Primary Care and the Development of Family Medicine


Marc Kivo, M.D., M.P.H.
Co-Director, WHO-WONCA Guide Project
World Organization of Family Doctors


Stefanie Stevenson, M.D.
University of Cincinnati
Department of Family Medicine

"To meet people's needs, fundamental changes must occur in the health care system, in the medical profession, and in medical schools and other educational institutions. The family doctor (general practitioner/family physician) should have a central role in the achievement of quality, cost effectiveness and equity in health care systems. To fulfill this responsibility, the family doctor must be highly competent in patient care and must integrate individual and community health care. The cooperation between the World Health Organization (WHO) and the World Organization of Family Doctors (WONCA) towards this vision is historic. This effort is strong evidence of the family doctor's contribution to the WHO's Health For All goals."

    (The World Health Organization and the World Organization of Family Doctors, 1994)6

Introduction
The landmark World Health Report: 2000, released by the World Health Organization (WHO) in June 2000, documented both the current impact and potential of health systems around the world to make a difference in people's lives. Objectively evaluating and then improving health system performance is not just a theoretical exercise. In the Report's foreword, WHO Director-General Dr. Gro Harlem Brundtland succinctly described what is at stake:

"Whatever standard we apply, it is evident that health systems in some countries perform well, while others perform poorly. This is not due just to differences in income or expenditure: we know that performance can vary markedly, even in countries with similar levels of health spending. The way health systems are designed, managed and financed affects people's lives and livelihoods. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation and despair."15

Health system performance is dependent on many factors. Effective health systems are organized and financed in a manner that provides the optimum mix of health services to the population served by the optimum mix of appropriately trained health professionals. Primary health care services and the contribution of well-trained family doctor in helping to organize and deliver these services are being seen as two important components of effective health systems. This paper will describe the contribution of the family doctor in delivering primary care services and the collaboration between WHO and WONCA towards this vision.

The challenge of improving health system performance
As we enter the 21st century, the world's community of nations has unprecedented opportunities to improve the health and well being of its six billion inhabitants through the organization, financing and delivery of health care. During the previous half century, human life expectancy improved more than it did during the entire span of human history. The organization and delivery of essential health services that promoted, restored and maintained health had much to do with this increase.

Health systems, and the estimated 35 million or more health workers worldwide who deliver care, can make a profound difference in the lives of the people they serve. Health systems have three major objectives, as described in the World Health Report 2000:
These three objectives matter in every country, independent of relative wealth or available resources for health care and how the health system is organized.

However, the WHO and the World Bank have identified similar significant challenges that need to be addressed to improve the quality, cost-effectiveness, equity and relevance of health care systems. First, they concluded that resource misallocation; inequities in access to medical care and delivery system inefficiencies prevent rich and poor countries alike from improving health and productivity. In many developing countries, public dollars are often spent on high cost hospital services that disproportionately serve the more affluent urban sector. Unfortunately, expensive hospital-based diagnostic and treatment services consume funds that could instead provide essential and cost-effective personal and public health services, such as immunizations, maternal and child health care and the treatment of common chronic conditions such as hypertension and diabetes. The World Bank reported that, in some countries, a single tertiary care hospital may absorb 20% or more of the Ministry of Health budget, at the expense of delivering more effective clinical care through small, health facilities decentralized throughout urban and rural communities.

In middle income countries, public funds often subsidize private insurance that is available only to a small and affluent majority. The remainder of the population has to rely on out-of-pocket payments to private doctors or government services that are largely inaccessible. At the same time, in middle and upper income countries, health care expenditures are rising significantly. Health care costs may be driven by the growth of specialist physicians, the availability of expensive medical technology, the over production of hospital beds and medical equipment that need to be utilized and fee-for service reimbursement. All of these factors lead to resource misallocation, with little for essential and effective personal and public health services to be provided to the public.

Primary care as a strategy for improving health systems
The contemporary beginnings of primary care as a strategy for improving health systems date back to the 1940 and 1950s. Countries, such as Costa Rica, Sri Lanka, Indonesia, China, South Africa, Cuba, Guatemala and India experimented by attempting to provide to the entire population essential curative and preventive personal health services along with public health measures to assure safe water supplies and basic sanitation. By providing basic personal and public health care to everyone, some of these countries were able to add 15 to 20 years of life expectancy at relatively little cost in a span of just 2 decades.

This vision of essential health services for all, termed "primary health care", was placed on the global agenda in 1978. During the International Conference on Primary Health Care held at Alma-Tat, USSR (now Almaty, Kazakhstan), sponsored by the WHO and the United Nations International Children's Fund (UNICEF), the Alama-Ata Declaration adopted primary health care as the principal strategy for achieving the goal of "Health for All". The Alma-Ata conference defined "primary health care" as:

"Essential health care... made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford".

Over the remaining two decades of the 20th century, economically developing and developed countries alike attempted to incorporate low cost primary health care interventions targeting individuals and communities. Primary health care initiatives by individual countries were monitored and assisted with technical support and funding by WHO, UNICEF, and countless other non-governmental organizations, foundations, and academic institutions.

Throughout these two decades, the WHO maintained that all countries could and should prioritize their health care budgets in a manner that provides quality and affordable clinical and public health services to the entire population. In the 1990s, the World Bank and its global financial institutions added their influence and financial backing to this worthy goal. In its 1993 World Development Report, the World Bank identified and then estimated the cost of providing a proven package of the most cost-effective and essential personal (i.e., delivered to individuals) and public health (i.e., delivered to the population) services. These low costs, primary health care services addressed the major causes of premature morbidity and mortality in most countries.

The identified package of essential cost-effective clinical services delivered to individuals included:
The most highly cost-effective package of public health services delivered through community-wide programs that were identified include:

In its World Health Report 2000, the WHO observed that dramatic improvements in health status measures during the last half-century have been partly due to the primary health care revolution.15 Countries or part of countries have successfully shown that a substantial improvement in health can be attained at affordable costs. Many countries tried and demonstrated that training and using less educated, community health workers could deliver basic, cost-effective services in simple rural health centers to populations that previously had little or no access to modern health care. Some countries undertook massive health system restructuring and reform to bring primary health care to all. For example, in India, hundreds of thousands of health workers were trained and deployed in over 100,000 health posts intended to serve nearly two-thirds of the population. Other primary health care initiatives were multinational targeting individual communicable diseases. Through global primary health programs that were unprecedented in scope, smallpox was eradicated and polio brought to the verge of extinction.

At the same time, the WHO acknowledges that for numerous reasons the results of the last two decades of primary care reform have been mixed. First, because "primary health care" quickly acquired a variety of meanings, no single primary care "model" emerged that could be easily replicated and integrated. Second, since "primary health care" was initially targeted to the poor its deployment suffered in many countries from the lack of a powerful political constituency and inadequate funding. As a result, "primary health care" was, in part, marginalized and not viewed as an integral part of major health system reform. Similarly, funding for the delivery of primary health care services were largely directly to untrained health workers. As a result in many countries and virtually all economically developing countries, the physician community, arguably the most influential part of the health workforce, were not intimately involved in either the discussion of the philosophical merits of primary health care nor the retraining and redeployment of the health care workforce. The active participation, support and leadership of the physician community in primary care are seen by many as an important strategy for significant health system reform.

The challenge of restructuring the physician workforce
While many countries, especially developing economies, devoted their limited health resources and attention towards the training of unskilled health workers, the physician workforce was left out of the equation. This was a serious miscalculation for individual countries and the WHO, since physicians were influential key health system decision makers and the health care they ordered and provided consumed a large portion of the finite health budget of many countries.

Prior to World War II, many countries, especially developing countries suffered from a lack of well-trained physicians. For example in the entire continent of Africa, there were only six medical schools. By the 1960's, many governments established new medical schools to train physicians in the hope of providing essential health services to the entire population. However, less attention was placed on training the number of physicians with the specific knowledge and skills necessary to meet the people's health needs. The medical schools established produced physicians with a limited knowledge and skill base for general practice. The medical schools established post-graduate (ie, residency) programs to train numerous different kinds of "specialists" in such fields as surgery, cardiology, obstetrics and gynecology, etc. However, the general practitioners that did not get into a specialist residency were considered "trained" sufficiently for practice. At the same time countries were experimenting with effective and affordable strategies to bring health for all, the biomedical revolution and the rapid growth of medical schools was spawning explosion of highly specialized physicians. The result of was an increase in the number of well-trained, hospital-based specialists and a decrease in the number of well-trained generalists. Even more importantly, the generalists were labeled more by their absence of post-graduate specialty training than by their acquisition of a broad set of skills for community-oriented, primary care practice.6

In the last half of the 20th century, the world's physician workforce grew at twice the rate of the general population and the number of medical schools more than doubled. The number of physicians increased more than fivefold since 1955, from 1.2 to 6.2 million and the global physician to population ratio doubled from 50 to 120 physicians per population. It is important to note, however, that physician distribution was not equal in all countries. Partly as a result of this dramatic growth in the physician supply, physicians are unemployed or underemployed in both developing and developed countries.

Figure 1. Supply of physicians by demographic Region, 1990 or most recent available year


As importantly, the enormous growth and resultant surplus of narrowly trained medical subspecialists hampered efforts to expand essential and affordable health services to the entire population. The narrowly trained specialist physicians did much of their practice in secondary and tertiary hospitals, which were located mainly in large cities. As a result, countries with a large majority of specialist physicians had many doctors working in urban areas in much greater numbers than they are in rural areas. Even more paradoxically, developing countries, which need physicians that are distributed throughout the country, have even more serious imbalances in physician distribution. The ratio of the lowest percent of physician per 10,000 population to the highest percent of physician per 10,000 is roughly 0.5 in developed countries, but in developing countries it is much lower at 0.02 (see Table 1).6

Table 1
Geographic Imbalances in Developing Countries
CountryPercent
Rural		Physicians per
10,000 Population		Rate Ratio
Rural/Urban
TotalUrbanRural
Afghanistan82.31.565.940.080.01
Benin61.40.621.410.290.21
Burkina Faso91.50.172.550.080.03
Burundi93.50.475.360.290.05
CAR55.50.430.670.090.13
Djibouti20.82.402.730.520.19
Guinea76.10.174.890.100.02
Malawi85.40.861.510.030.02
Mali81.40.432.840.020.01
Myanmar83.02.673.150.060.02
Nepal95.60.336.570.060.01
Niger82.10.261.580.040.02
Sources: Total physicians per 10,000 population, percent rural: World Bank (1989). Urban and rural physicians per 10,000 population: HFA questionnaires and WHO country reports.6

The overspecialization of physicians not only ran counter to the goals of primary health care (ie, providing essential and affordable health services to all), but also substantially increased the health system costs. The World Bank reports that, in some countries, a single tertiary hospital may absorb 20% or more of the Ministry of Health Budget.6

As a result, in many countries the overall health care workforce consisted of a massive number of inadequately trained, funded and supported health workers and a limited number of highly trained and compensated specialist physicians. In its World Health Report 2000, the WHO concluded:

"Despite these efforts, many such (primary health care) programs were eventually considered at least partial failure. Funding was inadequate; the workers had little time to spend on prevention and community outreach; their training and equipment were insufficient for the problems they confronted; and quality of care was often so poor as to be characterized as "primitive" rather than "primary", particularly when primary care was limited to the poor and to only the simplest of services. Referral systems, which are unique to health services and necessary to their proper performance, have proved particularly difficult to operate adequately. Lower level services were often poorly utilized, and patients who could do so commonly bypassed the lower levels of the system to go directly to hospitals."15

Often times the only available higher level of health care was very expensive and inefficient tertiary care hospitals in urban settings.

Health system reform and the potential contribution of the family doctor
As the WHO was articulating a vision of Health For All in the 1970s, countries throughout the world were busy producing a new breed of general practitioner/family physician (gp/fp) called a "family doctor" who was properly trained through post-graduate training programs to diagnose and treat the majority of people's health problems and to integrate individual and community health needs. At the 5th World Conference on General/Family Practice in Melbourne, Australia, in 1972, 23 member countries of family doctors established the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA). Today, known as the World Organization of Family Doctors, WONCA has 65 member organizations from 56 countries representing more than 150,000 family doctors worldwide, as well as 1,580 Direct Members from 84 countries. The remainder of this paper will describe the primary care knowledge and skills of the well-trained, family doctor as well as review the important contribution of the family doctor in improving health system performance. Finally, this report will review the collaboration between the WHO and WONCA to enhance the contribution of the family doctor to health system reform.

The family doctor is a physician who is educated and trained in family practice a defined and broadly encompassing field of medicine. The family doctor possesses unique attitudes, skills, and knowledge which qualify them to provide continuing and comprehensive medical care, including health maintenance and preventive services, to each member of the family regardless of sex, age, or type of problem; be it biological, behavioral, or social. These family physician specialists, because of their background and interactions with the family, are best qualified to serve as each patient's advocate in all health-related matters, including the appropriate use of consultants, health services, and community resources.

Over the last 50 years much has been learned about primary care through the research and experience of the GP/FP. It has been discovered that the well-trained GP/FP, as the physician of first contact, can care for 90% of the medical problems presented by patients, is trained to provide continuity of care to the patient and to the family over time, and understands the importance of prevention and caring for people in the context of their community. The scope of practice of this physician is broad and can include care for all ages, obstetrical care, some surgical procedures, and the care of hospital patients. The practice scope of the GP/FP will depend on the health care needs of the community and the resources available.

The GP/FP is a well-trained generalist physician who can meet the majority of people's basic needs. He/she knows how to integrate individual care and community/population based care. This basic concept is critical to understanding the value of the GP/FP. To focus on individual care and ignoring population-based care is as problematic as focusing on population based care and excluding individual care. The GP/FP is trained to understand both concepts and include them in his/her practice. The GP/FP is flexible regarding the scope of practice based on local needs, and is also flexible regarding the practice location. The GP/FP does not need to be close to a hospital or technology backup in order to practice effectively.

In 1993, WONCA conducted a membership survey to ascertain what are the specific knowledge and skills that family doctors provide in most countries. Responses to the survey were received from 52(79%) of the 66 countries. While the survey was limited to WONCA member organizations which only represented 25% of WHO member nations, the survey provides useful information on the role of the family doctor.

The survey indicated that family doctors have a broad knowledge base. The care of children, adults and the elderly, women's health, mental health, prevention, and community medicine were mentioned by more than 90% of respondents. Family doctors engage in office practice, provide emergency care and make some house calls in virtually all countries. Of particular note, family doctors primarily practice in the community. Family doctors care for patients in hospitals in less than one-third of responding countries. Over 75% of the reporting countries have developed formal postgraduate training programs for family doctors. Over two-thirds of the countries encourage or require continuing medical education for practicing family doctors. A well- trained generalist physician can diagnose and treat greater than 90% of the problems seen in a population. Kark, in 1974, estimated that as few as one in 1,000 health-related problems ever needs to be managed in tertiary care hospitals.9 When the goal is health of the world, essential preventative and diagnostic health services need to be available to all people. Family physicians naturally fit this role, since they are trained in over 90% of the disease portion of health care while maintaining an emphasis on preventative and whole- family care.

It is important to note that family doctors are trained and prepared to practice in all communities in a country. For example, in the United States the family doctor is the only physician type to be evenly distributed through all community sizes. Countries with a large percentage of family doctors in their physician workforce (ie, family doctors approaching 40-50% of all physicians) are able to expand the delivery of quality, primary care services to their entire population.

Table 2
Physician Supply & Specialty Mix in Selected Developed
Countries OlECD Physician Work Force Data
Total MD
/100,000(a)		General Practitioner
/100,000		Specialist Practitioner
/100,000
Australia200    
Austria210    
Belgium360191169
Canada220110110
Denmark28070210
Finland25062188
France270103167
Germany32086234
Greece340    
Iceland280    
Ireland1506486
Italy130    
Japan160    
Luxembourg210    
Netherlands25095155
New Zealand190    
Norway31071239
Portugal280    
Spain390    
Sweden29067223
Switzerland300    
Turkey90    
United Kingdom1406773
United States(b)23076154
Source: a. OECD Health Systems: Facts and Trends, 1960-91, OECD, Paris 1993. b. For US, percentage includes General Family Practitioners, General Intenalists and General Pediatricians. The percentage for General Practitioners is 27.6%6

These well trained family doctors contribute to health system improvement because they improve the delivery of effective and efficient personal health services to individuals and can help integrate the care of individuals with the provision of public health services to the community. Somewhat paradoxically, economically developing countries have not yet made the commitment to include the training and support of the family doctor in their health system reform agendas. In its World Health Report 2000, the WHO concluded: "In developed countries, primary care has been better integrated into the whole system, perhaps because it has been more associated with general and family medical practice and with lower-level providers such as nurse practitioners and physician assistants (ed note: nonphysicians with specific primary care training). Greater reliance on such practitioners forms the core of many developed countries' current reform agendas."

Optimal health system conditions for the contribution of the family doctor
In 1998, The WHO Regional Office for Europe published The Framework for Professional and Administrative Development of General Practice/Family Medicine in Europe. This document was a the product of a decade of collaboration among the WHO, their collaborating centers for primary health care and national and international associations and organizations of physicians and family doctors. Without ignoring the contribution of other medical specialties and other health professions, they were convinced general practice has the potential to contribute to Health For All, by offering:
For the family doctor to contribute optimally to Health For All, the document identifies l3 necessary conditions in the health system, medical practice and medical education. The conditions required for general practitioners to provide high-quality services were specified at a number of levels. Some are related to the structure of the health care system. Others are related to its organization at the local level. Some may be easier to realize and at an earlier stage than others. The aspects that are specific to general practice are considered below, under the following 13 headings: structural conditions, organizational improvement and professional development.

Structural Conditions
1.Family doctors serve a discrete population. `The provision of personal, comprehensive, and continuous care is encouraged by a continuing relationship between the family physician and the patient, based on mutual trust and agreement between the patient and the doctor. Such a relationship and continuity of care over time are facilitated when family physicians look after a well defined group of people, for example those registered in a personal or family list system. Having a specific family physician does not contradict the basic right of patients to choose their doctor, or the right to change from one doctor to another.

2.Family doctors care for all ages and both sexes. Family physicians must be trained to deal with the health problems of all population, including children, men, women and the elderly, without distinction. Providing integrated care to the population is enhanced when services are not fragmented among different specialties and agencies that deliver care to certain categories of patient or of the population.

3. Family doctors work in accessible community office practices. General practice is based in the community, close to patients, with easy access by them. When large populations are served and there is an increase in the number of health care providers, extra precautions should be taken to avoid reducing accessibility and threatening the personal character of the provision of care. Administrators, health authorities and doctors should find balance between the need for efficiency and the requirements of family practice.

4. Family doctors determine and coordinate referrals. The coordinating role of the family physicians is best carried out when their training provides them with the knowledge and skills required to manage the majority of the unselected cases that present to them and to refer appropriate cases to other health care providers, either within primary health care or to secondary specialized and hospital-based services. Cost- effective use of secondary care services is best achieved when only those cases that actually warrant these services are referred to them. Successful implementation of a referral system requires its acceptance by patients, which can be achieved through education and by fostering their trust in the family physician. It also requires good cooperation, exchange of information and reciprocity between family physician and other medical specialists and health professionals: family physicians must make appropriate referrals, and information must be fed back to them from specialists. Patients must also be similarly referred back.

5. Payment systems ensure the delivery of a full range of general practice services. The payment system should be well balanced, preferably combining a salary or other form of fixed payment, a capitation fee, and fee-for-service. Its aim should be to stimulate provision of the full range of services within the domain or general practice and to promote high quality primary health care by offering different incentives. The payment system may help to ensure the delivery of health promotive, preventive, curative and palliative services, as well as other aspects of practice such as team-based activities, general availability, operating an information system, carrying out teaching tasks when appropriate, and maintaining the premises and equipment. If market elements are introduced, standards of quality should be safeguarded.

Organizational Improvement
 6. Family doctors keep complete and detailed records. Systematically keeping detailed, problem-oriented and complete records of all encounters is important to maintain continuity over time, to identify episodes of illness, to create a patient history, and to coordinate care where several providers of care are involved. The records should also include other information relevant to patients' care, for example on matters relating to their living and working conditions and their lifestyles. Systematic preventive procedures and assessment of the health needs of the population are impossible without a sound record system that enables patient groups at risk to be identified. Finally, records are an essential requirement for quality development, audit of care, and peer review. As in any type of health care service, patient records may contain highly confidential information, and the confidentiality of the information must be preserved in accordance with existing legislation. Patients also have the right to access their own records, and information may only exceptionally be withheld from them when it reasonably appears that it would cause them serious harm without any expectation of obvious positive effects.

7. Family doctors are trained to work as a "team" with other health care providers. Coordination in health care requires general practitioners to have knowledge of the training of other health professionals and an understanding of what and how they can contribute of the work of other health care providers. Furthermore, cooperation among all health care providers involved in diagnosis, treatment and care, as well as with social care professionals, is a patient's right. Teamwork is by no means restricted to providers who work in shared premises. Those who work from separate offices and premises should have incentives to meet regularly and develop common aims and shared objectives and to evaluate the attainment of these objectives together. Teamwork makes it easier to pool the skills and expertise of a number of health and social care professionals and enhances their respect for each other's role.

8. Family doctors have adequate offices, equipment and staff to provide optimal care. Family physicians need adequate premises, equipment and ancillary staff. These should respect the privacy of patients, provide opportunities for diagnosis and treatment and facilitate accessibility. Family physicians may work alone, in groups or in health centers, but whatever the structure, the Practice organization should be flexible, which among other things means providing direct help for emergency cases, an appointment System for patients with less urgent problems and home care, whenever appropriate. Supporting services, such as X-ray and laboratory facilities, must be accessible to the family physician. With respect to 24-hour coverage, family physicians should be involved in the planning and management of out-of-hours services for the population and contribute to finding solutions that are feasible and acceptable to all parties involved.

Professional Development
9. Quality undergraduate, postgraduate (vocational) and continuing education in general practice is available. All health professionals and medical specialists work in primary health care must receive undergraduate, postgraduate and continuing education in the concepts and specific content of primary health care. The appropriate education of general practitioners is thus a crucial element in providing the integrated, comprehensive services that are referred to in this document. Education for general practice can usefully be considered under three headings: undergraduate training, postgraduate vocational training, and continuing medical education.
Undergraduate basic medical training. General practice should be an integrated part of undergraduate programs. All medical students should be exposed to general practice, so they may acquire the knowledge specific to this discipline.
Postgraduate (vocational) training. This must be a requirement to become a family physician. This vocational training should be equivalent to that of other main clinical specialties and should be primary-health-care-oriented and based, to a considerable extent, in general practice. Practices, possibly affiliated to academic departments, should have a prominent role in teaching. The trainee must be offered sufficient opportunity to acquire broader skills, for instance in communication with patients, counseling and practice management. Drawing up a core content of general practice is required for developing a proper vocational training program.
Continuing medical education. Continuing medical education and professional development are prerequisites for updating skills and maintaining and improving quality of care,. CME programs must be general-practice oriented and based on research, in particular in primary health care. The prime responsibility for CME rests with each medical practitioner, who needs to use different modalities to achieve and maintain their competence. Distance learning techniques may be of great benefit to facility access to training by doctors. Interactive learning generally gives the best results.

10. Family doctors are trained in and use clinical audit and quality improvement systems to enhance clinical care and service. General practice should be open to evaluation. Quality assessment and development is essential, irrespective of the employment status of family physicians. Systems of clinical audit organized by doctors themselves and carried out in peer groups are effective. Agreed upon professional guidelines, as they are currently being developed in some countries, are important tools for professional development and should be adapted to national and local circumstances.

1l. Well-funded academic departments of general practice with adequate numbers of well-trained faculty are available. Given the specific characteristics of general practice as a specialty, its recognition as an academic discipline is essential to the acceptance of general practice as a full partner in the provision of health care. Efforts must be made to establish fully funded academic departments and professors of general practice where they do not yet exist. These departments, with sufficient resources of all kinds, must be headed by practicing family physicians or persons with a solid background in general practice and appropriate academic credibility, and supported by their peers. They should be continuously involved in clinical general practice and should have close links with other disciplines.

12. General practice research is adequately funded and tied to relevant primary health problems. Academic discipline cannot be created in a vacuum. It needs a scientific basis to create its own body of knowledge. Academic departments of general practice should concentrate not only on training and education but also on research. There should be opportunities for trainees to carry out research in the vocational training program. General practice research should be sufficiently funded and closely related to the health problems that family physicians care for and to the clinical activities that they carry out in their daily work.

13. An effective professional organization represents family doctors. From the conditions described above, the profession of general practice clearly needs an effective organization to identify professional needs and promote professional needs and promote professional development at national and international levels and to support local initiatives. The two functions, political and academic, are usually organized separately, although a single organization combining both functions is possible. Family physicians must be represented at the highest levels in all the relevant medical decision-making bodies.

Collaboration between WHO and WONCA to enhance the contribution of the family doctor
At the 5th World Conference on General/Family Practice in Melbourne, Australia, in 1972,23 member countries of family doctors established the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA). Today, known as the World Organization of Family Doctors, WONCA has 65 member organizations from 56 countries representing more than 150,000 family doctors worldwide, as well as 1,580 Direct Members from 84 countries.

Embracing the global vision of Health For All, this growing world community of family doctors opened a dialogue with the WHO in the early 1980s that has since expanded into a common global vision and action plan for improving people's health. During the 1980s, WONCA and the WHO established an informal liaison to explore a common action plan for improving the health of individuals and communities. In the 1980s, WONCA established official relations with the WHO as a nongovernmental organization. In October 1993, WONCA and WHO representatives met during the International Conference on the Education of the Family Physician, held at the National Institutes of Health in Bethesda, Maryland, USA, to organize a global working meeting to develop a common vision and action plan for improving the health of individuals and communities. In November 1994, WONCA and WHO convened a Strategic Action Forum in London, Ontario, Canada, involving 60 government health officials, medical educators, family doctors and public representatives from around the world. The purpose of the forum was to identify specific actions to contribute to the Health For All goals by improving health care, medical practice and medical education and by examining the roles of physicians and especially family doctors in the health system. This Strategic Action Forum contributed to the release in January, 1995, of a historic WHO-WONCA working paper entitled "Making Medical Practice and Education More Relevant to People's Needs: The Role of the Family Doctor". The vision guiding this partnership was captured in a joint statement:

"To meet people's needs, fundamental changes must occur in the health care system, in the medical profession, and in medical schools and other educational institutions. The family doctor (general practitioner/family physician) should have a central role in the achievement of quality, cost effectiveness and equity in health care systems. To fulfill this responsibility, the family doctor must be highly competent in patient care and must integrate individual and community health care. The cooperation between the World Health Organization (WHO) and the World Organization of Family Doctors (WONCA) towards this vision is historic."6
The WHO-WONCA working paper and its recommendations contributed to the adoption of a historic resolution by the World Health Assembly in May 1995 entitled, "Reorientation of Medical Education and Medical Practice for Health for All." This resolution called for the WHO Director General to facilitate global efforts to reform medical practice and education in concert with the principles of Health For All and to assist general/family practitioners to enhance the quality, relevance, cost-effectiveness and equity of health care systems.

Collaborative activities between WHO and WONCA since 1995 are summarized in the WHO-WONCA 1995-1998 Process Report and 1998-2001 Action Plan.7 Contained within are progress reports from more than 30 countries who contributed to the WHO's Health For All goals by improving their health systems and enhancing the contribution of the family doctor.

In addition, this Report contains the WHO-WONCA Memorandum of Understanding for Collaborative Activities for the Period of 1998-2001. This document summarizes the following set of joint projects between WHO and WONCA:
TUFH (Towards Unity for Health). This international conference and project will identify and disseminate global collaborative models that integrate medical and public health care.
World Survey of Family Medicine and General Practice. This WHO administered survey will establish baseline information against which the progress of future initiatives may be measured.
Rural health. WHO and WONCA will support family practice initiatives to respond to rural health needs.
WHO collaborating centers in general practice/family medicine. WHO will support the development of such centers around the world.
Development of a practical guide to assist countries to enhance the contribution of the family doctor. WHO and WONCA will assist member states in making appropriate decisions regarding the development of family practice and education in support of health system reform through the a practical guide. This "guide" is intended to help those who wish to improve the health and well being of their community and nation by making health systems more relevant to people's needs, and to enhance the contribution of the family doctor towards this goal.

Final Comment
The "specialty" of family medicine is increasingly embraced by governments and health care advocates as one potential solution to health care systems that have failed to provide relevant, quality and cost-effective care to the entire population. Family Medicine programs that emphasize unique care directed to the person in the context of family and community promise to deliver the type of care that people want and need. Goals of WHO and WONCA include increasing the numbers of family physicians worldwide with the bigger goal of the attainment of health for all people worldwide.

References
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