Quality and Equity and Global Family Medicine: perspectives from Latin America

March 20, 2015

I have been a frequent visitor to this region over the past few years, and I am very proud of the work our WONCA member organisations are doing in this part of the world. I am going to share some examples with you as I outline ways family medicine is ensuring both quality and equity in global health.

The greatest privilege of being WONCA president is that I am invited to visit family doctors in their clinics in countries all around the world to gain insights into the challenges that each of us faces in providing the best possible care to the people of our local communities.

Family doctors like Katia Medina Matos who lives in Lechuga Village, a small rural community on the island of Cuba.  Katia works in partnership with a community nurse, Gladys Garnier Martinez, and together Katia and Gladys provide health care to 844 people based in four rural villages. They know everybody in these four communities. Working together they see 40 patients on average each day, including up to 15 in their own homes.  And how do they get from village to village?  They walk.  Katia and Gladys are supported in their important work by the staff of the multidisciplinary polyclinic in the nearby rural town of Managua.

I met Katia and Gladys on a recent visit to Cuba. As you all know, Cuba is a small island nation and it has a health system based on primary care that is the envy of many much more wealthy countries.  In Cuba 36,000 family doctors provide health care to the entire community of 11 million people.  Every person has their own family doctor and primary care nurse team.  And this includes teams based in 3000 clinics in rural areas, like Katia’s, across the country.

Cuba provides one of the best examples of personalized family medicine, based on quality and equity, ensuring every member of the community has access to quality primary health care, delivered by well-trained doctors and nurses.

Every Cuban, including every person living in rural areas, has free access to their own primary health doctor and nurse team.  These teams of a doctor and a nurse have a list of all people in their community, and they are expected to know the health status of everyone in their community, including the elderly, the disabled and the housebound, and they will go to visit these people, rather than expecting them to come to their clinics.  It is a proactive approach to ensure all people, and especially the most vulnerable, are getting access to the health care they need. 

Cuba offers a model of cost-efficient, effective and equitable primary care that can be adapted by many other countries struggling to provide health care coverage to their entire population.

Cuba also trains more primary care doctors than their own country needs and sends missions of family doctor teams to areas of need around the world.  For example, Cuba sent a team of doctors to Haiti during the 2010 earthquake, and Cuba was among the first nations to send medical teams to West Africa following the Ebola outbreak. Cuba supported the new nation of Timor-Leste by sending 300 recent medical graduates to meet the health care needs of the people of Timor-Leste and at the same time trained 300 young people from Timor-Leste in Cuba to become doctors.

Cuba’s Medical School of Latin America (Escuela Latinoamericana de Medicina – ELAM), was established in 1998 and, in an extraordinary contribution to global health, 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. After all, if a small, developing nation like Cuba can make extraordinary contributions like this to humanity, why can’t other nations?

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.

Cuba’s Medical School of Latin America is part of a global movement of socially accountable medical schools, supported by WONCA, and dedicated to training medical students from marginalized communities to better meet the needs of the people they will serve as doctors, with a specific focus on the importance of primary care.  This is equity in action.

Cuba provides us with exciting examples of the potential for family medicine to ensure health coverage for all people in each nation of the world and demonstrates how much we, as family doctors, can achieve by working together.  

This was the message from our very first WONCA president, 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.” 

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.

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, and it includes all of us here today, 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.

WONCA is playing our part in supporting quality and equity in global health, and we have set ourselves 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 all nations of this region, to ensure that all people have access to high quality family medicine.

WONCA’s second challenge, recognizing the importance of the next generation of family doctors, is our commitment 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 young family doctor to represent the world’s young family doctors on the WONCA executive. Over the past 12 months we have seen young family doctor movement established in all seven regions of the world. In this region young family doctors can become involved with WONCA through the Waynakay Movement, and for those from Europe, through the Vasco da Gama Movement.

WONCA’s third challenge is our commitment to strengthen 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. 

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.  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. WONCA has developed a system to accredit family medicine training programs against our global standards.

Last year the Shanghai Medical College of Fudan University 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 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.  We hope that many other family medicine training programs across the world will step up to the challenge of meeting WONCA’s global accreditation standards, like our colleagues in China.

Last year I met 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.

WONCA is committed to supporting rural practice. Last year, at our WONCA rural conference in Gramado in Brazil, 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.

We saw a wonderful example last year of engagement of family doctors with government and international health organisations at the 5th Iberoamericana Summit (or Cumbre) on Family Medicine, convened in Quito in Ecuador by the Ministry of Health of Ecuador, in partnership with the Pan American Health Organization (PAHO) and with WONCA through CIMF (our Iberoamericana Confederation of Family Medicine).

I always knew the Summit was going to be exciting with representation from 20 WONCA member organisations and their governments from across the Iberoamericana region. Delegates shared details of the family medicine-based health reforms and developments underway in many countries across the region. The health system in Ecuador in particular is undergoing some impressive reforms based on strengthening access to family medicine for all people in that country.

The Summit ended with the presentation of “The Quito Letter”, a strong statement expressing commitment to the ongoing development of family medicine across the region. It is notable that the letter was signed by the Ecuador Minister of Public Health, Carina Vance, as well as by PAHO and WONCA, and this is a great credit to our colleagues from across the region and reflects your enduring commitment to the role of family medicine in strengthening the health systems in each of the countries of this region. 

There are those who say that family medicine has no real role to play in low and middle-income countries.   Well WONCA has shown this is not true.

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.  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.” 

This is something our young family doctors are learning, as WONCA supports exchanges between countries by young family doctors. Our young family doctors around the world are embracing the mission of WONCA and our commitment to universal health coverage.

Universal health coverage does not mean meeting the needs of 60% or 80% or 90% of the population – it means meeting the challenge of ensuring that health care is available to everybody. 

One of the countries in this region 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, Inez and 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 we 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 and I hope many of you will attend our next WONCA world conference in November next year in Rio in Brazil, and see this all for yourself.

2015 is a landmark year in global health as we come to the end of the Millennium Development Goals.  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 Ebola 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 set of challenges.  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.”

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.

Our work with the World Health Organization becomes stronger and stronger thanks to the leadership of our WONCA WHO liaison person, Maria-Luisa Pettigrew.  The WHO has released release two interim reports on its new Global Strategy on People-Centred and Integrated Health Services.  WONCA is contributing to the development of this strategy and we led a consultation process that involved hundreds of family doctors from around the world.

This new global strategy aims to provide a compelling vision of a future in which all people have access to health services.   The strategy calls for reorienting care to prioritize primary and community care services. Although greater reference to the fundamental role of family medicine is needed, there is reference to the important role of family practice in countries like Brazil. What I find most remarkable is that this WHO strategy contains 10 quotes; four from patients and carers, two from health care managers, and four from family doctors.  This recognition of the importance of family medicine is long overdue and most welcome. Here are some of the extracts:

“I really value the long term relationship I have with many patients.  I also know their families and the community well.” Female family doctor from the WHO Western Pacific Region.

“We need more support from the government to adopt more family medicine and to increase the budget for primary health care.” Female family doctor from the WHO Eastern Mediterranean Region.

“What I value the most in my work is good relationships with the people the nurses and I care for. We have a post-conflict multi-ethnic population. Once as bad enemies they now sit in my waiting room together and talk and understand each other.” Male family doctor from the WHO Europe Region.

“Politicians need to understand that primary care is the backbone of any health system and getting it right will lead to cost benefits, healthier populations and public faith in the system.” Male family doctor from the WHO Region of the Americas.

There is hope for global health as the world wakes up to the importance of strengthening primary care and the role of the family doctor.  Family medicine has the power to play a transformative role in the shaping of societies.

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.

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.  This is why last year, in a historic move, WONCA established a new working party on health issues for Indigenous people and minority groups.

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.  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 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 you do.  World Family Doctor Day recognises your commitment every day to providing the best quality health care you can to the people of your community.  The member organisations in Latin America have been very active in promoting 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 18, 2015
Montevideo, Uruguay