The 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 CRC Press is an imprint of the Taylor & Francis Group, an informa business First Edition 2002 (published by WONCA) © 2013 WONCA WONCA has asserted its right under the Copyright, Designs and Patents Act 1988 to be identified as the author of this work. Chapter 6 © 2013 World Health Organization All rights reserved. The WHO has granted the publisher permission for the reproduction of this chapter. Every effort has been made to ensure that the information in this book is accurate. This does not diminish the requirement to exercise clinical judgment, and neither the publisher nor the authors can accept any responsibility for its use in practice. CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal respon sibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not neces sarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all mate rial reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or uti lized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopy ing, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library. ISBN- 13: 978 184619 554 9 (pbk) Typeset by Darkriver Design, Auckland, New Zealand 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