From the Wonca President: Our Commitment to Develop
Family Medicine in Areas of Need

As we look forward to the Wonca World Council Meeting in Orlando Florida in October it is important that each member organisation prepares to review its global commitment.

As a world organisation, Wonca has grown substantially in recent years. It now has member organisations in all regions. Most of the countries of Central and South America have joined 'en bloc'. Important contacts have been made with the countries of Central Asia including Mongolia. These will hopefully lead to the creation of a new region in that area. At a historic meeting of Arab countries in Beirut at the end of last year, representatives agreed to prepare for the establishment of a Wonca Arab Region. Europe has continued to expand along its eastern border. Already it is clear that the special needs of Western, Southern, and Eastern Europe may, at times, require a sub-regional approach. Wonca as a global organisation must have the flexibility to respond appropriately according to the needs of its member organisations.

Africa: Challenges to Health for All

This sub-regional approach will be particularly necessary in Africa. Travel costs are prohibitive; the vast distances, currency weakness, and communication difficulties make effective collaboration at the Pan-African level almost impossible.

Africa's communicable diseases - particularly HIV/AIDS, TB and Malaria - pose challenges which are almost beyond our comprehension. Healthcare in East Africa is underdeveloped. It relies heavily (40 percent of healthcare in Kenya) on hospitals and medical stations operated by externally funded faith-based missions. As Table 1 shows, average per capita healthcare spending in the United States in 2000 was between 60 and 100 times greater than in three countries of East Africa. Furthermore, in Tanzania more than a quarter of all public spending was devoted to healthcare.

Table 1. The World Health Report (2000)

It is disappointing, to say the least, that 25 years after the Declaration of Almaty for Health for All, so little has changed for the peoples of sub-Saharan Africa. If anything, disparities are widening and economic disadvantage has been compounded by catastrophic epidemics and political instability. Healthcare reform must go hand-in-hand with political and economic reform.

One of the lessons of the last 25 years must be that healthcare reform has to go beyond the important traditional concerns of public health. Primary health care for the future must include the personal care provided by family doctors and office practice and community based nurses working together. For too long the importance of a quality system of personal primary care has been undervalued and poorly resourced.

Not surprisingly, given the perilous state of family practice in Africa, Wonca has had very few member organisations in the Region; they include South Africa, Zimbabwe, Nigeria (2 organizations), and Ghana.

East Africa: An Opportunity for Collaborative Subregional Development

At last, in East Africa, this is beginning to change with the establishment of the Kenya Association of Family Physicians by Dr. Humphrey Belcher and his colleagues. The KAFP has joined Wonca. Similar national associations are being considered for Uganda and Tanzania.

I was very honoured to be invited recently to visit Kenya and to address The First International Family Medicine Symposium held at the Aga Khan Hospital in Nairobi last month. The Aga Khan Hospital Network has been particularly supportive of Family Medicine.

It was well attended by family doctors, not just from Kenya, but from Uganda, Tanzania and even the Democratic Republic of the Congo. Some had made considerable personal sacrifices and arduous journeys to attend the meeting. The symposium brought together INFA-MED (the Institute of Family Medicine), Moi University Medical School in Eldoret (the first Kenyan medical school to establish an M.Med Course in Family Medicine), and representatives of the Royal College of General Practitioners (United Kingdom). The programme included a number of powerful personal accounts of the difficulties of delivering personal and family healthcare in the African setting.

A regional 'Association of Family Physicians of East Africa' (AFPEA) has also been established. The plan is to make it an academic accrediting body - 'The College of Family Physicians of East Africa' - focused on accrediting training programmes, publishing a journal, coordinating research, and establishing a 'Society of Teachers of Family Medicine'.

The vision of WHO is that all citizens should enjoy a level of health that permits them to lead socially and economically productive lives. Recent developments in East Africa provide some grounds for optimism. There is evidence that leaders of education and health care in Kenya have identified primary health care systems as critically important in meeting the challenges they face. As a result a national system of continuing professional development (CPD) for all doctors is proposed.

Those of us representing Wonca - President Elect Bruce Sparks, Africa President Abra Fransch and myself - joined our KAFP and other African colleagues in meeting with senior Health Ministry officials to discuss not just the CPD proposal but the future of family doctor education and training in Kenya.

Evidence already assembled by Wonca in the 'Guidebook´ has confirmed that well trained generalist physicians are integral to the delivery of quality care that is cost-effective, relevant and equitable. These personal care services are enhanced when integrated with public health measures such as immunisation, nutrition, and health surveillance.

In November 2003, a needs assessment report on family practice and community oriented primary care training programmes in the East Africa was undertaken on behalf of The World Organisation of Family Doctors (Wonca), (The Network: TUFH) and Global Health Through Education, Training and Service (GHETS). The University Medical Schools such as Moi University in Kenya and Makerere University in Uganda have been very supportive.

The report challenges Wonca to share our expertise and to coordinate our activities with those of other agencies in the field. Together with them we can assist in the development and adaptation of relevant curricula and educational modules, and disseminate information through electronic means. We can facilitate publications describing innovative work in the region. Within our countries we must try to identify individuals and institutions willing to contribute their resources. Working together with African regional stakeholders it should be possible to reach a strategic consensus that reflects the heritage and resources of the countries while maximising the contributions of all involved.

Six years ago in Killarney, the Wonca World Council identified the development of family medicine in countries and regions where it was weak or non-existent, as our number one priority. The nations of Africa represent the greatest challenge to the achievement of that aspiration. These East Africa initiatives are an important start.

It will be a matter for each of our member organisations when we meet in Orlando to tell us how they plan to meet the challenge.

Michael Boland
President
World Organization of Family Doctors