Dr. Garth Manning from WONCA (World Organisation of Family Doctors) quoting Baicker & Chandra, Health Aff 2004 and Wennberg et al, Health Aff 2005, described that areas with high use of resources and greater supply of specialists have neither better quality of care NOR better results from care, and that countries have achieved better health outcomes, greater patient satisfaction, lower prescribing and healthier populations through emphasis on primary care systems. He proposed that a family physician must be clinically competent, have expertise in management of common problems, coordinate care and involve in research and continuous professional development and take up the roles of care provider, decision maker, communicator, community leader and manager, in order to deliver appropriate care.
Dr. Preethi Wijegoonwardene, President WONCA South Asia Region, presented an update on the development of academic family medicine in South Asia Region. He gave an account on how family medicine has evolved in Sri Lanka, Pakistan and Nepal and how it is catching up in India.
Prof. Bob Mash from South Africa, in his presentation on ‘Building consensus on Family Medicine in Africa’ puts forth the skills to be acquired during the training period. In African countries, the family physician must handle the patient taking a bio-psycho-social approach in an ethical manner. He must also take a leadership role and facilitate the resources of the community for ensuring health. Training is provided at various levels of CHCs, district hospitals and regional hospitals. They have eligibility criteria to take up the exit exam and both written parts and OSCE must be attempted as part of the exam. A research assignment must also be done to successfully qualify the final exam to become a family physician.
Dr. William Chi Wai Wong, from Hong Kong in his presentation described the role of family physicians in improving the health of the marginalised groups. He argued that inequities in health among the marginalised groups can be addressed by family physicians. He particularly took example of female sex workers who have poor health outcomes and quality of life and adds that how inequities faced by them is best addressed by family physicians who will be able to facilitate greater participation of the patients in healthcare. The Hong Kong programme is an intensive post-graduation plus residency providing a high range of skills.
Dr. Francisco Campos, former Secretary (Health) from Brazil, shared that Universal Health Care is a Citizenship right in Brazil since it is guaranteed by the Constitution itself. He shared that 100% of population depend on NHS’ health promotion and high cost treatments. The ‘Family Health Teams’ (10 member team comprising of doctor, nurse, dentist and community health agents) within the NHS is playing a key role in delivery of primary care. The system is highly decentralised and managed by municipalities. Under the NHS an open university, (una-sus) is formed which is a collaborative network of educational institutions, a repository for educational resources for health and also provides health worker information system. This is the largest national open access / open educational resources repository in Latin America. He shared that similar models can be adapted in India also. Here the emphasis is not on a post-graduate degree, but continuous skill up-gradation of primary care practitioners.
Prof. David Mant from Oxford University, UK put forth the argument that primary health care is useful to reduce costs, improve health outcomes and to bridge social inequities in health. He identified the problems with primary health care as mainly in the areas of staffing, governance and leadership. He proposed that focusing on staff wellbeing and flexibility in roles could improve staffing, autonomy etc. Rational prescription and maintaining international standards of quality can solve governance issues and improving existent and establishing new training schools with international partnerships will help address leadership issues. He shared a set of suggestions for India;
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(a)
Focus on high quality clinical staff for primary care
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India's strength in information technology could be applied to greatly increase the potential for effective governance of primary care.
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The current leaders in hospital medicine and public health in India bear a responsibility to train a cadre of leaders in primary health care.
Towards implementation of the same, the key evidence needed is whether the conditions necessary for the proposed solution to be effective will be met locally or not.
Prof. Clara Gerada Chair of RCGP, UK made observations on the existing state of general practice in the UK. She highlighted the mandatory certification and validation processes that a GP must undergo to prepare for their role adequately. Difficulties of working in a rural area, career progression and a still primitive regulatory framework are issues for which solutions and support were sought.
Dr. Tabinda Ashfaq from Pakistan, explained the entire gamut of family practice training provided at the undergraduate and postgraduate level in Pakistan. The Family Medicine programme in Pakistan started in 1972. The country introduced family medicine in the undergraduate curriculum in 1986 in Aga Khan University. Though the program has strengths of catering to the needs of the community, the challenges of low awareness among the people, absence of adequate training and scarcity of expected jobs are yet to be solved.
Dr. Sahadev Swain from UK, discussed how thousands NRI doctors have opted for career in Family Medicine / General Practice. Many of them have vast experience in academics and service delivery. There is a desire among them to contribute back. He urged to develop an environment, where NRI doctors can work towards development of family medicine services in India.
Dr. Mark Zimmerman from Nick Simon's Institute, drew heavily from the Nepali context of family medicine and found relevance for it in the Indian scenario. The MDGP program in Nepal is a 3 years post-graduation and the training is imparted at the level of the district hospitals where they will serve later. The MDGPs are ensured that they have a good staff support program and are also eligible for scholarships. After the introduction of MDGP programme, there has been considerable increase in the OP, IP, and delivery rates and greatly increased the number of secondary case management of all communicable and non communicable diseases including all basic surgeries. The hospitals also started offering C-section services. Such an incentivised approach may also work in the Indian CHCs where there is a dearth of specialists.
Prof. Michael Kidd, President Elect WONCA, from Australia, described General Practice Education & Training Ltd, an initiative by the Australian Government to address the workforce shortage of GPs and to deliver postgraduate vocational education and training through a regionalised model. The Australian General Practice Training program (AGPT) under GPET is a 3 year program on clinical competencies and rural practice with an additional year for FACRRM (Fellowship of Australian college of Rural and Remote Medicine) and FARGP candidates providing advanced specialist skills. The training program is delivered by regional training providers and is therefore, regionally responsive but challenges with vertical integration, capacity, curriculum and workforce distribution still remain.
Prof. Riaz Qureshi from King Saud University, Saudi Arabia, explained about the MRCGP International, South Asia Examination. The programme was developed by a group of Family Physicians of South Asia region(India, Pakistan, Bangladesh, Sri Lanka, Nepal and Afghanistan) in collaboration with the Family Medicine Department of the Aga Khan University, Karachi and the International Department of the Royal College of General Practitioners (RCGP), UK. The syllabus, the curriculum and the assessment focus on the South Asian clinical context, but the rigor to pass the exam is similar to the MRCGP, UK. Dr Kay Mohanna made Dr Qureshi's presentation on his behalf due to his travel difficulties.
Prof. Mala Rao presented the importance of primary health care in India. An example is drawn from the UK-USA experience where UK has achieved reduction of mortality cost effectively whereas USA has achieved the same with least cost effectiveness. The lesser increase in catastrophic health expenditure in AP is partly attributed to the Arogyasri health scheme. She details that what UK and India need to learn from each other is that it is possible to provide holistic, patient focussed care using low technology and by a multidisciplinary team close to the patient and community itself.
Prof. Pratap Narayan Prasad from Nepal described the post graduate training program in Nepal called ‘MDGP’. He emphasised that in resource poor countries family medicine experts should learn advance clinical skills to be able to practice independently in community settings. He shared that after three years of training in Nepal the candidates are able to handle all major emergencies, including provision of C-Sections, Spinal Anaesthesia and are helpful in preventing maternal mortality in the country.
Dr. Jeffrey S. Leman presented the historical evolution of family medicine speciality in USA. He underlined the challenges a country may face while developing services based on family medicine concept.
