The growth of the academic discipline of primary care all over the world has led to more primary care practitioners taking part in research. Primary care has a generalist personality (1), and several research methods are therefore needed to understand the multifaceted interaction between medical and psychosocial factors in the discipline (2). Evidence-based medicine has conventionally relied on efficacy research-research conducted under comparatively perfectly controlled conditions. The conclusions of efficacy research though, possibly will not be suitable for real-world conditions in which medical practices face multiple rival demands, and patients have multiple comorbidities and special inclinations. Efficacy research furthermore, is usually performed in academic medical center sites whose populations are not representative of the general population (3). On the other hand, effectiveness research refers to studies conducted under real-world conditions. More than one half of all office visits in the United States are to primary care practitioners (4). Effectiveness research for many clinical questions thus needs to be conducted in primary care settings. Practice-based research networks (PBRNs) have been fashioned as primary care laboratories for performing effectiveness research(5,6).

The development of primary care research in the World, varies widely. Generally there are three levels of development of primary care research. Firstly, in many economically developed Western countries research in primary care is already well recognized. Academic institutions have traditionally supported the primary care disciplines for many year. Clinicians are enthusiastically drawn in (often through primary care research networks), and governmental support (although limited) has been offered. In another group of countries, also including some Western developed countries, it is only lately that primary care disciplines have achieved a minor position in the academic institutions and support for research is only minimally available. In a third group of countries, there is almost no organized training or research in the primary care disciplines or it is just beginning in a few locations. Wretchedly in some of these countries, war and political volatility have made the pursuit of any scholarly agenda practically unfeasible in the face of serious issues of physical and economic survival.(7-9)

Primary care research networks (PCRNs) are becoming a global resource for research (9). Data from the International Federation of Primary Care Research Networks (IFPCRN) indicates that PRCNs, which link clinicians in community practices as partners with academic researchers, now exist in at least 39 countries with interest evident in many more. The IFPCRN which is organized under Wonca, has been developed to facilitate communication between these networks, to aid in their development and the dissemination of success stories. National federations of networks exist in the US, the UK, and Canada.

In the United Kingdom primary care research networks started in the 1960s. The networks gradually formed an important part of the backbone of primary care research by 1980(10). It took another 20 years s for political recognition of their importance so that primary care research was specifically included in the NHS research and development strategy for England and Wales for the first time in 1997.

Research network endeavor in primary care has developed around the world. In the United States multiple small and large networks have materialized since 1980. For example, the Ambulatory Sentinel Practice Network has effectively recruited large numbers of patients to studies in the United States and Canada (11). The Dutch Sentinel Stations in the Netherlands have been collecting data since 1970. Health sector reforms in Eastern Europe have encouraged international collaboration through networks. For example, the European General Practice Research Workshop is facilitating collaboration between several eastern European countries, and Scandinavian general practice researchers network with primary care workers in the Baltic states.

Regional development in research includes the establishment of a number of research networks, including Saudi Arabia research group, Middle East Primary Care Research Network (MEPCRN), and Middle East Network on Aging (MENAR). The aim of the MENAR is to develop Geriatrics and Gerontology Research in the area. There are currently more than ten countries represented in the network.

MEPCRN was established recently due to a substantial research need in primary care in the Middle-East. Research is an essential prerequisite in developing the specialty further in the region, and in developing evidence-based practice. Areas of research fields that have been neglected includes a substantial part of illness and disease presenting to health services, of which the bulk is only encountered in primary care.

In addition, the behavioural aspects, multidisciplinary cooperation and teamwork, are among areas that traditionally have been ignored in research. The aim of the MEPCRN is to develop family medicine research in the region. Membership in the MEPCRN is being developed rapidly, and now includes representatives from many different countries.

PBRNs have newly assumed a function separate from, but related to, their research mission: practice improvement. Primary care research networks (PCRNs), have the potential to incorporate different efforts for quality, including education and services (12).. There is a rising appreciation that primary care is not able to live up to its promises to provide high-quality and accessible chronic illness and preventive care to all patients (13,14). Therefore, PBRNs are increasingly seen as institutions that can simultaneously conduct effectiveness research and catalyze practice change.
A number of authors have reported on PBRN-based research with implications for practice improvement (15-18). These authors, however, do not comment on obstacles that may come up in harmonizing the dual goals of research and practice change. Primary care research provides "the missing link in the development of high quality, evidence based health care for populations."(19, 20)

A systematic review of the literature about public and private sector networks to draw lessons about network management, was carried out in the UK (21). The study identified 3 types of network structure: enclave, a structure based on shared commitment; hierarchical, one with a regulatory organizational core; and individualistic, one with a loose association of affiliates.

A network presents a set of pathways for people and ideas to come together. Networks may facilitate the coordination of diverse activities and disseminate information quickly, membership can be closed or open, and the direction can be rigidly defined or self organised. Closed, rigidly defined networks for example, road systems, tend to have outcomes that are more predictable. Open, self organising networks, for example, the internet, tend to be more uncertain.

Research networks lead to multidisciplinary coalitions of researchers, provide extensive ownership of research activity, and encourage members to disseminate research findings quickly. They do not have to focus only on research. Indeed, there may be value in researchers sharing a network infrastructure, which is slow to build and expensive to maintain, with those concerned with education and service development. This will enhance opportunities for collaboration and reduce costs(22,23).

A network comprises "a set of nodes and the set of ties representing some relationship, or lack of relationship, between the nodes." (24) Nodes are people, places, or organizations that enable multidisciplinary transfer of information, broker partnerships for quality improvement, and access a variety of resources and power. They are places where different paths converge, and the means whereby a network reaches places that bureaucratic structures cannot reach (25).

Primary care networks could help incorporate academic and service initiatives for research purposes and, equally importantly, development purposes. Coordinators of networks must, however, ensure that managing the complex interactions involved does not hinder good primary care research. Hickner (26) stresses that the power of practice-based research networks is the ability to help practitioners examine vigilantly what matters in practice, and to test these ideas in a broader field with friends who are skilled at collaboration. We must not lose this original inspiration.

Practice-based research has the possibility to lead to quality improvement , to train and assist practices to adopt these improvements, and to judge how the improvements are working for practitioners, practice staff, and patients. Research and practice improvement can be innate partners, with research acting as a facilitator of practice change.

Notwithstanding the optimism articulated above, huge challenges linger in the task of developing the research needed to improve the world's health care at its most fundamental level. In all cases the lack of sufficient funding for primary care research remains a major issue, even in the developed countries, and is particularly problematic given the need to build the infrastructure for research in primary care and the lack of trained primary care clinicians with researcher skills. Furthermore, due to historical factors in several countries where the "GPs" were physicians receiving no supplementary education beyond basic medical school education, there is an absence of effective primary care clinician leadership in academic institutions. A strong primary health care research system, with adequate power to tackle local and national needs and the ability to relate evidence to practice and policy making, is required in each country.