Table Of ContentThe Contribution of Family Medicine
to Improving Health Systems
A GUIDEBOOK FROM THE
WORLD ORGANIZATION OF FAMILY DOCTORS
Second Edition
Edited by
MICHAEL KIDD
President, World Organization of Family Doctors (WONCA)
Executive Dean, Faculty of Health Sciences, Flinders University, Australia
CHAPTER LEAD AUTHORS
Cynthia Haq, Jan De Maeseneer, Jeffrey Markuns, Hernan Montenegro,
Waris Qidwai, Igor Svab, Wim Van Lerberghe, and Tiago Villanueva
ORIGINAL EDITION AUTHORS
Charles Boelen, Cynthia Haq, Vincent Hunt, Marc Rivo, and Edward Shahady
Foreword by
DR MARGARET CHAN
Director- General
World Health Organization
Boca Raton London New York
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First Edition 2002 (published by WONCA)
© 2013 WONCA
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as the author of this work.
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Contents
List of boxes and tables v
Foreword ix
Executive Summary xi
Glossary xiv
List of contributors xx
1 Meeting people’s health needs 1
1.1 Identifying people’s current and evolving health needs 2
1.2 Responding to people’s health needs 3
1.3 Meeting the challenges and convincing the leadership 6
2 Improving health systems 15
2.1 Values of health systems 15
2.2 Goals of health systems 18
2.3 Functions of health systems 19
2.4 Trends affecting health service delivery 25
2.5 Challenges to optimal health service delivery 29
2.6 Meeting the challenges through primary health care 31
2.7 Strategies for implementing primary health care 32
3 Family doctors in health systems 41
3.1 The nature of family medicine 41
3.2 Family doctors’ contributions to health care 42
3.3 Family doctors as effective clinicians 51
3.4 Family doctors as health care coordinators 62
3.5 Family doctors as leaders, managers, and supervisors 67
4 Education and professional development 75
4.1 What is family medicine education and training? 76
iv CONTENTS
4.2 Why is family medicine education and training different? 88
4.3 How should family medicine education and training be
implemented? 109
4.4 Family medicine teaching programs 129
4.5 Transitioning from education to practice 148
5 Creating a supportive environment for optimal family practice 155
5.1 Promoting positive relationships 156
5.2 Establishing professional organizations for family doctors 165
5.3 Financing primary health care services and family doctors 170
5.4 Improving access to primary care 175
5.5 Supporting primary care research 178
5.6 Enhancing quality of care and outcomes 183
5.7 Moving ahead 192
6 Family medicine in lower- and upper- middle income countries 197
6.1 The Brazilian Unified Health System: primary health care
in action 202
6.2 Promoting universal primary health services in China through
general practice reforms 212
6.3 Family practice progress and prospects in countries of the
Eastern Mediterranean 219
6.4 Family medicine and community orientation as a new approach
of quality primary care in Thailand 231
7 “The African family physician”: development of family medicine
in Africa in the twenty- fi rst century 247
Annexes
A Declaration of Alma- Ata 267
B Reorientation of medical education and medical practice for
health for all 271
C Extract from World Health Report 2008: Primary Health Care –
Now More Than Ever 274
D WHO-W ONCA collaboration 276
Acknowledgments 279
Index 283
List of boxes and tables
Boxes
1.1 Range of contexts where family doctors may work 5
1.2 Scope of practice of family doctors 5
2.1 Compass of interrelated values 18
2.2 Example of a patient presenting for primary care 32
2.3 Partnership pentagon 35
3.1 Definition of general practitioners/family physicians 42
3.2 Underlying principles of family medicine 44
3.3 The JANUS project: family doctors meeting the needs of
tomorrow’s society 45
3.4 How to provide effective and efficient health care services with
family doctors 48
3.5 Profile of the “fi ve- star” doctor 49
3.6 A typical month of health care in the United States 51
3.7 The work of a family doctor in South Africa 54
3.8 Scope of family practice: an analysis in Australia, Germany, and
South Africa 58
3.9 The family doctor’s role in smoking cessation counseling in
Denmark 59
3.10 Coordinated care for a patient with tuberculosis 63
3.11 How to enhance family doctors’ coordination of care 64
3.12 How to increase the community orientation of family doctors
and primary care teams 66
3.13 Practice management for family doctors 68
3.14 Family health program in Brazil 69
3.15 How to enable family doctors to become leaders 70
4.1 Aligning family medicine efforts in Brazil 80
4.2 Using family medicine to enhance local health human resources
in Africa 86
4.3 Longitudinal integrated clerkships 96
v
vi LIST OF BOXES AND TABLES
4.4 Essential elements of communication in medical encounters 106
4.5 Fundamental infrastructure in developing training programs in
family medicine 111
4.6 Establishing family medicine training in the Eastern
Mediterranean Region 112
4.7 Core content of family medicine includes … 114
4.8 A new curriculum in family medicine in Austria 117
4.9 How to establish an academic department of family medicine 120
4.10 How to strengthen an existing department of family medicine 121
4.11 Family medicine in Denmark 122
4.12 EURACT: a regional academy for teachers of general practice
and family medicine 125
4.13 How to enhance the medical school curriculum 132
4.14 How to attract students to careers in family medicine 134
4.15 Renewing postgraduate family medicine education in Canada 136
4.16 Two cases for retraining in family medicine in Southeast Asia 139
4.17 How to provide effective continuing medical education 143
4.18 Bringing together all the components of family medicine training
in Sri Lanka 143
4.19 Checklist for family medicine experiences 145
4.20 Protocol for change in medical education 147
4.21 Applying international standards to family medicine 148
5.1 How family doctors can promote positive relationships with the
community 158
5.2 How family doctors can promote positive relationships with
colleagues 159
5.3 How family doctors can promote positive relationships with
medical schools and academic medical centers 160
5.4 Partnerships between the government and family medicine in the
Philippines 161
5.5 How family doctors can promote positive relationships with
government health authorities 162
5.6 How New Zealand provides a central government- driven, tax-
funded health system with the government as dominant payer
and with support provided by network organizations 162
5.7 How primary health care in Australia has been reformed by the
establishment of local primary health care organizations 163
5.8 General practice is the cornerstone of Danish primary health care 163
LIST OF BOXES AND TABLES vii
5.9 Canadian provincial and territorial health systems have taken
diverse approaches to strengthening primary care delivery 164
5.10 Recent innovations in Dutch health care reforms 164
5.11 Enhancement of family medicine and health care in Poland 169
5.12 Bamako Initiative 174
5.13 Financing strategies to improve primary health care services 175
5.14 How to encourage family doctors to work in medically
disadvantaged areas 178
5.15 Primary care research categories 178
5.16 How to promote primary care research (World Organization of
Family Doctors Kingston conference recommendations) 182
5.17 Ways to promote primary care research 183
5.18 Mission of the World Organization of Family Doctors Working
Party on Quality in Family Medicine 185
5.19 How to improve health care quality 189
5.20 Family medicine trainees improving quality of care in South Africa 190
5.21 Strategies to support quality improvement eff orts 191
5.22 Elements of family medicine program planning 192
6.1 Tendency of overinvestigation comparing family practices and
non-f amily practices in response to a patient presenting with
minor stomachache, anxiety, and fear 239
7.1 Poverty is the world’s biggest killer 249
7.2 “I dream of the day when these doctors will return” 250
7.3 “One can easily break one twig, but a bundle of twigs is
unbreakable” 252
7.4 Resolution 62.12 of the World Health Assembly on primary
health care, including health system strengthening, 2009 260
7.5 “Message of hope” from Archbishop Emeritus Desmond Tutu 262
Tables
3.1 Percentage of countries in which the majority of family doctors
include this knowledge in their practices 52
3.2 Percentage of countries in which the majority of family doctors
provide these services 52
3.3 Percentage of countries in which the majority of family doctors
perform these procedures 53
3.4 Top 20 episodes of care 56
3.5 Top 20 reasons for encounter (N = 829 572) 57
3.6 Complementary clinical and community health skills 66
viii LIST OF BOXES AND TABLES
4.1 Requirements for training family doctors in the United States 116
4.2 Parallel processes of patient care and medical teaching 126
4.3 Retraining family physicians 141
5.1 Key conditions for optimal family practice 155
5.2 Dimensions of quality in health care 184
5.3 Sources of data to assess quality of health care 187
6.1 The number of primary health care facilities, physicians, and
outpatient visits in primary health care facilities in 2005 and 2011 218
Foreword
Human rights and dignity, fairness, participation and inclusion have long been
core values of WHO. They underpin our contribution to global welfare and
sustainable development. Delivering health services in line with these values
remains a major challenge in the health sector globally, despite tremendous
gains made over the past few decades. Those who end up suffering the most are
vulnerable populations, especially in low-i ncome settings. Investing in health
and health systems thus remains essential not only for improving overall health
service delivery but also to overcome poverty, build human capital, and promote
sustainable development.
Universal health coverage (UHC), based on available, acceptable, accessible
and affordable health services of high quality, is of extraordinary signifi cance in
delivering better health to all, and is a unifying goal for health system develop
ment, as envisioned by Alma Ata and other more recent global declarations. Th e
path to universal health coverage requires considerable investment in improv
ing health services based on primary healthcare principles and values. Health
services can be too costly for a population (aff ordability barrier), too far away
(accessibility barrier), poorly staffed with long waiting hours (availability bar
rier), or do not conform to people’s cultural and gender preferences (acceptability
barrier). And when people do access services, they are often of poor quality, and
in some cases, even harmful. In addition, services tend to be fragmented, cura
tive, hospital-b ased and disease-o riented, all of which further hampers access to
comprehensive and quality care services.
Launching and sustaining primary healthcare as an integral part of a com
prehensive health system requires several key elements: among others, good
governance, adequate and sustainable financing, and an able and motivated
workforce. An important component of the latter is family medicine, within the
context of a multidisciplinary team working closely with the family and com
munity, and delivered around people’s health needs. These elements must come
together to help overcome the barriers of change, draw on the lessons of the past,
and identify specific avenues for the future.
This guidebook systematically analyses the contribution of family medicine
ix
