In my view… Family Medicine, PHC and UHC

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Jan de Maeseneer, Emeritus professor Family Medicine and Primary Health Care, Department of Public Health and Primary Care, Ghent University (Belgium), will be a familiar name to many of you. He has been a staunch advocate for family medicine for many years and continues his interest despite his so-called ‘retirement’! I am pleased to invite Jan to contribute his view about issues of note within primary care and family medicine to this month’s WONCA News.

Family Medicine, Primary Health Care and Universal Health Coverage: What is WONCA’s role?

After the Astana-Declaration on Primary Health Care (PHC) in October 2018, the time for implementation of the principles has come, putting the Memorandum Of Understanding (MOU) between WONCA and WHO into practice.

The first goal WONCA can contribute to is documenting the evidence that PHC, integrating Family Physicians, really can make a difference in terms of access to and quality of health care. Reports from USA (Robert Graham Centre, Washington, USA[1] ), from OECD[2] (Paris, France), the EU QUALICOPC-study[3] (Nivel, the Netherlands), and research in Africa (South-Africa[4], North-Sudan[5] , all document better results for access and outcome in settings where Family Physicians contribute to PHC. Thanks to the WONCA leadership in recent years, WONCA engages in both the global and the local debate on the role of Family Medicine.

In August 2019, a delegation of WONCA Africa region and Primafamed met with WHO Africa region in Brazzaville. There was a positive and proactive atmosphere, which resulted in a joint document. While the document is a strong demonstration of intent, there were no concrete commitments for action and no specifically identified resource commitments to strengthen the development of Family Medicine. That is a pity, because there are resources available: in June 2019 the European Union gave a donation to WHO of €102 million for action towards Universal Health Coverage (UHC).

What can we learn from this experience? First of all, WONCA should continue to interact with WHO, not only at the global level in Geneva but also at the level of the seven WHO regions. Secondly, national WONCA Member Organisations (MOs) should be encouraged and supported to build contact and engagement with WHO Country Representatives (WRs), where there is a WHO country office, to explain the role of Family Medicine in PHC. These meetings should be reported to WONCA Executive, to reflect on the momentum building on the WHO-WONCA MOU.

Finally, WONCA should continue its engagement at WHO Geneva level to motivate WHO not only to distribute finances through the national health ministries, but also to financially support the contribution to UHC by multilateral agencies and NGOs such as WONCA, Primafamed (in Africa), African Forum for Primary Care, the newly formed and enthusiastic AfroPHC, and European Forum for Primary Care. The power of multilateral agencies lies in their capacity to overcome local “sensitivities”.

Moreover, WONCA can play an important role in the creation and expansion of inter-professional Primary Care Teams (see WONCA News ‘In my view’, September 2019). Family Physicians are the clinical medical experts in the PHC team and work with nurses, social workers, community health workers and others, with each of these team members contributing to improved health outcomes.

Therefore, it was very appropriate that WONCA reacted immediately to a recent BMJ-editorial authored by Agnes Binagwaho (Rwanda) and the WHO-Director General, that suggested that “…community health workers (CHWs) serve as the first point of contact for people needing healthcare; they are the functional link between communities and health facilities, such as hospitals[6].” (BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2391).

The WONCA President, Donald Li, was very clear in his rapid response: “We urge you to champion the contribution of ALL health care workers in PHC, including professionals like nurses/midwives, clinicians/physician assistants, and family doctors. If we want to truly re-invent PHC to provide accessible, affordable, cost-effective, comprehensive, quality primary health care then we need teamwork including family doctors, especially in Africa and especially considering the resources of the whole health system. UHC built around hospitals will be disastrous for Africa. We urge you to actively support our efforts in Africa to achieve UHC and leave no one behind.”

However, on 29 August a blog in BMJ, written by Paul Kagame, President of Rwanda, repeated the same analysis: ‘In Rwanda, a combination of community based health insurance, community health workers, and good external partnerships together led to the steepest reductions in child and maternal mortality ever recorded’[7].

This position needs to be challenged, using the evidence which already exists and evidence which is being built, in Africa, in real time. It is obvious that big donors are emphasising the focus of their investments on CHWs and not on nurses and family physicians in their rationing strategy, aimed at reduction of their support for human resources for health.

Finally, WONCA can take a strategic role in capacity-building, advocating that at least 40% of all students who graduate in medicine, should engage in a post-graduate training in Family Medicine[8]. By doing so, WONCA clearly illustrates its social accountability in this important process of societal change for Universal Health Coverage.

References

[1] Robert Graham Center. Investing in Primary Care: a state-level analysis. Washington, July 2019. Available at: https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/Investing-Primary-Care-State-Level-PCMH-Report.pdf

[2] OECD. Realising the full Potential of Primary Health Care. Policy Brief May 2019. Available at: http://www.oecd.org/health/health-systems/OECD-Policy-Brief-Primary-Health-Care-May-2019.pdf

[3] Schäfer WLA, Boerma WGW, van den Berg MJ et al. Are people’s health Care needs better met when primary care is strong? A synthesis of the results in the QUALICOPC study in 34 countries. Primary Health Care Research and Development 20(e104). doi: 10.1017/S1463423619000434

[4] Mash R, von Pressentin KB. Strengthening the district health system through family physicians. South African Health Review. 2018 Mar 1;2018(1):33-9.

[5] K. G.Mohamed, S. Hunskaar, S. H.Abdelrahman, and E.M.Malik. Scaling up family medicine training in Gezira, Sudan: a 2-year in-service master programme using modern information and communication technology: a survey-study. Human resources for Health 2014,12:3. Available at: http://www.human-resources-health.com/content/12/1/3

[6] Binagwaho A, Ghebreyesus TA. Primary Healthcare is cornerstone of Universal Health Coverage. BMJ 2019;365:l2391 doi: 10.1136/bmj.l2391 (Published 3 June 2019)

[7] Paul Kagame: Transforming a continent with universal health coverage. BMJ,August 29,2019. Available at: https://blogs.bmj.com/bmj/2019/08/29/paul-kagame-transforming-a-continent-with-universal-health-coverage/

[8] De Maeseneer J. Scaling up Family Medicine and Primary Health Care in Africa: Statement of the Primafamed network Victoria Falls, Zimbabwe. Afr J Prm Health Care Fam Med. 2013;5(1), Art. #507, 3 pages. Available at: http://dx.doi.org/10.4102/ phcfm.v5i1.507