Sustainable Development Goals for the Health of the People of Africa

Akwaaba! (Welcome in the Akan language of Ghana).

On behalf of the World Organization of Family Doctors (WONCA), I thank everybody involved in the organization of our 4th WONCA Africa Conference held here in Accra in Ghana. Thank you to the chair of our host organizing committee, Dr Henry Lawson, and to all our WONCA members from Ghana for inviting us to Accra and for your perseverance in ensuring this conference happened here in West Africa.

I thank our WONCA Africa Regional President, Dr Matie Obazee from Nigeria. Since taking on the role of regional president in 2013, Matie has been tireless in his advocacy for family medicine in Africa and I know has visited many countries and has supported the development of new WONCA member organisations and new family medicine training programs across the continent.

I acknowledge the presence here today of our wonderful WONCA CEO, Dr Garth Manning, and I bring greetings from the other members of our WONCA world executive, including our president-elect, Professor Amanda Howe, who sends her best wishes to you all.

And thank you to the community singers who greeted us on our arrival. Beautiful music is wonderful medicine and makes us all feel spiritually uplifted.

I am told that, despite the challenges of travel restrictions, there are over 250 delegates from nearly 30 countries from across Africa and around the world. It is also wonderful that we have had a meeting of the amazing Primafamed Network here in Accra this week, a preconference meeting of Afriwon, our WONCA Young Doctor Movement established by young doctors in Africa in 2013, and a preconference meeting of our WONCA Africa Women in Family Medicine Working Party, led by Kate Anteyi from Nigeria.

I am not an expert on family medicine in Africa, but I did work for a short time in Africa as a family doctor, back in 2008, assisting in the establishment of new HIV testing and treatment facilities in the Limpopo Region in the north of South Africa. This is what an Australian family doctor looks like when he is working in Africa. Sunglasses and big hat to protect me from the African sun, wearing a white coat so everyone knew I was a doctor, and carrying a large stick, in case I was attacked by baboons.

My exposure back then to the challenges of delivering health care to the people of Africa taught me many things. And I was fortunate to learn from some of the great family medicine leaders of our region. People like our former WONCA president, Professor Bruce Sparks from the University of Witwatersrand in Johannesburg, our former WONCA Rural Working Party chair, Professor Ian Couper, our first WONCA Africa President, Alan Fatayi-Williams, and former WONCA Africa president, and dean of the medical school at the Walter Sisulu University in South Africa, Professor Khaya Mfenyana. Khaya once said, “We want to go deeper in defining family medicine within the context of Africa. Our first goal is to be on the same page in the African context. Secondly, we want to influence the world in terms of focusing on horizontal rather than vertical programs. Our third goal is to examine family medicine education in Africa. Family physicians have to be educated in the community.” Key lessons and I hope we will leave this conference on the same page with plans for our shared future work.

People like Bruce and Ian and Alan and Khaya and Kate and Matie and the members of the Primafamed Network have been leading a revolution in health care across Africa. In countries all around the world, the message is getting through about the importance of primary care and family medicine in ensuring universal access to health care and equitable health outcomes. Nowhere is this as important as in Africa. Compared to the rest of the world, health care in Africa is characterized by a huge discrepancy between the high burden of disease and the scarcity of health care workers, particularly doctors. Low-income countries in Sub-Saharan Africa face enormous challenges including high rates of infant and maternal mortality, HIV/AIDS, TB-infection, endemic malaria, non- communicable diseases, violence, trauma and pervasive poverty.

As the world considers the new United Nations Sustainable Development Goals, many countries are examining how models of family practice can contribute to a more productive, coordinated and cost-effective approach to ensure the provision of health care for all their citizens. The evidence is clear that the most cost-effective way to decrease morbidity and mortality and increase positive health outcomes in a population is through a well-developed system of primary care services that ensure accessible, comprehensive, coordinated, and people-centred care. And so in this presentation I will focus on how this might apply to addressing the health of the people of Africa and on some of the challenges that we need to overcome. I will also share with you some of the work of WONCA, and our partners and member organizations both in the Africa Region, and around the world.

There are some who say that family medicine has no real role to play in the countries of Africa. Well we know that this is not true and the great work of the Primafamed Network and of WONCA has provided the evidence about how family medicine can change health care outcomes for the people of Africa.

In 2013, the Director-General of the World Health Organization (the WHO), Dr Margaret Chan, launched the new edition of WONCA’s guidebook on the contribution of family medicine to improving health systems. The guidebook includes 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. I am going to be drawing on that chapter in my talk today and I thank and congratulate the authors, Maaike Flinkenflogel from Rwanda, Bob Mash from South Africa, Olayinka O Ayankogbe from Nigeria, Steve Reid from South Africa, Jan De Maeseneer from Belgium, and Akye Essuman from Ghana. I want to pay special tribute to the contribution of Dr Essuman who was the first graduate of family medicine in Ghana and who works as a senior specialist family physician here in Accra and also as a member of the Family Medicine Unit of the Department of Community Health at the University of Ghana Medical School. I have a copy of the new WONCA Guidebook to present to Dr Essuman.

It is doctors like Akye Essuman who are changing the face of health care here in Africa. I want to highlight for you the extraordinary work of the Primafamed Network, the "Primary care/family medicine education network", which, over the past 20 years, has established an institutional network between both emerging and established departments and units of family medicine in universities across Sub-Saharan Africa. Building on existing strengths across Africa, the network linked up the 8 academic departments at universities in South Africa, with departments of family medicine in in Tanzania, Kenya, Uganda, Democratic Republic of Congo, Rwanda, Sudan, Nigeria and Ghana. Since that time linkages have also been made with family medicine in other countries including Swaziland, Malawi, Lesotho, Mozambique, Gambia, Zimbabwe, Togo, Namibia, Botswana, and more. While this has been the work of many, it has been conducted under the inspiring leadership of Professor Jan De Maeseneer from Ghent University in Belgium, and we owe a huge amount to Jan for his foresight and infectious enthusiasm.

I also wish to highlight the work of Dr Katherine Rouleau and the Besrour Global Family Medicine initiative of the College of Family Physicians of Canada, which is linking up family medicine academics from Canada with colleagues in French-speaking nations of Africa, including Mali and Tunisia, but also Ethiopia and Tanzania. The Besrour Initiative has been funded by a Canadian family doctor, originally from Africa, from Tunisia, Dr Sadok Besrour, one of the major philanthropists in global health care.

The greatest privilege of being WONCA president is that I am invited to learn about extraordinary contributions like these as I visit family doctors 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.

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.

Our first WONCA president was the Australian Monty Kent Hughes, who said at the very first WONCA world council held in 1972, “The future of our professional discipline will depend on our ability to work together in the service of humanity.”

And that is what we have been doing ever since. Working together. This sentiment is echoed in a quotation from Professor Nelson Sewankambo, Dean of the Faculty of Medicine at Makerere University in Kampala in Uganda, who said, “One can easily break a twig, but a bundle of twigs is unbreakable – together we may achieve more than a single institution.”

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 142 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 in the world, joins us in our commitment to deliver high quality primary care to our patients and communities. And we need to bring family practice to every person, every family, every community in the world.

WONCA has three big challenges. First, we need to better understanding the strength of each of our member organisations in each region, and work 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. While we have some strong member organisations in Africa, we need to do all we can to support family medicine developments in every nation.

One of the most exciting recent developments has been the establishment of the first family medicine training program at Addis Ababa University in Ethiopia in 2013. This program has been developed with support from family medicine educators from the University of Toronto in Canada and the University of Wisconsin in the United States of America.

The potential contribution of family medicine to the Ethiopian health care system is immense. The country is growing at a rapid rate and its population is approaching 90,000,000. Many people still have difficulty accessing anything more than basic care provided by health extension workers with one year of training. The country’s doctor-patient ratio is extremely low, roughly one per 20,000 population, well below WHO’s recommendation of a minimum of one per 10,000. In recent years Ethiopia has opened thirteen new medical schools using an innovative community-based curriculum, and will soon be graduating 3000 new doctors each year. The community-based curriculum should be an ideal foundation for attracting new graduates to family medicine.

Family medicine development in Ethiopia is providing a wonderful example of how much we can achieve by working together.

WONCA’s second big challenge is recognizing the importance of the next generation of family doctors, and we are addressing this through our commitment to support 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 Afriwon Movement, established by young family doctors in this region in 2013, and led by Dr Kayode Alao from Nigeria. Here in Ghana, Dr Roberta Lamptey and Dr Gerald Kwadwo Osei-Poku have been leading Afriwon. Afriwon is an incredibly energetic movement, using social media to make connections across national borders, and supported by great family doctor mentors in East, West and Southern Africa. We have just had a wonderful workshop here in Accra involving our young doctors. I also acknowledge the financial support of the American Board of Family Medicine, which assisted a number of our young doctors in attending this meeting.

WONCA’s third big 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, to support universal health coverage, and to ensure that each country has a well-trained and supported family medicine workforce.

WONCA works closely on health system strengthening with the World Health Organization, both at a global level, and in each of the regions of the world. The WHO Director General Dr Margaret Chan is a staunch supporter of the importance of family medicine. At a meeting in Hong Kong a year ago Dr Chan stood up and proclaimed, “I love family medicine”, which didn’t please the members of the other medical specialties in the room!

This region of the world has faced huge challenges over the past year, especially from the impact of the Ebola crisis. I hope this conference will tackle how we can work together to support rebuilding the health care services in the countries of this region that have been affected by the Ebola crisis, especially Liberia, Sierra Leone and Guinea, and reinforce the need to focus on strengthening community based health care services in all nations in Africa.

On behalf of WONCA I offer our condolences to those families that have lost loved ones to the Ebola outbreak, including the families of the brave doctors, nurses and other health workers who were infected while providing treatment and support to their patients. As you know many front line doctors and nurses were among the victims of Ebola and this has left the health services in affected countries vulnerable and unable to cope with meeting the continuing health care needs of their communities. In August last year the WHO reported that the Ebola outbreak in West Africa had taken an unprecedented toll on health care workers, infecting more than 240 and killing more than 120. Sadly, even more of our colleagues have died since that report, with recent figures reporting 820 health care workers infected and more than 490 deaths.

Many of our colleagues from across Africa and across the world have been involved in the response, through global organisations like the WHO, Médecins Sans Frontières (Doctors Without Borders) and the International Red Cross/Red Crescent, and through international response teams. Community education has been essential, as has been the training and support of front line health workers. The challenges witnessed in the initial response to the outbreak reinforced the essential need for strong primary care systems in every nation with well trained and suitably equipped primary care teams, and the ongoing need for strong and coordinated national and international support. Later in the conference we are going to hear from one of our colleagues from Ghana, Dr Gerald Kwadwo Osei-Poku who led a medical team to Liberia to provide care to people affected by the Ebola outbreak.

I want to share with you another personal face of the Ebola crisis through the story of a remarkable family doctor involved in tackling the Ebola crisis. This is Dr Atai Omoruto from Uganda.

I first met Atai in 2007 at the Network Towards Unity for Health conference, which was held that year in Uganda. At the time Amanda Howe was chair of WONCA’s working party on women in family medicine, and Amanda shared with me Atai’s contact details, and Atai and I arranged to meet in Kampala. Atai took me to her university department at the University of Makerere. Her academic department of Family Medicine was housed in a building called “The Hippo House”, so named because in the past the building had actually housed a hippopotamus that was used for physiology experiments. So Atai and her family medicine education team were occupying the former living quarters of a hippopotamus, with a deep concrete pit in the middle of the room where the hippo had lived. Atai showed me the training facilities for medical students at the university, took me through the main hospital primary care clinic and also took me to her own private clinic in Kampala where she provided care after hours to some of the poorest people in that city, including providing a space where women could deliver their babies safely under her supervision. Atai also introduced me to some of her many children, some her biological children, and some adopted orphans, mainly from parents who had died of HIV/AIDS.

Since our first meeting in 2007 Atai has become involved with WONCA and is a strong voice for family medicine in Africa as a member of our WONCA Africa Regional Council and as a member of our global working party on women in family medicine.

In July last year, Atai travelled to Liberia as the head of a medical unit of 12 health workers brought from Uganda by the World Health Organisation to fight the Ebola outbreak. Uganda has experienced a number of outbreaks of Ebola in the past and, through her experience in her own country, Atai has become one of the world’s most experienced doctors in managing cases of Ebola.

In an interview with Liberia’s Daily Observer newspaper, Atai said that on arrival in Liberia, “what I saw was dead bodies everywhere; there were more dead bodies than patients, and nobody seemed to know what to do.” Atai and her team got to work, setting up systems to treat those affected by Ebola and supporting the training of local health care workers. The WHO had reported that in many cases, “medical staff had been at risk because no protective equipment was available – not even gloves and face masks, and that the compassionate instincts of those who sometimes rush to aid "visibly ill" people without pausing to protect themselves also put health workers at increased risk. Health care workers were overworked, stretched thin and exhausted”, which risked mistakes happening in infection control. And doctors reported that working in protective suits was very challenging in the heat, especially in the absence of air conditioning. Indeed many facilities had no power or lighting at all.

Through their work, Atai and her team made a major contribution towards changing the course of this terrible epidemic. And it was not without its toll. At least two Ugandans died while assisting the people of Liberia. Atai stayed in Liberia for six months, working under very arduous conditions, and not returning home to her family in Kampala until December.

Atai has since been named as one of the 11 most important contributors to tackling the Ebola crisis in Liberia. Liberia and the world owe a huge debt of gratitude to Atai and to the many other health workers from across Africa and across the world who came to West Africa to provide their support during this dark hour. Atai has shown us the extraordinary contributions that family doctors can make. I admited Atai greatly before the Ebola crisis. She is now one of my all time heroes of family medicine.

Part of the tragedy of Ebola has been that health services were paralysed and unable to provide care for the other health care needs of the affected communities. We will probably never be able to quantify the preventable deaths from other conditions that occurred as a result of the loss of health care services. How many children died of malaria and pneumonia and gastroenteritis in countries where the health care systems had collapsed? How many women died as a result of loss of maternal health services?

One of the biggest health care challenges facing this region is providing health care to people living in rural regions. Last year, WONCA’s working party on rural practice 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. I commend it to you. We need to ensure family medicine is available to the people living in rural communities in this region of the world.

While our clinics may be different from country to country, and from urban to rural to remote locations, 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 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 for themselves and the members of their families, access to caring clinicians, access to life saving medications.

We need to tackle the shortages of health care workers in the countries of this region. This is often exacerbated by the migration of health care workers. The 2002 WONCA Melbourne Manifesto is a code of practice for the international recruitment of health care professionals, which emphasises the responsibility of each country to ensure it is producing sufficient health care professionals to meet its own current and future needs. And that those countries that can afford to do so, train more health care professionals than they need and so help to redress the shortages in many parts of the world.

In the words of the former president of South Africa, Thabo Mbeki, “I dream of the day when these …doctors … will return from London and Manchester and Paris and Brussels to add to the African pool of brain power, to enquire into and find solutions to Africa's problems and challenges.”

A particular challenge for some of the nations in this region of the world is rebuilding health services following emergency situations, including crises like the Ebola outbreak, or natural disasters like the earthquake that affected our friends and colleagues in Nepal over the past week. Our hearts go out to our friends and colleagues in Nepal.

Emergency situations can also be due to armed conflicts and civil unrest as we have seen in some of the nations of this region. Regardless of the cause of emergency situations, a cascade of human suffering is often the result including large scale displacement with refugees moving across borders, shortages of food and clean water and sanitation, disease outbreaks and the risk of terrible human rights abuses.

The WHO has been working to address the mental health consequences of emergencies and has produced an excellent report on Building Back Better Sustainable Mental Health Care after Emergencies. It documents work underway to support rebuilding of more sustainable mental health services in countries and areas like Somalia and Burundi. WONCA works closely with the WHO on the integration of mental health into primary care services. We need to re-energise this commitment and work together to ensure that the entire primary health care systems in affected nations are strengthened after conflict and catastrophe. It is only through strong primary care that each of our nations will have the resilience to withstand future crises and be able to support our people at their times of greatest need. This should be a key part of our contribution to the nations of West Africa affected by Ebola.

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, including in this region of the world. 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” and 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”.

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

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.

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.” I agree with Iona.

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.

The challenges we face also test our own resilience. While we continue to innovate within our practices to ensure that our patients receive the highest possible standards of care, it is critical that we also continue 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 this region have been very active in promoting World Family Doctor Day. Activities have been held in many countries including Kenya, Mozambique, South Africa, Ghana and Nigeria.

My final quotation is from another hero of Africa, Archbishop Emeritus Desmond Tutu, who wrote a message of hope his preface to Hugo and Allen’s book, “Doctors for tomorrow: Family medicine in South Africa”.

"Doctors in family medicine are aware of the challenges, attempt to understand them better and work to address them… The issues of principles and values, relationships and meaning are not left to chance, but become an important element of service, systems, training and research.

"This gives me hope of a transformation in the health service that can take care of our people, which can guide us through this difficult time. This hope is not only for South Africa, but also for our brothers and sisters in the rest of the continent and the rest of the world.

“If the family medicine movement can play that role, let us join hands and realise that dream"

I share Desmond Tutu’s hope for the future, and I invite you to join hands.

The future is in your hands, my sisters and brothers in family medicine.

Thank you for coming together here in Accra to share your knowledge and gain new inspiration. Thank your commitment to being a great family doctor. Thank you for the wonderful and important work you do.
And thank you for the 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,
President, World Organization of Family Doctors (WONCA),
May 6 2015, Accra, Ghana

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