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Strengthening service provision in the Region: the family practice approach

Background

Improving access to quality health care services is a priority for health system strengthening in the Eastern Mediterranean Region (EMR). Although it has been more than 30 years since Alma-Ata, primary health care remains fundamental to delivering universal health coverage and providing equitable and accessible quality health care. Countries of the EMR have committed to the principle which was reiterated at the 60th session of the Regional Committee held in 2013 that urged Member States and WHO to expand the provision of integrated health services that address the major burden of ill-health and are based on primary health care. Furthermore, the 61st Regional Committee in 2014 endorsed a framework for action on advancing universal health coverage in the Region which includes key actions for countries to expand the coverage of needed health services.

Family practice is characterized by comprehensive, continuous, coordinated, collaborative, personal, family- and community-oriented services and comprehensive medical care with emphasis on the family unit. Health care services in family practice are provided by family doctors often supported by a multidisciplinary team. Therefore, a clear vision is required for all health workers when implementing a family practice approach.

The family practice approach offers a model for providing access to affordable, quality health care in the Region. While the majority of EMR countries have included family practice in their national health policy and plans, the proportion of primary health care facilities with full implementation of family practice varies tremendously within and between the countries.

Some countries have reasonably functioning family practice programmes. Some have committed to such programmes but are still struggling to scale up their implementation across the country. Other countries may have some way to go before they can establish family practice programmes. However, all countries face challenges in implementing family practice. There are some concerns, for instance, about whether countries have the appropriate workforce, comprising trained teams of family physicians and nurses, or even a strategy for producing such a skilled workforce to implement a family practice programme. A lack of family medicine departments in medical schools is limiting the exposure of medical students to this specialty. A significant need has been identified to establish family medicine departments in all medical schools in order to expose and sensitize students to this field. Inadequate training capacity, low salaries and lack of career development opportunities mean that family medicine is not fully supported as a medical specialty and thus makes it less attractive to graduates compared to other specialties.

WHO is committed to assisting Member States in the EMR improve access to quality, comprehensive and affordable health care services through implementation of the family practice approach. Recognizing the challenges faced in expanding family practice in the Region, WHO held a regional consultation on strengthening service provision through the family practice approach in Cairo, Egypt from 18 to 20 November 2014.

The objectives of the consultation were to:

1. present the current status of family practice in the Region highlighting challenges, opportunities and priorities for moving towards universal health coverage;
2. share regional and global good practices in implementing family practice programmes including aspects related to the integration of services, quality and safety of care, essential package of health services and alternative options to complement family practice approach; and
3. develop a roadmap and action framework for improved service provision as part of the commitments towards universal health coverage that is compatible for the three groups of countries of the Region. Representatives of Member States, academia, United Nations agencies, the World Organization of Family Doctors (WONCA) and nongovernmental organizations participated in the consultation and shared experiences on family practice from within and outside the Region.

Issues discussed

Countries in the Region are very diverse and face different challenges. For some countries, universal health coverage may require a major reform of the health system. It was suggested that integrating a family practice approach into service delivery should be a goal for every Member State of the Region with each country identifying how this goal can be achieved in the short- and long-term. Piloting will help to identify priorities and develop models for each country in line with the existing infrastructure and national needs. From the implementation perspective, family practice has 13 elements designed to maintain quality standards of service delivery. The elements arecategorized in three groups outlined below.

Awareness of the community in the catchment area

1. Registration of the catchment population and development of family folders
2. Development of a family physician roster
3. Community engagement

Family health centre

      4. Essential health services package

      5. Essential medicines list

      6. Staff pattern based on family practice with updated job descriptions

      7. Standard set of medical equipment and furniture

Management

     8. Training programmes based on the new job descriptions

     9. On-the-job training for general practitioners and other support staff

    10. Availability of updated treatment protocols

    11. Functional referral system

   12. Health care information system 13. Quality and accreditation programme

It is not realistic for countries to implement all elements at the same time. Rather they should focus on scaling up those elements that are the most feasible and then expand to include the others.

A series of themed technical discussions focused on: establishing family practice programmes (governance/regulations); scaling up training of family physicians in the Region; strategic purchasing – the interface between provision and financing of care; integrating health services – vertical versus integrated approach; improving the quality and safety of care, gaining the trust of populations through the family practice approach; alternative service delivery options to complement family practice programme, for example community health workers and outreach services.

Based on these themes, a draft roadmap was developed for improved service provision as part of the commitment towards universal health coverage through implementation of family practice in countries in the Region. Some of the key actions of the draft roadmap for Member States to consider are shown in Table 1.

The next steps

In concluding the consultation, Dr Ala Alwan, Regional Director, stated that WHO would continue to work with Member States, regional institutions and WONCA and with GCC Council Ministers of Health. A small working group would review the recommendations and develop a draft on the way forward covering all areas of the health system building blocks and the options within the country contexts, which would be presented for discussion at ministerial forums.

Table 1 Key actions for implementation of family practice