senior physicians	- Postgraduate training in community-based general practice - Established to improve access to quality care in rural areas and provide jobs to young physicians - Professional identity as a PCP built during postgraduate training and through the MGC association	- Postgraduate training in clinical specialties - Opportunities for building professional identity during postgraduate training and through professional association. However, this is not geared toward PCP values and requirements - Many don’t consider themselves PCPs
Governance	- Some documents and laws regulate the private health sector, but almost no guidelines for PCP practices - Majority not affiliated with a professional organization - Almost half without work contracts - Limited access to in-service training and resources - Some equipment purchased from private funds - Very little support or supervision - Minimal involvement in health district activities and little performance monitoring	- Several policy documents and regulations for public sector health workers, but nothing specific to PCPs - Majority not affiliated with a professional organization - Most have work contracts - Access to in-service training mainly through health programs, not structured continuous education - Good access to public sector resources, but a lack of equipment and infrastructure - Have a defined area of responsibility and regular monitoring of activities	- Some documents regulate the private health sector but very few specific to PCP practices at national level - Guidance provided by a MGC guide and a charter - Majority are affiliated to the Benin MGC association - Most own their facility or are in partnership with local authorities to run the community centre - Some access to in-service training, but not part of structured continuous education - Limited access to public sector resources and supportive supervision - Some involvement in district activities - Have a defined area of responsibility	Few policy guidelines at national level, apart from general policies - Majority affiliated with a professional organization (mostly linked to their specialty) - Most have work contracts - Limited access to in-service training and public resources - Some equipment bought from private funds - Very little support or supervision - Little involvement in district activities and little performance monitoring
Roles and Activities	- Primarily curative activities - Rarely involved in preventive care or health promotion	- Mostly curative care - Also administrative duties, staff supervision, and organization of public health activities	- Primarily curative care - Also involved in staff supervision	- Primarily curative care related to their specialty
Outputs and Outcomes	- Higher costs than public GPs and MGCs - Perceived as providing better diagnoses and quality of care than nurse-practitioners - However, criticism that they do not follow national guidelines	- Perceived as providing better diagnoses and quality of care than nurse-practitioners - However, often available for patient care, because of other duties	- Perceived as providing better diagnoses and quality of care than nurse-practitioners - Bring medical care closer to the communities	- Higher costs than GPs and MGCs - Perceived as providing better diagnoses and quality of care than the other groups regarding their specialties

Summary of the key findings and comparison with the literature

Characteristics of PCPs

This mixed-methods study explored the practices of primary care physicians (PCPs) in Benin and proposed a typology. A total of 214 PCPs were identified, with 155 (72.4%) participating in the quantitative phase. The data confirmed the presence of physicians at the frontline of care in Benin and highlighted an underestimation of this phenomenon. Indeed, national health statistics for the year 2019, when our quantitative data were collected, reported only 81 physicians in the four health districts we studied [32].

The PCPs in this study worked primarily in urban areas (89.7%) and the private sector (92.3%), with most located in major cities along main roads. These findings are not surprising, as the increase in physicians at the primary care level in Benin and other African countries largely stems from the limited capacity of the state to employ them [33]. Additionally, most opportunities for PCPs in the private sector are concentrated in urban settings [34]. This uneven distribution raises equity concerns, as PCP services primarily benefit urban populations and those who can afford private care. To address this, strategies are needed to improve financial access to PCP services in the private sector and incentivize PCPs to practice in rural areas.

Types of PCP practices

We identified four distinct types of PCPs in Benin:

Private general practitioners (private GPs): PCPs without postgraduate training working in the private sector (62.6% of the sample).
Public general practitioners (public GPs): PCPs without postgraduate training working in the public sector (3.4% of the sample).
Médecins Généralistes Communautaires (MGCs): PCPs with postgraduate training in community-based general practice (5.2% of the sample).
Specialists: Physicians with postgraduate training in a clinical specialty working in primary care (28.4% of the sample).

These categories slightly differ from the findings of the scoping review on PCP practices in sub-Saharan Africa that we conducted earlier [6]. In Benin, no family physicians (i.e., physicians with a postgraduate diploma in family medicine) were identified. This is understandable, as Benin’s universities lack academic departments for family medicine, general practice, or primary care. Only the University of Parakou hosted a postgraduate certificate in community-based general practice for MGCs, although this program has been suspended for some time. Another difference from the scoping review is that our study differentiated general practitioners (GPs) into two categories, namely, public GPs and private GPs, on the basis of empirical data showing distinct characteristics between the two groups. Finally, our typology includes a "specialist" category, which was excluded from the scoping review. We included specialists because they represent a significant portion of physicians working at the primary care level in Benin and influence care organizations. However, our findings showed that most specialists do not consider themselves PCPs and focus primarily on activities related to their specialties (see Table 4). Therefore, future studies and efforts to improve PCP practices may benefit from focusing on physicians providing generalist care.

Professional Identity

All types of PCPs in Benin share core professional values such as respect, integrity, and professionalism, which are consistent with those promoted by physicians in several parts of the world [35–37]. However, some values specific to primary care, such as equity, were not explicitly cited. Equity of care is a fundamental principle in primary care [38]. While some PCPs, especially MGCs, appeared to focus on improving access to medical care for underserved populations, this value was not strongly emphasized among the broader group of PCPs in Benin.

This is not surprising, as most PCPs, apart from the MGCs, did not benefit from a structured process for developing a specific professional identity. Furthermore, most PCPs did not receive any sort of postgraduate training specifically designed for primary care practice. This lack of tailored training and the absence of a strong professional identity may hinder their ability to provide high-quality primary care and negatively affect their retention in these roles. Research indicates that a lack of clear professional identity for family physicians or general practitioners can decrease motivation to fully embrace discipline and lead to skepticism from the public and other health workers about the value of PCPs [39, 40].

Indeed, despite their intrinsic motivation to assist people in need, most PCPs in our study, except for the MGCs, did not actively choose to work in primary care. For most of them, it is a choice-by-default, as a temporary or fallback option while awaiting other opportunities. These findings echo those from another study across eight African countries, which revealed that the absence of a defined career path for PCPs made the field an unattractive option for many physicians in Africa [35].

Governance

Our findings indicate that governance is the weakest dimension of PCP practices in Benin, negatively influencing other dimensions of their work. This observation aligns with the results of our scoping review on PCP practices in sub-Saharan Africa [6] and likely reflects the broader issue of weak governance in African health systems [41].

Our study identified several governance challenges. One-third of PCPs (33.3%) lack formal work contracts, contributing to instability in their roles. Furthermore, only 27.1% of PCPs had access to continuous medical training, and fewer than half (47.7%) received supervision in the 12 months preceding the survey. Most PCPs, particularly those outside the public sector, have limited relationships with health district managers and minimal involvement in district-level public health activities. Although most PCPs have access to national guidelines, they tend to rely more on personal books and online resources. This may indicate a lack of trust in national guidelines or that these guidelines are not well suited to their needs. Additionally, a comprehensive accountability mechanism that can support PCP performance is lacking. Only a few (15.5%), primarily MGCs and public GPs, had defined populations for which they were responsible. While sanctions are increasingly enforced in Benin, many PCPs still lack clear guidance on their specific roles and responsibilities. They largely operate in a policy vacuum. These governance issues were most acutely felt by private GPs, who form the majority of PCPs, reflecting the broader challenge of weak coordination and support for the private health sector in African settings [41].

However, a positive development in Benin is that the latest health policy document (covering the period of 2018–2030) explicitly addresses PCPs and prioritizes increasing the number of physicians at the first line of care [21]. In line with this, the Government of Benin launched the “Fill the Gaps” project in 2024 [42], which led to the recruitment of 416 health professionals, including physicians, to enhance community health. These physicians were assigned to first-line facilities in densely populated areas and occasionally to district hospitals. This initiative demonstrates the government's recognition of the importance of PCPs and presents an opportunity to improve the structuring of PCP practices and enhance their role in primary care. However, there remains a need for a robust policy framework to effectively structure the practices of these physicians, including those in the private sector.

Roles and Activities

The PCPs in this study performed a broad range of activities, with a predominant focus on curative care. The reasons behind this vary across sectors. In the private sector, the drive for financial survival and profitability, coupled with inadequate regulation, pushes healthcare providers to prioritize lucrative services, such as curative consultations, deliveries, and other profitable procedures. Conversely, in the public sector, health promotion and preventive activities are handled mainly by nurse practitioners and community health workers, with PCPs playing a planner and coordinator role. Our findings also show that health authorities primarily expect PCPs to increase the technical quality of curative care and, to some extent (although not explicitly stated), to contribute to the facility’s income. While this expectation may explain the focus of PCPs in areas where they can add significant value, it also highlights the hospital-centered and curative nature of Benin's health system, even at the primary care level—a concern previously flagged by the WHO [43]. This emphasis risks compromising the delivery of sound primary care in Benin.

The median workweek for PCPs in Benin was 48 hours (IQR: 36–72), which aligns with the recommendations of the European Working Time Directive and is comparable to the workweek of general practitioners in a high-income country such as Norway in 2017 [44]. However, it is shorter than the workweek of physicians in other countries, such as South Africa, where physicians work approximately 60 hours per week [45], or Portuguese-speaking African countries, where the average workweek is approximately 65 hours [34].

The median number of patients seen per day by the PCPs in Benin was 8 (IQR: 5–15). The number of patients is very low given the working time. Two reasons can explain this fact. First, in private health facilities, GPs are meant to stay on duty in health facilities, even if there is no patient. Second, some PCPs (mostly public GPs) spend much of their time on nonclinical activities. This discrepancy between the worktime and number of patients consulted by the PCPs may, however, contribute to inefficiencies if the PCPs’ time is not employed in other activities meant to strengthen the primary care team or the services offered.

PCPs typically work in teams with a median of 2 physicians (IQR: 1–4) and 3 nurses or midwives (IQR: 1–5). This is an opportunity for fostering teamwork and coordination at the primary care level.

Both PCPs and health authorities unanimously agreed on three core roles for PCPs: clinician, trainer and supervisor of nonphysicians, and leader of the primary care team. These roles mirror those established for family physicians in South Africa [46] and other low-income countries [6]. Although there is no formal policy document explicitly defining the PCPs' roles, it appears that PCPs in Benin have an intuitive understanding of their potential contribution to strengthening primary care teams. The key challenge will be ensuring that they have both the autonomy and resources to carry out these responsibilities effectively.

Outputs and Outcomes

The median cost of a medical consultation was 2,000 FCFA (IQR: 1,000–3,000), and in 52.8% of facilities, it exceeded the cost of nurse-practitioner consultations. This may compromise financial access to care in a country where 36.2% of the population lives on less than 790 FCFA (1.2 euros) per day, especially in rural areas and urban slums [47]. Private GPs and specialists had higher consultation costs, further threatening access to care.

Fewer than half (47.6%) of the PCP facilities provided 24/7 physician availability, with the remaining offering only part-time coverage. This limited availability may pose an accessibility issue, as patients might not be able to see a physician when needed. However, since this study revealed that PCPs in Benin typically see a relatively low number of patients, maintaining full-time availability at the facility may not be the most efficient approach. Despite their increasing numbers, physicians remain a scarce and expensive resource. An efficient approach could involve positioning physicians as support resources within primary care teams, where they handle complex patients and strategic tasks, while simpler cases can continue to be managed by nurse practitioners.

Only 57.4% of PCPs adhered to the national referral pathway by referring critical cases to district hospitals, whereas 41.9% bypassed this system and referred patients directly to regional hospitals. The qualitative data attributed this to geographic proximity or distrust in the capacity of district hospitals. These results raise the question of whether the presence of PCPs, who often possess the same competencies and sometimes similar technical facilities as district hospitals do, necessitates a reassessment of the referral system in Benin. It may be time to review this system, considering both the needs of patients and the capabilities of PCPs. Furthermore, although concerns have been raised about the adherence of some private GPs to national guidelines, PCPs are generally perceived to add significant value in managing complex cases and enhancing the quality of care. Stakeholders noted that their presence discouraged reliance on alternative practitioners and elevated the clinical standards of nonphysician healthcare providers.

The overall career satisfaction of PCPs was moderate, with an average score of 4.3 (SD: 0.5) out of 6. Professional satisfaction ranked the lowest (4.1, SD: 0.7), whereas inherent (or intrinsic) satisfaction, reflecting PCPs' motivations, was rated the highest (4.8, SD: 0.5). Qualitative findings confirmed that dissatisfaction with salary and unmet expectations regarding personal and professional fulfilment in primary care contributed to this situation.

PCPs reported several barriers in achieving optimal practice outcomes, including limited resources, financial constraints among patients, and systemic dysfunctions within the healthcare system. Private-sector PCPs face particular difficulties, with financial and operational challenges that limit their ability to focus on preventive care or health promotion activities, which could undermine the overall quality of care.

Relevance of our findings

This study highlights the growing presence of PCPs in Benin, a phenomenon largely overlooked by national health policies and rarely identified in health statistics. By providing detailed data on the number of PCPs and their practices, the study offers a clearer understanding of their practices in the healthcare system. It also raises awareness about the challenges stemming from inadequate preparation and guidance for PCPs, which could serve as a valuable lesson for other countries experiencing similar growth in PCPs. Furthermore, the study underscores the importance of effective governance tools, such as tailored policy frameworks, to ensure that PCPs can fully contribute to primary care and improve health outcomes.

Strengths and limitations

This study has several strengths. This study is the first to comprehensively map the practices of PCPs in Benin, providing valuable data on a phenomenon that has been largely overlooked in national health policies and health information systems. The mixed-methods approach used enhances the robustness of the findings, integrating both quantitative and qualitative data and leading to a nuanced understanding of PCP practices. Additionally, the study raises awareness about challenges arising from the insufficient preparation and guidance of PCPs and offers insights that are relevant not only for Benin but also for other low-income countries experiencing similar growth in primary care. Finally, the research underscores the importance of effective governance tools, such as an adapted policy framework, to better support PCPs. Finally, the creation of a typology of PCP practices in Benin is a novel contribution, helping to better understand the different types of PCPs and their distinct challenges and roles.

This study also has limitations. First, the reliance on self-reported data from PCPs introduces the possibility of response bias. Second, the study provides a snapshot of PCP practices at a specific point in time. Longitudinal data could indeed offer more insights into trends and changes in PCP practices over time. Finally, the study does not include patient perspectives, which could have provided valuable insights into their needs and perceptions of the quality of care delivered by PCPs, complementing the findings from PCPs and health authorities.

The study highlights the diversity of PCP types in Benin and provides an inventory of the most important challenges they face regarding their professional identity, prevailing governance arrangements, available resources, and provision of support. While PCPs are intrinsically motivated by their ability to help local populations, systemic challenges and inadequate support structures hinder their potential to improve primary care outcomes. A key gap identified is the absence of a well-structured policy framework tailored to the specific practices of PCPs. The development of such a framework could address the abovementioned challenges and constraints. Providing an evidence-based policy framework is therefore essential in fostering robust primary care in Benin.

Cot 2-3: Cotonou 2-3

GP: General practitioner

MGC: "Médecins généralistes communautaires"

NKP: Nikki-Kalalé-Pèrèrè

OKT: Ouidah-Kpomasse-Tori

PCP: primary care physician

PHC: primary health care

PN: Parakou-N’dali

QUAN: quantitative

QUAL: qualitative

Ethics approval and consent to participate

This study received ethical approval from the Institutional Review Board of the Institute of Tropical Medicine of Antwerp in Belgium (N° 1324/19) and the local ethics committee for biomedical research of the University of Parakou in Benin (N°0193/CLREB-UP/P/SP/R/SA). All participants provided informed consent, and the data were treated with strict confidentiality.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was performed as part of the doctoral program of KB. This program is funded by a grant from the Directorate-General Development Cooperation and Humanitarian Aid (DGD), Belgium (https://diplomatie.belgium.be/en/policy/development_cooperation/who_we_are/our_org anisation/dgd). Grant number: FRM 1178 v1.0 between the Institute of Tropical Medicine, Antwerp (https://www.itg.be/), and KB.

KB also benefited from the support of KU Leuven (Katholieke Universiteit Leuven), Belgium, during the data analysis and writing process.

The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors' contributions

KB conceptualized the research; led all the processes for data collection, data management, and data analysis; verified the results; wrote the first draft of the manuscript; and revised the subsequent drafts.
JDL contributed to the research conceptualization and data analysis and revised and edited various drafts of the manuscript.
CA supported data collection and quantitative data management and assisted in the quantitative data analysis and its visualization.
DMZ contributed to the research conceptualization, supervised the data collection, and revised the manuscript.
BC coconceptualized the research, supervised the entire research process, contributed to the data analysis, and revised and edited various drafts of the manuscript.

Acknowledgements

Thanks are extended to Mr. Elias Avahoundje, Dr. Schadrac Agbla, Dr Hashim Hounkpatin, and Dr. Jean-Paul Dossou for their valuable advice and support during the design and implementation of this research. Gratitude is also expressed to the research assistants who assisted with data collection and to all the study participants.

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In-depth mapping of primary care physicians’ practices in four health districts in Benin: a mixed methods study

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Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Study Design

Study settings

Study population and sampling

Definition and analytical framework

Definition of PCPs’ practices

Analytical framework

Data collection

Quantitative strand

Qualitative strand

Data analysis

Characteristics of PCPs and their practices (research questions 1 and 3)

Typology of the PCPs’ practices (Research Question 2)

Selection of relevant attributes for regrouping PCP practices

Grouping the cases and checking the relevance of the groups

Analysis of the relationships between the various groups

Characterization of the constructed types

Results

Research question 1: Number and characteristics of the PCPs

Research question 2: Typology of primary care physicians

Grouping the cases and checking the relevance of the groups

Analysis of the relationships between the various groups

Characterization of the constructed types

Research question 3: Characteristics of PCP practices

Professional identity of the PCPs in Benin

Postgraduate training

Values underlying the PCPs’ practices

Motivation to work first-line

Governance features of primary care physicians

Policy guidance and regulation

Affiliation with a professional organization and work contract

Resource allocation

Interviewer: 60%... What about the other 40%?

Support received

Involvement in health districts’ activities and collaboration with district managers

Accountability

Roles and activities of primary care physicians

Outputs and outcomes of primary care physicians’ practices

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

References

Additional Declarations

Supplementary Files

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Version 1