WONCA President's address to the 2013 annual conference of the Royal College of General Practitioners

October 07, 2013

A worldwide approach to progressing primary care medicine

My congratulations to the members and staff of The Royal College of General Practitioners (RCGP) on the occasion of your annual primary care conference, and thank you for the opportunity to speak with you about progressing primary care medicine around the world.  

WONCA, the World Organization of Family Doctors, has come a long way since it was established in 1972 by 18 national family doctor organisations including the RCGP. 

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

And those words have guided us ever since. 

WONCA represents you and your college at a global level.  WONCA advocates for the important work you do every day in meeting the health care needs of your patients and your communities.

WONCA, through our member organisations, now represents over 400,000 GPs and other family doctors in over 130 countries and territories around the world.  The 400,000 family doctors represented by WONCA, and including the members of the RCGP, each year have over two billion consultations with our patients. Two billion. That’s the scope of our current work and our influence.

But we need to do more. We need to continue to strengthen our global work with the World Health Organization. We need to support the development of GP education and training in those 80 countries where it is not yet present.  And we need to support the next generation of GPs, our recent graduates and trainees in each region of the world.

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

At a time of rapid change and social unrest and conflict in many parts of our world, general practice provides some comfort to our patients, our communities and our nations.  

We can provide comfort because we are used to dealing with complexity and uncertainty.  

We provide comfort at a time when uncertainty is increasing for our patients who are faced with a barrage of choices and options and a wealth of misinformation thanks to the Internet.  

We provide comfort to our nations, which are facing uncertainty about their capacity to provide health care to all people and know that they should be keeping people out of expensive hospitals, but are not sure how to do this.  

At this time of uncertainty about the future of health care, the role of the GP continues to grow around the world.  And this need for comfort moves our global organization into an increasingly strategic roles with the World Health Organization and other global health organisations.

Last week I attended the United Nations General Assembly in New York, representing WONCA and global general practice at a summit called to examine progress in meeting the Millennium Development Goals, and to discuss what happens beyond the end of 2015 when the set of Millennium Development Goals concludes.  

You are no doubt aware of the Millennium Development Goals.  They are eight aspirational goals, agreed by all the world’s countries in 2000, which aim to halve extreme poverty rates by 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 Millennium Development Goals 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 already ahead of schedule, 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.  Some of the coordinated partnerships created to achieve these gains have been wonderful.

Examples of successful global programs include the United Nation’s Every Woman Every Child initiative, which has been adopted by governments in many countries and includes ensuring access for women and children to quality health care facilities in the community and skilled community-based health workers. 

Another is the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has led to a decline in new HIV infections in many of the countries most affected by the HIV epidemic.

The United Nations Millennium Development Goals debated actions needed to further diminish global poverty, improve health worldwide, and achieve sustainability of the environment, and provided recommendations for consideration by the leaders of the nations of the world.

Among the key messages that I took away from the summit was how success has occurred when there has been national and local ownership to give the Millennium Development Goals traction, and also the importance of allowing the local adaptation of the Millennium Development Goals to target local conditions.  

And it was no surprise to be reminded that low income 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 primary care workforce in every nation.

High-level statements and commitments are one part of the solution, but they are meaningless without effective in-country action. 

Part of the challenge with the Millennium Development Goals has been in their, sometimes patchy, implementation. Often initiatives to support the Millennium Development Goals in a country have failed to engage with the existing primary care workforce, setting up parallel programs that can diminish, rather than strengthen primary care provision.

The Millennium Development Goals have also come in for some criticism because of what is missing. They don’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.  This is part of the challenge looking beyond 2015.  What should be the focus of the next set of global priorities and targets?

As the world debates what happens next, with the clamour of thousands of interest groups and self-interested industries, WONCA and our member organisations, including the RCGP, need to ensure the clear voice of primary care on behalf of our patients and communities continues to be heard during these debates. 

We need to be clear about our role as GPs in working with our patients and communities to increase life expectancy and achieve equitable outcomes. 

And we need to support the focus on the social determinants of health and how we ensure marginalized populations, those groups of people in our communities most at risk of poor health, are not excluded from health care. 

To support our important work we need strong standards for clinical care and standards for education and training and we need strong government and community support.

Governments need to value our generalist traditions.  I’ve been watching the prime minister’s pronouncements this week about general practice and the college’s response, and while as a visitor to this country I wouldn’t dream of expressing an opinion, it is obvious to everyone that workforce arrangements need to support the generalist approach to high quality primary medical care.

What percentage of our medical graduates do we need to train in each country in the specialty of general practice?  If we are to meet the true health needs of our communities, in most of our countries it is likely to be at least 50% and probably more.  You might like to reflect on the current percentage in this country.  Many nations continue to train large numbers of consultant specialists and sub-specialists way beyond their nation’s needs. 

We also have an unbalanced distribution of our primary care medical workforce around the world.  There are roles that the RCGP and WONCA can play in addressing the redistribution of our global workforce.  

How do we support GPs who would like to spend part of their career working in other countries?  How do we support and encourage GPs to spend part of their career working in rural and remote locations?  How do we support and encourage GPs to spend at least part of their careers working with disadvantaged and vulnerable communities?  

A specific focus of this year’s United Nations General Assembly was on people with disability, and how people with disability are being excluded from a number of the initiatives set in place in many countries to meet the Millennium Development Goals.  

People with disabilities make up an estimated 15 % of the world’s population, around one billion people.  At least 80 % of people with disability live in developing countries and are at greater risk of living in absolute poverty due to their exclusion from equitable access to resources such as education, employment, health care, and social and legal support systems. Think about the challenges that must face a person who is blind or deaf or unable to walk in some of the world’s poorest nations.

As GPs we provide care and we are advocates for all our patients, and especially for those who are most marginalized or disadvantaged in our communities.  We have a responsibility to ensure that our services are accessible and available to everybody, including those with disabilities.

The global health policy pendulum swang too far in its focus on high technology tertiary care, but is now swinging back to a focus on primary care and universal coverage.  And for very good reasons. 

Universal health coverage has been part of the charter of the United Nations since 1948.  And universal coverage does not mean meeting the needs of 80% of a nation’s population – it means ensuring that health care is available to everybody.  It’s a great lesson shared by the United Kingdom with the rest of the world.

People-centred care is a core component of universal health coverage, and there will be an increasing role for general practice over the coming years in many countries to ensure this happens. We also need to see a rebalance of resources – as GPs we are skilled and dedicated but we can’t continue to do more and more with less and less.  We need to see some rebalance with resources moving from our tertiary services into primary care. 

There are those who say that general practice/family medicine has no real role to play in low and middle-income countries.   Well we have blown that notion out of the water.  In June this year, the director-general of the World Health Organization, Dr Margaret Chan, launched the new edition of the WONCA WHO publication on the contribution of family medicine to improving health systems. 

The guidebook includes contributions from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many middle-income nations including Brazil, China, Thailand and countries in the Middle East.  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 health care workforce, including GPs, community nurses, community health workers, and traditional birthing assistants, and support the primary care team 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.  

The digital world also provides a lot of challenges.  In our asynchronous world, how do we achieve continuity of care?  

We need to embrace the opportunities provided by new technology.  And this is nothing to be afraid of as British GPs have shown the world.  As GPs we are experts at adopting innovations into our practice and acting as translation agents for new technology. We are used to working quickly. We are used to change. We can accommodate innovation quickly when we see a direct benefit to the care of our patients.

Something your immediate past president, Dr Iona Heath 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.”

I am impressed with the commitment of GPs to human rights issues.  I am convinced that as GPs we care about human rights.  The basic expectations we all have about how we and our families and all people should be treated.  

As GPs we have social responsibilities. Each of us needs to be an advocate for social justice and human rights.

We need to stand up for freedom and justice and peace.  1.5 billion people live in countries affected by violent conflict with the associated terrible immediate and longer-term health consequences.

We need to speak out for what is right, to say “this is not OK”, and in so doing contribute to social change, both locally and globally.

And we need to contribute towards ensuring equity of access to health care – “a fair go for everyone”.  Are you familiar with the term “a fair go”?  It is an Australian expression meaning that we treat everyone equally.  

And we need to care for the health of our planet as well as the health of our patients.  What is good for the climate is also good for our patient’s health – reducing obesity, increasing physical activity and healthy improvements in diet. 

And why do I say that we should focus on these social issues.  It is because if we, as GPs, with our privileged position in society, and our access to pretty much the entire population in our communities, don’t stand up for these things, who will?

I am going to finish by paying tribute to the many contributions of the Royal College of General Practitioners is making to progressing primary care medicine around the world.

I commend your council, your international committee, your dedicated staff and the many individual members of the college involved in supporting global improvements in clinical standards and education and training in general practice/family medicine in so many parts of the world.

WONCA has been blessed to have your immediate past president, Dr Iona Heath, as a member of the WONCA world executive over the past 6 years.  As WONCA president-elect and now president I have had the opportunity to work closely with the college leadership, including your chair, Dr Clare Gerada, your president, Professor Mike Pringle, your incoming chair, Dr Maureen Baker, your international committee chair, Professor Val Wass, and the immediate past president of WONCA Europe, Dr Tony Mathie.

The RCGP is a major contributor to global family medicine.  The impact of the MRCGP International program has been extraordinary and is supporting doctors in Brunei, the United Arab Emirates, Egypt, Kuwait, Malta, Oman, India, Pakistan, Bangladesh and Sri Lanka, as well as doctors from many other countries who are international members of the RCGP. 

And the impact continues to expand.  In July I was with Clare and Mike in China providing advice to the government of the world’s most populous country which is aiming to train an additional 400,000 family doctors by 2020 and is seeking support and advice from the RCGP and other leading GP colleges and academies from around the world. It seems wherever I am in the world, I only have to turn around to see the RCGP in action. 

I want to say how impressed I am with the work the college is doing with your new program to support primary healthcare workers in Sierra Leone.  Working in partnership, supporting our colleagues throughout Africa is a key focus of the work of WONCA and I look forward to providing my personal support to your international programs in Africa over the coming three years.  This is critical work and whatever I can do to support you, I will.

Many individual members of the RCGP are active in global health education, research and community development initiatives, including many of your leaders in academic general practice.  And so are many of your young doctors.  We are fortunate to have RCGP member, Dr Luisa Pettigrew, as WONCA’s new liaison person to the World Health Organization.  And we have recruited RCGP member and past staff member, Dr Garth Manning, as our new CEO for WONCA.

And finally, of course your Honorary Secretary, Dr Amanda Howe, was elected as president-elect of WONCA and will take over from me as WONCA president in November 2016.  Amanda’s presidency will be historic as she will be the first woman president in the history of the World Organization of Family Doctors.  And about time too.

I congratulate you all on the great global commitments of your college, and on your personal commitment to making a difference to the lives of the people of your nation and our world.  I look forward to our work together during my time as WONCA president.  

Michael Kidd
World Organization of Family Doctors (WONCA) 
October 5, 2013