Family Medicine and WONCA in the Asia Pacific Region – New Horizons and New Challenges

March 10, 2015


Thank you to Professor Tai-Yuan Chui as chair of the host organizing committee, and to President Meng-Chih Lee and to all the members of the Taiwan Association of Family Medicine, for bringing us all to Taipei for our 2015 WONCA Asia Pacific Regional Conference.  Thank you to our WONCA Asia Pacific Regional President, Professor JK Lee, and the hardworking members of our Asia Pacific executive. I acknowledge the presence of our WONCA President elect, Professor Amanda Howe, our Honorary Treasurer, Dr Donald Li, Member at Large, Dr Karen Flegg, and our Chief Executive Officer, Dr Garth Manning.  I also acknowledge all our family medicine colleagues from Chinese Taipei, from across the Asia Pacific Region and from around the world.

The President of WONCA is not allowed to have a favorite region, but, as a member of the Asia Pacific Region for the past 30 years, I am very proud of the work our member organisations are doing in this part of the world, and I am going to share some examples with you.

The greatest privilege of being WONCA president is that I am invited to visit family doctors in their clinics all around the world to gain insights into the challenges that our colleagues face in providing the best possible care to the people of their local communities.  During this presentation I will share with you stories from some of the remarkable family doctors I have met over the past year and a half as WONCA president.

One of my very first invitations as WONCA president was to visit Chinese Taipei in July 2013.  During that visit I travelled to the beautiful rural north coastal region of this island and met Dr James Heng-Chia Pen.  James is a rural family doctor and works at the Jinshan District Public Health Center.  Like many of us, as well as providing an excellent clinical service to the people of his community and surrounding district, James is a dedicated teacher of medical students and family medicine trainees. 

James and our other colleagues in the images I will show you have agreed that I can share their images with you.  The patients you see in these images are other family doctor colleagues role-playing, so that there is no breach of patient confidentiality.

I need to begin with a word about words. When I say family doctor, I mean you. Whether you call yourself a general practitioner, or a family physician, or a primary care doctor. Whatever you call yourself, and whatever your patients call you, when I say family doctor I mean you, my sisters and my brothers in family medicine.  The language we use to describe who we are differs from place to place.  What matters is the common work that we do, the vision that we share, the outcomes that we achieve for our patients and their families, and for our communities.

Our global WONCA executive has three main challenges. First, we are committed to better understand the strength of each of our member organisations in each region, and to expand WONCA’s influence by supporting the development of new member organisations in more low- and middle-income nations, including in the Asia Pacific Region.

Second, recognizing the importance of the next generation of family doctors, we are committed to supporting the next generation of family doctors through the development of young family doctor movements in all seven regions of the world, and through the appointment of a family doctor to represent young family doctors on the WONCA executive.

And third, we care committed to strengthening WONCA’s work with the World Health Organization at global and regional levels to expand the role of family medicine in strengthening primary health care in all countries and supporting universal health coverage, and to ensure that each country has a well-trained and supported family medicine workforce.

Our medical schools shape our future doctors, and in so doing shape our health systems. Doctors are granted substantial privileges and resources by our societies. These privileges imply a corresponding responsibility to participate in improving health systems and training the next generation of doctors to meet the needs of our societies.

WONCA is part of a global movement to transform medical education by making it more socially accountable.  This involves seeking a commitment by the world’s medical schools to direct their education, research and service activities towards the priority health concerns of the community, region or nation that they serve. Such responsibility to society should guide every medical school and the scope of their activities. 

Late last year I visited Cuba. In an extraordinary contribution to global health, Cuba’s Medical School of Latin America (Escuela Latinoamericana de Medicina – ELAM) over the past 15 years has trained 27,000 young people from disadvantaged communities in 65 countries to become doctors. It is clear that, while many wealthy nations source doctors and nurses from other countries to meet the health care needs of their populations, what they should be doing is following Cuba’s example and training more health care professionals than they need and making a net contribution to the rest of the world. If a small, developing nation like Cuba can make extraordinary contributions like this to humanity, why can’t other nations?

Cuba’s Medical School of Latin America is part of a global movement of socially accountable medical schools dedicated to training medical students to better meet the specific needs of the communities they will serve as doctors.  The medical education provided in Cuba emphasises the importance of primary care, and family practice teams are the basis of Cuba’s excellent system of universal health coverage.

Many medical schools around the world have seen the light and found ways to make a positive impact, especially towards health equity.  Our medical schools need to select students from among the members of marginalized communities in both urban and rural locations, and prepare all our medical students to work where they are most needed.  WONCA is proud to support the socially accountable medical school movement underway around the world.  We are also pleased to see a greatly heightened interest among many medical students in global health and primary care and the contributions we can all make towards health equity and universal health coverage.

WONCA was founded in 1972 by 18 colleges and academies of general practice and family medicine from around the world; 18 organisations with members sharing a commitment to improving the quality of life of the peoples of the world through fostering high standards of care in general practice/family medicine, and through respect for universal human rights.

In the words of our very first WONCA president, Australian Dr Monty Kent Hughes, speaking to the first WONCA world council held in Melbourne in 1972: “the future of our professional discipline will depend on our ability to work together in the service of humanity.” 

Forty-three years later WONCA’s mission remains the same and WONCA, through our member organisations, now has a membership of over half a million family doctors in 140 countries around the world. The 500,000 family doctors represented by WONCA each year have over 2 and a half billion consultations with our patients.  Two a half billion.  That’s the scope of our current work and our influence.

But we need to do more. WONCA is an inclusive organization.  We need to work to ensure that every family doctor, every GP, every primary care doctor, joins us in our commitment to deliver high quality primary care to our patients and communities.

We also expect our members to do their part and share our commitment to education and training and a commitment to quality care.  And while we recognize that there are excellent family doctors in the community who may not have received formal postgraduate training in family medicine, and we welcome these doctors as members of WONCA, we believe that these doctors need to share our commitment to continuing professional development and continuing medical education.  We also believe that all new medical graduates should receive formal postgraduate training before being eligible to practice as family doctors in the community.  Every person, every family in every community deserves to receive high quality medical care from a well-trained and qualified family doctor.  This is why WONCA was established. 

We also need to expand our commitment to the education and training of family doctors and quality care and primary care research to the nations of the world where WONCA does not yet have a presence, and our Asia Pacific Regional President, JK Lee, is working with colleagues across this region to support the develop of new organisations of family doctors and new family medicine training programs.

Why do we do all this?  Because family medicine is important. 

Because the evidence is clear that health systems based on strong primary care, which includes strong family medicine, are the most efficient, equitable and cost-effective.

Because strong primary care is the best way to improve the health of individuals, families and communities. 

Because we believe every family should have a family doctor who the members of each family can trust for their medical care and advice. 

Because family doctors and the members of our primary care teams are part of the social fabric of our societies and we work together to keep the fabric of health care together.

We are seeing some great developments in family medicine in this region of the world.  Our WONCA World Council meeting in 2013 endorsed WONCA’s new global standards for postgraduate family medicine education, developed by our working party on education.  These standards provide a benchmark for those developing training programs for family doctors around the world. Our CEO, Garth Manning, has developed a system to accredit family medicine training programs against WONCA’s global standards and to provide formal accreditation.

Last year the Shanghai Medical College of Fudan University, led by Professor Shanzhu Zhu became the first Family Medicine Training Program in the world to receive accreditation against the WONCA Global Standards for Postgraduate Family Medicine Education. This is a wonderful achievement and I was recently honoured to present a certificate of accreditation to representatives of this training program in the presence of the Director-General of the World Health Organization, Dr Margaret Chan.  I hope that many other family medicine training programs across this region will step up to the challenge of meeting WONCA’s global accreditation standards.

We have many great family medicine training programs in this region. Last year I visited the Capital Medical University training program in Beijing and was taken to training practices both in Beijing, but also in rural areas.

This is Dr Yin Shoulong, a rural general practitioner in Tai Shitun Village in China, who hosted my visit to his clinic last year. Tai Shitun is in the Mi Yun District, two hours drive north of Beijing and a very different world from the densely populated metropolis to the south.

Dr Yin lives in a typical Chinese rural village house built around a central courtyard with his clinic occupying one side of his home.  His patients are from his farming community and many are impoverished and elderly and frail. 

Dr Yin has devoted his career to supporting the health and well being of the people of his village and the surrounding district.  Recently he has become involved in providing experience in rural medicine to young family medicine trainees on rotation from the Capital Medical University in Beijing.  He is part of the primary care revolution underway across China.

China has embarked on a massive drive to train and recruit up to 400,000 general practitioners in the next seven years in order to reform the country’s health system to meet the current and future needs of the population, especially the 800,000,000 people living in rural areas.

The reforms underway in China will have major implications for the rest of the world, and especially for those countries where family medicine is not yet well established.  The Chinese Government recognizes that one of the biggest challenges is training the family doctor workforce to meet the needs of rural China.  We cannot tackle health equity without addressing the health needs of people living in rural areas right around the world.  If the rural challenges in China can be met with success, then this should provide lessons that will flow to many other parts of the world facing the challenge of providing universal health coverage. This bold initiative by China needs to be supported by solid research and evaluation.

Last year WONCA released our new Rural Medical Education Guidebook which reinforces our commitment to ensuring we meet the health care needs of the 50% of the world’s population living in rural areas, as well as those in urban areas.

While our clinics may be different from country to country, what is important is the way we are the same – through our commitment to comprehensive, continuing, coordinated whole person care. Through care that is person-centred, and family and community-oriented.  Through first-contact care, acute care, chronic disease management, prevention and health promotion.  And through our understanding of the interplay between population health and the health of individuals in our communities.

One of the founders of WONCA was Dr Prakash Chand Bhatla from India, who once wrote that “Every national health program should involve general practitioners. Education and motivation of the community has to be done on a personal basis. And who is nearer to the community than the family doctor?”

Who is nearer to the community than the family doctor? As family doctors we need to be engaged by our governments and international health organisations in the planning and delivery of national and local health programs. Family doctors are part of each local community and have the trust of the members of their local community and can be part of ensuring the successful delivery of health care programs, especially to the most vulnerable members of our populations.

WONCA calls for a family doctor for every family. This means that every family has access to a caring committed family doctor working with other primary health care providers, including dedicated nurses and community health workers, to provide comprehensive continuing care to all people.

In April last year I visited Indonesia and this rural family medicine clinic, called a puskesmas, or Primary Health Center, on the island of Timor, about an hour north of the main city of Kupang in West Timor. 

The amazing young woman family doctor who leads this clinic delivers primary care services to the members of the local community and also runs a birthing centre which has led to a substantial reduction in the rate of infant and maternal mortality in the region.

But this clinic has serious challenges due to its isolation.  The electricity supply is patchy at best and blackouts are frequent.  There is no running water.  Water for the clinic is drawn from a well.  I had never drawn water from a well before and enjoyed the novelty of hauling up buckets of fresh clear water from deep below the earth’s surface.  I was informed me that the novelty wears off very quickly.

There are those who say that family medicine has no real role to play in low and middle-income countries.   Well WONCA has blown that idea out of the water. 

In 2013 Dr Margaret Chan launched WONCA’s new guidebook on the contribution of family medicine to improving health systems.  The guidebook includes a chapter from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many nations of this region including China and Thailand.  And there is a chapter outlining the remarkable work that is underway across Africa to strengthen family medicine, especially involving WONCA member organisations within Africa supporting developments in neighbouring nations. 

What these developments demonstrate is the need to strengthen the whole primary health care workforce, including family doctors, community nurses, community health workers, and traditional birthing assistants, and support us working together to deliver appropriate care to all people.  People in low income countries still want and deserve access to health care, access to caring clinicians, access to life saving medications.

We also need to embrace the concept of reverse innovation.  What can health systems in high-income countries learn from the health systems in lower income countries?  It is something that each of who spends time working in another health system in another country learns very quickly. 

It is also a lesson that was emphasised by one of our past WONCA presidents, Dr Rajakumar from Malaysia, who once wrote that: “Experience in different health systems will make us better doctors and better human beings.” 

Dr Rajakumar’s name lives on through the Rajakumar Young Family Doctor Movement, our WONCA organisation for young doctors and medical students in the Asia Pacific region.

The Rajakumar Movement is led by Shin Yoshida from Japan, and builds on the great work of founder Naomi Harris from Austraia. Our young family doctors are embracing the mission of WONCA and our commitment to universal health coverage.

Universal health coverage does not mean meeting the needs of 80% of the population – it means meeting the challenge of ensuring that health care is available to everybody. 

One of the countries leading the world in strengthening family medicine to ensure that health care is available to all people is Brazil.  Brazil is the global leader in addressing universal health coverage through family health teams of doctors, nurses and community health workers.  Recently, in one of the favelas, or shanty towns, of Rio de Janeiro, I had the opportunity to visit one of the primary care clinics established to meet the health care needs of the poorest people of that great city.

At this family medicine clinic I met young family doctor Euclides Colaço and his colleagues. This is Euclides in one of the bright consulting rooms in this clinic.  Euclides works with a family medicine resident, two nurses and six community agents, or community health workers, providing comprehensive clinic-based and home-based care as a team to a defined population of 4,500 people. 

This visit allowed me to see the renowned “Family Health Team” model of Brazil in action.  Here is Euclides and one of the community health agents in his team in front of a map showing the geographic area they are responsible for. They are expected to know about the health status of every single person living in that area.

The community health agents in Brazil have a key role to play; they go out into the community and visit everybody and bring those in need of assessment and assistance to the clinic, or the community health agents escort the doctor or one of the nurses on a home visit.  This is true comprehensive primary care delivered to an entire community.  And there are over 33,000 such teams in operation across the entirety of Brazil.  It is a very impressive model.  I hope many of you will attend our next WONCA world conference in November next year in Rio in Brazil, and see this for yourself.

So what is on the horizon?  In 2000 the United Nations adopted the Millennium Development Goals, called the MDGs; eight aspirational goals, agreed by all the world’s countries, which aimed to halve extreme poverty rates by the end of 2015, provide primary school education to all children, empower women, reduce infant and maternal mortality, combat HIV, tuberculosis and malaria, and ensure the sustainability of our environment.

The MDGs have galvanized unprecedented efforts across the globe to meet the needs of the world’s poorest people.  And progress has been impressive with rates of extreme poverty halved, and significant reductions in infant and maternal mortality and HIV infection rates in many countries, with millions of lives saved through reductions in preventable deaths. 

It is clear that success in these areas has occurred only when there has been both national and local ownership to give the MDGs traction, and the importance of allowing the local adaptation of the MDGs to target local conditions.  And it is no surprise that this process has reinforced that developing countries want capacity, not charity – and that building self-reliance is critical; this is a key role for WONCA in our support through our member organisations for education and training for the members of the family medicine workforce in every nation.

The MDGs also came in for criticism because of what is missing. They didn’t have a specific focus on rural communities, they didn’t tackle the need to strengthen the primary care basis of each country’s health system, or to tackle chronic disease or mental health, or to address the social determinants of health, or to ensure universal health care access for all people in both rural and urban areas. 

Each nation needs a strong system of primary care.  We have seen the terrible consequences when a nation faces a serious health challenge without well-developed primary care and the capacity to respond swiftly to health threats. This is what happened during the recent crisis in West Africa. Those nations without strong established primary health care systems experienced the greatest challenges and significant loss of life.

Strengthening primary care must continue to be addressed beyond 2015. WONCA needs to ensure the clear voice of family medicine is heard on behalf of our patients and communities. ?We need to be clear about our role as family doctors in working with our patients and communities to increase life expectancy and achieve equitable health outcomes. ?

We are now facing a new horizon.  The United Nation has developed the Sustainable Development Goals and targets, or SDGs, which will guide the global development agenda post-2015.

In his inspiring address to the United Nations General Assembly last December, Secretary-General Ban-Ki Moon, discussed “The road to dignity by 2030: ending poverty, transforming all lives, and protecting the planet.”

The United Nations Secretary-General made a call to action to transform our world beyond 2015.  In his words “we are at a historic crossroads...  With our globalized economy and sophisticated technology, we can decide to end the age-old ills of extreme poverty and hunger.  Or we can continue to degrade our planet and allow intolerable inequalities to sow bitterness and despair.  Our ambition is to achieve sustainable development for all.”

He goes on to state that the 1.8 billion young people on the planet “are the torchbearers for the next sustainable development agenda through 2030.  We must ensure this transition, while protecting the planet, leaves no one behind.  We have a shared responsibility to embark on a path to inclusive and shared prosperity in a peaceful and resilient world, where human rights and the rule of law are upheld.  Transformation is the watchword.  At this moment in time, we are called upon to lead and act with courage.  We are called upon to embrace change.  Change in our societies.  Change in the management of our economies.  Change in our relationship with our one and only planet.”

The United Nations has adopted 17 Sustainable Development Goals.  There is only one health specific goal, number 3: “Ensure healthy lives and promote well-being for all at all ages.”  But each of the 17 new goals has an impact on global health and the health of individuals.

The Sustainable Development Goals are brought together into six integrated elements.  The element on People is to “ensure healthy lives, knowledge and the inclusion of women and children’.

The Secretary-General advises, “Millions of people, especially women and children, have been left behind in the wake of unfinished work of the Millennium Development Goals.  We must ensure that women and also youth and children have access to the full range of health services.  We must ensure zero tolerance of violence against or exploitation of women and girls … The agenda must address universal health-care coverage, access and affordability; end preventable maternal and child deaths and malnutrition; ensure the availability of essential medicines; realize women’s sexual and reproductive health and reproductive rights; ensure immunization coverage; eradicate malaria and realize the vision of a future free of AIDS and tuberculosis; reduce the burden of non-communicable diseases, including mental illness, and of nervous system injuries and road accidents; and promote healthy behaviours, including those related to water, sanitation and hygiene.”

These are bold ambitions, and as global citizens, family doctors must play our part.  People-centred care is a core component of universal health coverage, and there will be an increasing role for family medicine over the coming years in many countries to ensure this happens.  We need to support the focus on the social determinants of health and work to ensure marginalized populations, those groups of people in our communities most at risk of poor health, are not excluded from health care.

You and I know that the same model of care is not going to work for each community.  Which is why family medicine is so important.  We have the capacity to adapt to our community needs.

Fortunately one of the greatest strengths of the people working in family medicine is our diversity, our community leadership, our resilience and our unwavering commitment to our patients and our communities. These are qualities that we need to reinforce and cherish. 

Family medicine has the power to play a transformative role in the shaping of societies.  We have the power to tackle disparities and transform the world we live in but this will take a lot of hard work. 

WHO Director General Dr Margaret Chan has become a staunch supporter of family medicine.  At a meeting hosted by Dr Donald Li in Hong Kong a year ago Dr Chan stood up and proclaimed “I love family medicine” 

Dr Chan has recognised the value of family medicine and our contribution to primary health care. Dr Chan has also recognised that primary care is not cheap and must not be a “B-team” version of health care delivery. 

In order to provide universal coverage, our countries need to stem the costs of health care, and can do so through increasing investment in community-based health services.  And at the same time there must be a movement of funding from hospitals to the community, and especially to rural communities, rather then expecting more community-based care to be delivered with no increase in resources.

We need to continue our work with our global partners, the WHO, the World Bank and others to bring high quality primary care to the 1 billion people on this planet who currently have no access to any health care at all, many living in rural areas.

Last year, in a historic move, WONCA has established a new working party on health issues for Indigenous people and minority groups, led by Dr Tane Taylor from New Zealand.  And just a few months ago Tane was here in Taipei at a conference of the Pacific Region Indigenous Doctors Association, sharing the work of WONCA and gaining insights into new ways to better support the health of Indigenous people and members of other minority groups.

The paramount responsibility of WONCA, and of each of our member organisations, is to our patients and our communities.  Family doctors, no matter where we work, ensure that health is affordable, safe, appropriate and equitable. 

If we are going to have an influence on national health planning then we need skills in leadership.  It is one of the reasons why WONCA is so committed to supporting young family doctors around the world.

As family doctors we need to ensure that those groups of people in our communities most at risk of poor health, the most marginalized, the most vulnerable, are not excluded from access to health care.

Every human being should be treated with dignity and respect.  And as health professionals we should be leading by example.

Something Iona Heath, former president of the Royal College of General Practitioners in the United Kingdom and a great advocate for health equity, said a few years ago really struck a chord with me, “I believe that general practice/family medicine is a force for good throughout the world.”

Through my work as WONCA president, I have been impressed with the commitment of family doctors to human rights issues, embodied in this image by our wonderful colleague, Ryuki Kassai from Japan.  I am convinced that family doctors right around the world care about human rights; the basic expectations we all have about how we and our families and all people should be treated. 

I am pleased that during my time as WONCA president, our organization has established a new global group with a focus on health equity, bringing passionate family doctors from around the world together, through the marvels of the digital age, to share experiences and develop global policy which we can use in our advocacy with the WHO and the nations of the world.

As doctors we can be proud of our profession. Each of us has a set of values and principles that determine how we behave as ethical medical practitioners. Each of us has the potential to be a role model for future doctors, and to contribute our own lasting legacy through the examples that we set in the way that we live our lives and the way we practise medicine.

The challenges we face also test our own resilience. While we continue to innovate within our practices and within our communities to ensure that our patients receive the highest possible standards of care, it is critical that we also continue to innovate to find ways to support each other as well. 

Many family doctors work under very difficult conditions, often without the resources needed to do their jobs. We work long hours with arduous demands on our time.  Our resilience is tested regularly, and many of us feel unappreciated. And we don't often hear the words thank you.

This is why WONCA has established World Family Doctor Day, held on May 19 each year, to acknowledge the important work we do.  World Family Doctor Day allows us to say thank you for your commitment every day to providing health care to the people of your communities who trust you for their medical care and advice. 

Our colleagues here in Chinese Taipei have been among the family doctor organisations that have embraced World Family Doctor Day.

So today, on behalf of the two and a half billion people around the world who benefited from your care and support over the past year I say thank you. Thank you for your commitment to being a great rural family doctor.  Thank you for the great and important work you do.  And thank you all for the health care you provide each day to the people who trust you for their health care and advice.  Together we are changing the world.


Professor Michael Kidd
World Organization of Family Doctors (WONCA)
March 5, 2015
Chinese Taipei