From the Wonca President:
Lessons from the Americas
2
3
From the CEO’s Desk
:
Wonca’s Stimulating Regional Conferences
From the Editor
:
A New Resource for Global Family
5
Medicine Development
FEATURE STORIES
5
•Implementing the Family Group Practice Model in Mongolia
•The Past, Present and Future of Family Medicine in Uganda
•Wonca Launches its Global Resource Directory
Wonca REGIONAL NEWS
11
•More than 2,000 Attend the 11th Annual
Wonca European Regional Conference
HEALTH AND HEALTH SYSTEM NEWS
13
•WHO Issues Progress Report on Health and Millennium
Development Goals
•The Role of Physician Assistants in the Health Care System
MEMBER AND ORGANIZATIONAL NEWS
15
•Family Medicine in Russia: Letter to the Editor
•Damilya Nugmanova: Wonca Global Family Doctor for August 2005
•Alan Pugh: Wonca Global Family Doctor for September 2005
RESOURCES FOR THE FAMILY DOCTOR
17
•Fellowships Available to Attend 13th World Conference on
Tobacco or Health
•Improving Health Systems: The Contribution of Family Medicine
WONCA CONFERENCES 2005-2010 AT A GLANCE
19
GLOBAL MEETINGS FOR THE FAMILY DOCTOR
20
VOLUME 31
NUMBER 4
OCTOBER 2005
CONTENTS
Wonca website:
http://www.GlobalFamilyDoctor.com
Wonca President
Prof Bruce Sparks, South Africa
2 Cruden Bay Road
Greenside
Johannesburg 2193
South Africa
Tel: 27 11 646 2140
Fax: 27 11 717 2558
Email: brucespa@global.co.za
Wonca Chief Executive Officer
Dr Alfred W T Loh
Wonca Administrative Manager
Ms Yvonne Chung
World Organization of Family Doctors
College of Medicine Building
16 College Road # 01-02
Singapore 169854
Tel: 65 6224 2886
Fax: 65 6324 2029
Email: admin@wonca.com.sg
Wonca President-Elect
Prof Chris van Weel, Netherlands
Wonca Immediate Past President
Dr Michael Boland, Ireland
Honorary Treasurer
Richard Roberts, MD, USA
Wonca Regional Presidents
Dr Abra T Fransch, Africa
Warren A Heffron, MD, Americas
A/Prof Goh Lee Gan, Asia Pacific
Prof Igor Svab, Europe
Dr Shatendra K Gupta, Middle East
South Asia
Dr Adolfo Rubinstein,
Iberoamericana-CIMF
Wonca Executive Members at Large
Dr Javier Dominguez del Olmo, Mexico
Prof Michael Kidd, Australia
Richard Roberts, MD, USA
Chair, Bylaws and Regulations
Dan Ostergaard, MD, USA
Chair, Publications & Communications
Dr Geoffrey D Martin, Australia
Editor, Wonca News and Editorial Office
Marc L Rivo, MD
4566 Prairie Avenue
Miami Beach, Florida 33140, USA
Tel: 305 671 7327
Fax: 305 674 8839
Email: marcrivo@aol.com
WONCA GLOBAL SPONSORS
FROM THE WONCA PRESIDENT:
LESSONS FROM THE AMERICAS
“The cultivated general practitioner ...... you cannot
reach any better position in a community; the family
doctor is the man behind the gun, who does our
effective work. That his life is hard and exacting; that
he is underpaid and overworked; that he has but little
time for study and less for recreation-these are the
blows that may give finer temper to his steel, and bring
out the nobler elements in his character.”
Sir William Osler (1849-1919)
In my fortunate role within Wonca, I am continually
struck by the remarkable work being done by family
doctors around the world. I have just returned from a
visit to The USA and Chile where the role of family
physicians in health systems and the care of people was
once more emphasised.
In San Francisco, I had the opportunity of again
attending the Congress of Delegates of the American
Academy of Family Physicians, which precedes their
annual Scientific Meeting. The nation was still shaking
its head from the devastation and human suffering
experienced in the wake of hurricanes Katrina and Rita.
I, like many others around the world had been saturated
and even ‘immunised’ by the plethora of news reports
on the disasters, but only when I was able to listen to
the stories of those ‘who had been there’ did I
appreciate the impact of these events.
Repeatedly within the congress of delegates and the
smaller reference committees, I heard impressive stories
and impassioned testimonies of how family doctors
from private practice and academic units across the
nation, were among the first to respond to the disaster.
Under extremely difficult circumstances, they set up
makeshift clinics, emergency medical services, crisis
management and counselling units, immunisation
centres, and hygiene and health counselling services.
There was praise from many quarters for the magnificent
service of these doctors, who as generalists were able
to function in situations where specialist teams were
often impotent to act. Realising the essential role of
family physicians in such situations the Academy
resolved to support the recruitment and involvement of
family physicians in Disaster Medical Assistance Teams
(DMATS) and other disaster related training
programmes, and to ensure the development of cadres
of doctors for what was coined “Family Physicians as
First Responders”.
WONCA
News
FROM THE WONCA PRESIDENT
2
This initiative is something which I believe Wonca
should consider, and I have had exploratory discussions
with some of those in the field regarding possible
training programmes for countries with less
sophisticated services. At times of disaster we are often
contacted by doctors globally who would like to assist
meaningfully, not only during the initial event but also
in post-disaster rehabilitation and management.
Incidentally, a dilemma that was addressed by the
delegates to the meeting is one, which frequently
occupies discussions globally in Colleges and
Academies. There is division on whether to encourage
family doctors to obtain post-residency fellowships or
qualifications (called Certificates of Added Qualification
(CAQs)) in focused areas of practice such as trauma,
endoscopy, allergy, sports medicine, and cardiac or
respiratory care). The proponents argue that such CAQs
would discourage young doctors from pursuing
specialist training and so enrich our discipline and its
scope, while the detractors felt that such multiple
‘diplomatosis’ could fragment the uniqueness of the
generalist discipline. No consensus was reached at this
point!
My experience in Santiago, Chile was equally
illustrative of the fundamental role of family doctors in
health care systems. To set up a meeting with my
Minister of Health could be a major undertaking, but
imagine the gargantuan task of requesting the Ministers
of Health and staff of eighteen Iberoamerican countries
to travel to a foreign country, to attend a meeting to
discuss Family Medicine, and expect them to attend for
the full two days! I was totally overwhelmed by the
attendance and public support by Ministries of Health at
the Second Iberoamerican Summit of Family Medicine
entitled, “Family Medicine: Quality and Equity in Health
Systems in Iberoamericana”. This meeting was
organised by the South American region of Wonca
known as Wonca Iberoamericana-CIMF, together with
Chilean Society of Family Medicine, the Chilean Health
Ministry, and PAHO, (the regional organisation of WHO).
Wow! What a successful get-together in the shadow
of the glazier-clad Andes! What was so encouraging
was the obvious and encouraging support for Wonca
and for the development of Family Medicine within the
region. The goal of the meeting was to improve health
care of the peoples of the Iberoamerican Region by
incorporation of family doctors, as essential elements of
health systems, to deliver personalised, integrated,
comprehensive, equitable, and continuous care to
individuals, families and communities. There was also
an initiative to develop collaboration between
governments, universities, and related institutions to
WONCA
News
FROM THE WONCA PRESIDENT / FROM THE CEO’S DESK
3
FROM THE CEO’S DESK:
WONCA’S STIMULATING REGIONAL CONFERENCES
The growth of Wonca as a global organization from 78 member
organizations in the last triennium ( 2002 - 2004 ) to the current 105 is
most evident in the four exciting and well attended Wonca Regional
Conferences held in different venues around the world during the past five
months.
These were :
1.The Asia-Pacific Regional Conference in May in Kyoto, Japan.
2.The Wonca Europe Regional Conference in September in Kos Island,
Greece.
3.The Iberoamericana-CIMF Regional Conference in early October in
Santiago, Chile.
4.The Middle-East South Asia Regional Conference in mid October in
Colombo, Sri Lanka.
The Asia-Pacific Regional Conference in Kyoto, Japan
This was the largest ever regional conference for the Asia-Pacific Region
with over 2300 registrants. These consisted of a large number of local
registrants from the Japanese Academy of Primary Care Physicians and also
a larger than usual number of overseas delegates from 50 countries as far
as Europe and the Americas.
The Conference was graced by the presence of Their Imperial Highnesses
Prince and Princess Akishino of Japan at the Official Opening of the
Conference, a significant development for Family Medicine in Japan.
The Conference was also the venue for Wonca to announce to its
members the release of the International Primary Airways Group (IPAG)
Handbook with members of the international press attending the press
release and during which all conference delegates at the event were given
free copies of the Handbook. A lunchtime satellite symposium on COPD was
held in conjunction with the launch of the IPAG Handbook. The symposium
organised by Wonca World in conjunction with the HOC was very well
attended by over 450 delegates.
The Regional Council Meeting of the Asia-Pacific Region as well as a
meeting of the Wonca International Classification Committee took place a
day before the Conference to take advantage of the presence of
representatives from the various Wonca Member Organizations in the
Region. A full Wonca Executive Meeting was also held three days prior to the
Conference date and some Members of Executive were able to stay on after
the meeting to represent Wonca at the various official functions of the
Conference. An invitational post conference workshop was also held for
delegates from the Asia-Pacific Region.
train, integrate and support family
doctors in these health systems. The
Ministers and their staff attended all
sessions and workshops!
Dr Barbara Starfield presented
excellent international data on the
effectiveness of family doctors and
primary health care in health care
systems, all of which fell on very
receptive ears. Most speakers also
stressed the need for documented
research in the region to assist the
process. A major catalyst for the
initiative was the tangible and
overwhelming support of PAHO, but
the success of the meeting is largely
due to the remarkable facilitative
roles played by the Regional Wonca
President, Dr Adolfo Rubinstein and
Dr Oscar Fernandes Fuentealba, the
Congress Chairman. Of course, the
two days would not have been the
major networking opportunity that it
was, without the hospitable Chilean
festivities, entertainment, ‘Pisco-
sour’ cocktails and music!
It was a privilege to observe
family doctors making real
differences to the health of nations!
Bruce Sparks, M.D.
President
World Organization of Family
Doctors
WONCA
News
FROM THE CEO’S DESK
The Wonca Europe
Regional Conference in
Kos Island, Greece
This regional conference was the
largest in terms of registration for a
Wonca Europe Regional Conference
as over 2400 registrations were
received. But difficulties in obtaining
air connections between Athens and
Kos Island led to over 200
registrants having to cancel their
participation. The climax of the
Conference was the pageant and
Hippocratic Oath taking during the
closing ceremony held at the
Asclepion, the site where
Hippocrates practiced and taught his
pupils in ancient Greece.
The Regional Council for Wonca
Europe was held a day earlier and
the meeting was also attended by
the President-Elect of Wonca and
the CEO. Extensive discussions took
place during this meeting on
sponsorships by pharmaceutical and
non-pharmaceutical companies in
support of the global mission of
Wonca.
Two evening satellite symposia,
organized by Wonca World in
conjunction with the HOC were held
on the subject of Asthma and COPD
on different days. At the end of the
symposia, the two Wonca Global
Sponsors (ALTANA Pharma and
Boehringer Ingelheim) which were
also sponsors for the satellite
symposia, were each given a
certificate and a crystal momento for
their support for Wonca’s global
mission.
The Iberoamericana-CIMF
Regional Conference in
Santiago, Chile
This was the Second Regional
Conference for this new and
dynamic Region of Wonca. Held in
the beautiful city of Santiago, Chile
4
over three days, the Conference was
special in the very visible support
given to Family Medicine by the
various governments of the Region.
The Ministers of Health of Ecuador,
Paraguay and Chile were present at
various times during the conference.
The Conference had over 400
registrants with delegates coming
from all countries of the
Iberoamericana-CIMF Region,
including Cuba. Discussions were
held between the delegates from
Cuba, the Regional President and
the Wonca CEO on the possibility of
Cuba joining Wonca.
The support shown by Wonca
World was equally significant. The
Wonca World President, the
President Elect, the Regional
President and Wonca CEO were all
present throughout the Conference.
The World President and President-
Elect also took active part in the
conference programme as plenary
speakers and session chairs.
Simultaneous translation from
Spanish to English and vice versa
for certain parts of the programme
were offered as a courtesy to the
small group of English speaking
delegates, mainly from Wonca
World. This was highly appreciated.
Following this Regional
Conference, the Scientific Society of
Family and General Medicine of
Chile held their Annual Scientific
Congress which had over 650
registrants. The opening ceremony
for this national congress was
attended by the Wonca President-
Elect and CEO.
The Middle-East South
Asia Regional Conference
in Colombo, Sri Lanka
This was the second MESA
Regional Conference to be hosted
by the Sri Lanka College of General
Practitioners. About 300 registrants
attended from the various member
countries of MESA and as far as
England, Australia and New Zealand.
The scientific papers presented
included some from medical school
undergraduates, which were of a
very high standard. In addition,
teaching staff from the various
medical colleges in the country
attended.
World Wonca was represented by
the Regional President and the CEO.
At the Opening Ceremony, the CEO
presented a cheque of US $24,000
(equivalent to 2.4 million Sri Lanka
Rupees ) to the Sri Lanka College on
behalf of the University of
Nehmegen and the Dutch College in
aid of the Tsunami Relief Fund. This
fund was set up by the Sri Lanka
College to help rebuild the lives of
those affected by the disaster.
A large contingent from India
attended the Conference.
Discussions were held between the
Regional President, the CEO and
these delegates on how best to
have India’s family doctors and its
organizations more involved in
Wonca.
I must add that it is important
that Wonca Regions hold regional
conferences annually if possible
except in the year of a Wonca World
Conference. These events allow for
better networking between member
organizations in the region and
globally. The Wonca Regional
Conferences are also very useful in
identifying common agendas that
member organizations may work
towards for their mutual benefit.
Dr Alfred Loh
Chief Executive Officer
World Organization of Family
Doctors
WONCA
News
FROM THE EDITOR / FEATURE STORIES
5
FROM THE EDITOR:
A NEW RESOURCE FOR
GLOBAL FAMILY MEDICINE
DEVELOPMENT
Since the World Organization of
Family Doctors was established in
1972, Wonca has promoted family
medicine development as a key
health system strategy to meet
people’s health needs. Over the past
three decades, dedicated family
doctors from established Wonca
member organizations have
contributed their knowledge,
expertise and time to spread
general practice/family medicine
globally.
Wonca has served as an
invaluable resource for family
doctors to share their experiences
and help one another. The growth
and development of Wonca’s
Regions, member organizations,
working groups and their products -
- - reports, conferences, networking
opportunities - - - have improved
our ability to make a meaningful
impact on people’s health
throughout the world.
This issue of Wonca News
reports on the successful 11
th
Wonca
Europe Regional Conference held on
the Island of Kos, Greece. Wonca
Region Europe has been a model for
how member organizations and their
leaders can come together and help
each other promote family medicine
development throughout their
region and around the world.
This issue of Wonca News
features important and interesting
news on family medicine
development in Mongolia, Uganda
and Russia, very different countries
politically, economically and socially,
yet all seeking to reform their health
systems to improve access, quality,
equity and affordability for their
citizens.
In addition, this issue of Wonca
News reports on our new Global
Resource Directory (GRD) for family
medicine development that has
been established on Global Family
Doctor – Wonca Online at
www.GlobalFamilyDoctor.com. The
Global Resource Directory contains
additional reports and information
on family medicine in Mongolia,
Uganda and Russia that may be of
interest to our Wonca members.
Our new Wonca Global Resource
Directory will help us archive and
share in an organized, accessible
and user friendly manner valuable
information on family medicine
development around the world. As
importantly, it was enable family
doctors to identify and network with
others around family medicine
development in a particular country.
Please check this out!
Please send me your articles,
photos and additional background
information on family medicine
development around the globe that
you would like to publish in Wonca
News. All the information you wish
to share with your fellow family
doctors will be saved and made
available through our online Global
Resource Directory.
Marc L. Rivo, M.D, M.P.H.
Editor, Wonca News
marcrivo@aol.com
4566 Prairie Avenue
Miami Beach, FL 33140 USA
1-305-674-8839 (fax)
FEATURE STORIES
IMPLEMENTING THE
FAMILY GROUP PRACTICE
MODEL IN MONGOLIA
Like other countries influenced
by the Soviet model of health care,
the pre 1990 Mongolian health
system was centrally planned,
dominated by hospitals with no
tradition of general practice, and
exclusive of community involvement
or participation. Since the 1990-93
transition to a market economy,
health reform is now firmly on the
Mongolia agenda through the Health
Sector Development Program
(HSDP), an initiative funded from
Asian Development Bank loans. The
major reform element in Mongolia is
the Family Group Practice (FGP)
model aimed at developing General
Practice.
Under the old Mongolian system,
General Practice was unknown.
Public health doctors focusing on
prevention worked alongside
specialists in polyclinics attached to
hospitals. The reform program
provided the opportunity and
resources to develop a General
Practice focus. The program had
several key elements.
First, doctors from hospitals were
moved to practices in the
community, particularly poorer areas
(often with no water or electricity
supplies). Second, the population
was encouraged to register with a
Family Doctor of their choice – thus
strengthening the patient role. Third,
the payment status of the new
Family Doctors was changed from
state employees to private
practitioners paid under capitation
arrangements for patients in their
care.
The FGP program started in mid
1999 and currently, 234 FGPs have
WONCA
News
FEATURE STORIES
6
been established throughout
Mongolia: 118 in the capital,
Ulaanbaatar, and 116 in the
population centres in the aimags
(provinces). Over 56% of the
population is covered by the 234
FGPs (1.3 million people), which
include 940 Family Doctors and
almost the same number of staff
(mainly family nurses, assistants,
caretakers, etc). On average, one
doctor serves 1350 individuals
(similar to Australia and Europe).
Mongolian Family Doctors
A Mongolian FGP clinic
Mongolian doctors and nurses undergoing
training
Certain factors were critical in
establishing the FGPs. First, public
health doctors and interested
specialists were recruited to
comprise the pool of new Family
Doctors forming themselves into
FGPs (ranging from 3-5 doctors in
each practice). Potential FGP bases
were mapped out according to
target populations and doctors
selected their particular area.
Next, through an information and
education campaign, the population
registered with FGPs. To assist in
selection, individual doctor details
were circulated widely. Under a
capitation arrangement, doctors
were paid for each patient
registered. Capitation payments
were initially weighted according to
needs categories and risk adjusted
by age-sex and poverty ratings.
Subsequently, this was simplified
to Poor:Non-Poor (with significantly
higher rates for Non-Poor), and
applied selectively to urban and
rural areas and to poor areas within
cities to reflect the higher need for
services.
The next factor was a program of
training and retraining. Training took
the form of an introduction to
primary care principles; UK and
Australian type general practice;
practice management; and finance
and accounting. Re-training was
intended to refocus on General
Practice based on a series of clinical
modules emphasizing patient
centered approaches; management
of common conditions; holistic care;
and communication. Each FGP was
given an extensive package of
equipment, purchased under the
program, comprising basic items
such as stethoscopes,
ophthalmoscopes, suture sets,
sterilizers, folding table,
gynaecological chairs, lamps etc.
Each package contained over 100
items of
equipment. New
equipment was seen as an
important factor in demonstrating to
the public that the new FGPs were
professional and competent.
The final factor was establishing
a contract between FGPs and local
government for the provision of
services and as the basis of
payment. The Contract specified
targets and performance including
extended working hours; regular
home visits; health education and
prevention activities; ongoing
education; and targets for
immunization and vaccination. The
Contract sets out the payment rate
(based on aggregrated capitated
amounts for patients registered) and
frequency of payment (quarterly).
The lump sum payment covers all
FGP costs – salaries; rent; heating,
electricity etc.
For Mongolia, capitation is the
most appropriate payment system
to support overall reforms. Risk
adjustment means higher payments
for poorer areas and encourages
doctors to work there, thus
increasing access and equity. No
direct patient payment and universal
coverage encourages use of FGPs as
alternatives to hospitals and assists
in transferring resources from
hospitals to primary care. As more
people use FGPs, there will be a
corresponding reduction in hospital
use and resources can be redirected
to reinforcing General Practice.
Capitation also encourages
quality improvement and client
focus. In Mongolia, money follows
the patient. If patients register with
a doctor in another FGP, capitation
payments go from one practice to
the other. Thus, by voting with their
feet, patients drive improvements in
standards. Patients under this
market approach tend towards the
“better” doctors (as understood by
clients) – those who explain
treatments; provide comfortable
premises; emphasise courtesy; carry
out home visits etc. Capitation is
therefore an incentive for doctors to
focus on patients and quality
improvement.
7
WONCA
News
FEATURE STORIES
From 2000, FGPs extended from pilot areas to cover
all urban districts and population centres. Recent
survey evaluations indicate strong consumer
satisfaction with FGPs.
Family Doctors surveyed responded positively to the
new system. Family Doctors valued the autonomy and
increased clinical scope. Previously, their focus had
been narrowly preventive; now treatment and holistic
care are central aspects. The model has also increased
Family Doctors’ status, reinforced by ongoing
information campaigns.
FGP workload has also changed since the start
of the model with increases in clinic and home
visits, pointing to greater utilization of services.
Comparing a 2003 survey with a 1999 pre-model
baseline shows how practices and workloads have
changed.
•Excessive administrative work with numerous
government forms and statistics. This takes time
away from patient centered work. The aim is to
reduce paperwork by eliminating most forms and
developing a Minimum Data Set.
Mongolia’s relative success to date in establishing a
General Practice system provides valuable lessons for
former Soviet influenced systems in Central Asia
attempting to develop primary care. First, by putting
General Practice at the centre of the reforms, Mongolia
has been able to advance health sector change overall
by coalescing all the necessary elements into an
integrated package.
Second, earmarked funding was used to cover
training, equipment, acquisition of premises and
comprehensive implementation of the FGP program,
Table 1: Changes in FGP activities 1999 - 2003
FGP variables
1999 survey
2003 survey
Patients registered per doctor
790
1580
Clinic visits per day
18.8 (10.1 Poor: 8.7 Non-Poor)41.5 (23.4 Poor: 18.1 Non-Poor)
Home visits per day
9 (5 Poor: 4 Non-Poor)
21.5 (12.5 Poor: 9 Non-Poor)
Referrals per week
9
12
Patient education activities
50% of surveyed practices
100% of surveyed practices
Quality improvement activities
45% of surveyed practices
100% of surveyed practices
Continuing Medical Education activities
< 10% of surveyed practices
100% of surveyed practices
Source: FGP Surveys 1999 and 2003.
Generally positive results notwithstanding, problems
still exist in implementing the FGP model. Major current
concerns include:
•Delays in training. Mongolian logistics make
decentralized training difficult and the Training
Program has slowed in some areas. One solution is
to establish new groups of trainers to fast track
training
•Lack of clarity around the FGP legal and tax status
sometimes leading to problems with tax agencies.
Many now recognize the need to strengthen the FGP
legal basis and various regulatory amendments are
underway.
•Local authorities using the Contract to “control”
FGPs. To redress this, an information package for
local officials has been developed to help to change
attitude towards FGPs.
from pilot phase to nationwide extension.
Finally, health restructuring and development of
primary care has received continued and broad ranging
bipartisan support across the political spectrum for the
reform process.
The Government remains committed to primary
health care, but ongoing financial support will be an
ongoing strategic issue for Mongolia. The future
emphasis also needs to be on quality and continuous
improvement. Continuing education for Family Doctors is
now a condition of licensing and all doctors must show
commitment to ongoing development. Another
important objective for Mongolian Family Doctors is to
enhance their position as the community’s first point of
contact with the health care system.
Important organizations for advancing General
Practice are the Mongolian Association of Family
Doctors, aimed at supporting FGP education and the
WONCA
