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Fourth Wes Fabb Oration Diversity of primary care in Asia Pacific: pathways to convergence

Fourth Wes Fabb Oration Diversity of primary care in Asia Pacific: pathways to convergence Asia Pacific is one of the 6 regions of the World Organization of Family Doctors (Wonca). It is a region with 16 full and 2 associate members coming from 14 countries. One of the main activities in the region is the regional con- ference highlighted by the Wes Fabb Oration. This Fourth Wes Fabb Oration has a historical perspective and three main parts: the results of a cross sectional sur- vey done among member organizations and three countries not affiliated yet with Wonca which show Family Medicine as to status, practice, education and research; the regional initiatives and activities which indicate conver- gence; and, suggested action points which can further promote family medicine development, collaboration, and convergence. Introduction education. Thus, being webmaster of Global Family One of the great events in the World Organization of Doctor after his retirement as chief executive officer Family Medicine (Wonca) Asia Pacific Region is the and establishing the Journal Alert was not a surprise. establishment of Professor Wes Fabb Oration in 2001, Retiring as webmaster, he continued as one of its medi- an initiative done to honor Wes and his contribution to cal editors. the development and strengthening of family medicine Professor Fabb’s guiding principle is that “Wonca is around the world. Wes served Wonca for more than a inclusive,” a principle he infected us with, and is con- quarter of a century, first as honorary secretary and at tributory to the growth of Wonca. He is consistent with the time of his retirement in 2001, he was chief execu- his belief in what family medicine and Wonca stand for. tive officer. The Wes Fabb Oration also honors Asian Reading through articles he has written in more than family physicians who have personified what Wes stands 30 years, what stand out are his advocacies for optimum for and who have similarly contributed to family medi- quality and comprehensive care in family medicine and cine growth and the improvement in health and well high standard of family medicine education [1-3]. being of patients. In what way did Professor Fabb influence my career It is a great honor to deliver the Fourth Wes Fabb and advocacies in family medicine? As regional presi- Oration in the birthplace of Professor Fabb and dent (then called regional vice president) for Asia Paci- Wonca, after three previous orators who are giants of fic, reaching out to member organizations through family medicine - Professor Fabb himself, and former personal visits and constant communications at the time Wonca world presidents Dr. Peter CY Lee and Dr. MK when the internet is not that popular yet, I would say, Rajakumar. I thank the Royal Australian College of brought the member organizations closer to Wonca. In General Practitioners and Wonca Asia Pacific Region addition, we were able to have our own structure as a for this honor. region, with its own set of regional executives and I had the privilege of working closely with Professor bylaws like Europe. Member organizations were encour- Fabb, whom I consider to be one of my mentors. His aged to join forces with governments and medical love for family medicine and Wonca is a lifelong com- schools bringing with them the “Core curriculum for mitment, similar to his belief in lifelong medical family medicine residency“ and the London Ontario pro- ceedings on “Making health system more relevant to Correspondence: dfcmdada@yahoo.com people’s needs: the contribution of family doctors.” Department of Family and Community Medicine, University of the Strengths of each member organization and needs of Philippines Manila, Manila, Philippines © 2010 Leopando; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Leopando Asia Pacific Family Medicine 2010, 9:7 Page 2 of 7 http://www.apfmj.com/content/9/1/7 others were matched to facilitate collaboration. Work- region are so diverse in geographic size, population, reli- shops were institutionalized in the promotion of high gion, economics, politics, culture, and health care. standards of family medicine education, research work- If we group the member organizations according to shops and contests were held and the foundation for hemisphere of location, northern hemisphere will have Asia Pacific Family Medicine, the official scientific pub- organizations from China, Hongkong, Japan, Macau, lication of Wonca Asia Pacific, was laid down. Thus, by Mongolia, South Korea, and Taiwan. Central hemi- 2001 when my term as regional president ended, we had sphere will be the ASEAN region currently with organi- scheduled regional conferences up to 2008, called for zations from Indonesia Malaysia, Myanmar, the submission of papers to Asia Pacific Family Medicine, Philippines, Singapore, Thailand and Vietnam. Southern instituted the journal’s peer review process, and hemisphere has organizations from Australia, Fiji and approved the Wes Fabb Oration. New Zealand. (See Figure 1) The inspiration from Wes and the theme of the con- Wonca Asia Pacific has 16 full and 2 associate mem- ference motivated me to choose the topic “Diversity of bers. (See Figure 2) primary care in Asia Pacific: pathways to conver- Primary care in Asia Pacific is anchored on family gence” for this Fourth Wes Fabb Oration. medicine and general practice. The training and practice of primary care is diverse due to varying influences from Historical perspective the United Kingdom and United States of America. Asia Pacific is one of the 6 regions of the World Orga- Established in 1972, the Wonca has worked tediously nization of Family Doctors (Wonca). Serving 2.07 billion in hastening the development of Family Medicine. people, it is the only region that extends from the Through the efforts of its members, Wonca was able to northern to southern hemispheres. Countries in the conduct educational workshops which formulated the Figure 1 Map of Wonca Asia Pacific Region. Leopando Asia Pacific Family Medicine 2010, 9:7 Page 3 of 7 http://www.apfmj.com/content/9/1/7 Figure 2 Member organizations of Wonca Asia Pacific Region. core curriculum for family medicine, as well as the core still very relevant and I quote: “to meet people’sneeds, content of examination. Research workshops gave way fundamental changes must occur in the health system, in to the publication of several journals, including the Asia the medical professions, and in medical schools and Pacific Family Medicine [4,5]. In addition, Wonca, both other educational institutions. The family doctor should globally and regionally, has undertaken activities that have a central role in the achievement of quality, cost- guide countries in developing, strengthening, and enhan- effectiveness, and equity in health systems. To fulfill this cing primary care. Global activities include the 1994 responsibility, the family doctor must be highly compe- Wonca - WHO strategic meeting in Canada, Global tent in patient care and must integrate individual and Family Doctor website, 2002 Guidebook, and 2003 community health care [6].” I am thankful that when I Research Workshop. Among the regional activities in became Regional President for Asia Pacific, I had the Asia Pacific were regional conferences, regional struc- London Ontario document with its 14 vision statements ture and bylaws, the struggling Asia Pacific Family Med- on optimal medical care, optimal medical practice, and icine journal and family medicine education workshops. optimal medical education; and 21 specific recommen- WONCA has worked closely with the World Health dations which set the direction on how I would function Organization (WHO), which in 1978 identified primary in my office and in how I would lead the member health care approach as the strategy to attain the organizations toward the Wonca goal of excellence global target of “Health for All by the Year 2000.” With and relevance in family medicine practice and education. family physicians and general practitioners at the fore- The action points derived from the 1994 joint Wonca - front of care, Wonca supported the initiative. In the WHO strategic forum on the “Contribution of the WHO-Wonca conference on contribution of family doc- family doctor,” were monitored in the Asia Pacific tors, the executive summary was very challenging and Region from 1995 to 2001. Twinning between Leopando Asia Pacific Family Medicine 2010, 9:7 Page 4 of 7 http://www.apfmj.com/content/9/1/7 organizations was encouraged, and more frequent regio- care and only 37% affirmed its presence. All 7 with nal conferences were held, thus bringing member orga- mandate reported finishing a medical degree with nizations closer to Wonca and with each other [7-9]. license to practice as requirement. Only 3 identified WHO’s focus on family medicine was further intensified board qualified and/or trained family physicians as pre- in the late 1990s through the “Towards unity for health” requisite to practice. Of the 10 with no mandate, 8 have campaign, which integrated individual health with popu- no plan to work for a policy. But do we need a policy? lation health and clinical medicine with public health. Barbara Starfield in her studies showed that countries giving greater emphasis on primary care spend less on Diversity in status of primary care and family health care and have better outcomes. Primary care phy- medicine development sicians provide first contact, comprehensive care and An internet cross-sectional survey of all member organi- entry into the health delivery system is one of the char- zations in Asia Pacific and non member organizations in acteristics [11]. countries like Brunei, Laos and Cambodia was done to Multiple answers on locus of care showed that family determine the status of family medicine development. physicians provide continuity of care geographically. All There was a response rate of 86.4%. Respondents were answered community-based clinic followed by home distributed as follows: 6 from northern hemisphere, 10 care. More than 50% answered hospital-based clinic/sur- from central hemisphere and 3 from southern gery and industrial/occupational clinic. These are con- hemisphere. siderations in training family physicians because The 19 respondents included national office bearers, different areas have unique needs. Wonca council members, and academic department The predominant level of care provided is primary heads and three respondents from organizations not yet care at the outpatient level, sometimes with inpatient affiliated with WONCA. Table 1 shows summary of component or at secondary level of care. Family physi- results. (See Table 1) cians have mixed sector affiliations working with both the government health centers and the private sector for 1. Specialty status a fee. Less than half are with national health insurance Family Medicine is recognized as a specialty according or private health maintenance organizations (HMOs). to 13 respondents and recognition was given mainly by 52.6% answered no patient registration while 36.8% the national medical organizations, policy makers on mentioned that patient may either be listed with a medical education, and the departments of health. (See family physician or a health facility. About 52% of Table 1) In the 1960s, Professor Ian Mc Whinney, respondents indicated the presence of formal referral explaining why family medicine is a specialty, empha- policy and mechanism while 36.8% have none. sized its distinct core knowledge, unique field of action, In the 1990s, most countries underwent health sector training which is intellectually vigorous, and active area reforms, which included health financing through social of research [10]. insurance. More than half answered selective health insurance scheme, while a third answered that there is a 2. Practice of Primary Care national health service with universal coverage. Another On the role of family physicians in health care, 52.5% of third said there is free public sector at health center and respondents revealed the absence of law or policy man- fee for service private sector, indicating combination of dating family physicians to be the entry point of health ways by which health care is financed. Professor Goh Lee Gan mentioned in an article that improvement of payment scheme for primary care physicians is an Table 1 Specialty Recognition of Family Medicine in Asia important issue for survival [12]. Pacific, 2006-2008. Organization Giving HEMISPHERE TOTAL 3. Academic development Recognition Around 68% of organizations confer academic recogni- Northern Central Southern tion to members. However, terminologies for ranking National Medical Organization 4 6 3 13 are varied with the title of fellow as more commonly used. Majority (14/19) have certifying specialty examina- Policy making body of Medical 56 2 13 Education tion, and another majority (13/19) have no system of Department of Health/Ministry 25 3 10 recertification. of Health Compared to the 1992 survey on academic programs, General Medical Council 3 3 3 9 the recent survey revealed that there are more countries National Health Insurance 3 2 2 7 offering undergraduate program in family medicine. Pre- (n = 19) sently, there are 16 countries offering residency or Leopando Asia Pacific Family Medicine 2010, 9:7 Page 5 of 7 http://www.apfmj.com/content/9/1/7 vocational training. There were only 10 in 1992[13]. respondents are: Obstetrics and Gynecology, Mental Also available are continuing professional development Health and Psychiatry, and Emergency Medicine. and/or graduate programs. (See Table 2) Evaluation of trainees is both formative and summa- When asked to characterize family medicine under- tive. Feedback of the evaluation is an important feature. graduate educational program, it is noted that: Formative assessment covers observational rating scale for marking, review of portfolio and processing of video � Fourteen have family medicine course, thirteen tapes. Summative evaluation is done through written have clinic rotation and Family Medicine is offered and practical examinations which use multiple choice in all medical schools in eleven. questions, objective structured clinical examinations � Ten offer Family Medicine with Community Medi- (OSCEs) and long cases. In addition, graded case report cine but is offered as solo subject in 9. and thesis are reported. Evaluation of training programs � Eight respond that Family Medicine integrates clin- is done through accreditation and trainees’ feedback ical medicine, behavioral science and public health. evaluation of their experiences. Program accreditation is done by the Ministry of Sixteen reported having residency/vocational training Health at the national or provincial level, certifying in Family Medicine. Learning objectives include board, and the national accrediting committee. Accredi- expected competencies and characteristics of family phy- tation is conducted every 1 - 6 years using set criteria sicians (68.8%), preparation for practice of family medi- and standards. cine (37.5%), and domain (3/19). The guiding principles used in selecting the learning 3. Research and quality activities strategies are: adult learning, problem-based learning, Quality activities are important to family medicine. Pro- and learning by doing. Strategies include learning with fessor Fabb has promoted this since 1990, and Wonca patients such as: hospital and practice postings, bedside has a world committee for this. Of the 9 respondents rounds, direct observation or review of video tapes of answering this question, 8 identified the following activ- consultation. Learning with supervising physicians dur- ities: practice standards in family medicine; quality activ- ing conferences entails: case discussion/presentation, ities such as evidence-based medicine, utilization of lectures and workshops done either as monthly intensive clinical practice guidelines and medical audit. Six men- courses, modules, or weekend sessions. Self-directed tioned that physicians are required to participate in learning includes learning portfolio and its review, dis- quality activities with 4 reporting actual engagement in tance learning, and learning contracts. quality projects. Mechanism of practice review through Importance is also given to evidence-based medicine, peers/experts visit for assessment based on standards is quality assurance and research, with chart review, medi- mandatory in 3 but optional in 2. cal audit, critical appraisal of the literature, mortality Research is an important component of family medi- and morbidity review. cine as a specialty. Activities for research capability The venue for clinical training is mixed hospital and building include research writing workshop, research practice based clinic in the community. proposal making workshop, and research consultants The most popular rotations for the residency training assisting members. Other research-related activities have are: 94% each for Internal Medicine, Pediatrics, and Sur- something to do with research funding, technical and gery, which are higher than the combined Family Medi- institutional review, and practice based research cine/Primary Care/Health Center rotations. Considering network. that we are in family medicine, we would expect 100% Research dissemination activities include research pre- inclusion. Other rotations given by more than 50% of sentation in annual scientific assembly topping the list Table 2 Available Family Medicine Academic Program/s in Asia Pacific, 2006-2008 Training Program HEMISPHERE TOTAL Northern Central Southern Undergraduate Program (Medical curriculum) 5 9 2 16 Residency/Vocational training 6 8 2 16 Continuing Professional Development Program 5 5 3 13 Graduate degree (Master) 4 6 2 12 Diploma Course 3 5 1 9 (n = 19) Leopando Asia Pacific Family Medicine 2010, 9:7 Page 6 of 7 http://www.apfmj.com/content/9/1/7 followed by submission of abstracts to Wonca confer- 3. Primary care research network has started but ences and research contests. participation in face-to-face meetings and virtual dis- Nine reported that papers are submitted to Asia Paci- cussions has not included all member organizations. fic Family Medicine. Only 9 each have their own peer To start collaboration, the region has chosen “Family reviewed journal or give out awards to outstanding life cycle in Asia Pacific,”“Chronic disease manage- researchers. ment strategies” and “Teaching related research” as the priority research agenda. 4. Best Practices and needs lead to twinning 4. Family Medicine education workshops have opportunities (See Table 3) been done in conjunction with most regional confer- Table 3 shows twinning opportunities of areas with best ences. During the Training of Trainors (TOTs) practices with significant problems and needs for assis- workshop held in Vietnam, it was agreed that TOTs tance. The best practices make it easier for Asia Pacific will be held in areas where they are most needed. to establish a database on resources available. Thirteen This is easy because there are available experts in reported on their best practices, which included com- the region waiting to be tapped. munity based practice or community oriented primary 5. There is a clamor for a common regional exami- care; RACGP conjoint examination; training programs, nation. At present, three countries have conjoint including teacher training; on line teaching; and orga- examination with RACGP. Will RACGP examination nized tutors group. Significant problems and frustrations be the regional examination or will it be the gold cited by 14 respondents include: recognition/antagon- standard? ism, lack of funds, member participation, role of family 6. Twinning is happening between Singapore and physicians in health care, and migration. Needs for assis- Myanmar, Thailand and Cambodia, Hongkong and tance expressed were on research issues, networking, China, the Philippines and Vietnam, Australia and improvement of training programs, trained teachers, col- Fiji, and Korea and Mongolia. laboration with Wonca, legislation on family physician’s 7. WONCA Rural Health emanated from Australia, role, and regional recognition of programs. and its conferences have been held in China, Malay- sia, and Melbourne. There is a need to encourage Pathways to convergence rural doctors to be active in the Working Party. The pathways to convergence in the midst of diversity, Many counties are not yet integrated into the party. as indicated by the results of the above cited survey, In addition, we need to ensure that rural health start with what we already have and what we in Asia stream will be included in all regional and world Pacific can tread on. conferences. 8. WONCA Working Party for Women and Family 1. WONCA 2007 Resolutions on “Support to Medicine has championed Gender Equity with HER Hamilton Equity Recommendations (HER) Statement Statements and 10 Point Ways. Three sessions are and gender equity“, “A family physician for every included in this conference, but there is a need to family“ and “Family Medicine taught in all medical ensure that sessions on women are sustained. More schools“ are good starting points to review what the important to anticipate is what each member organi- member organizations can collectively advocate. zation will be doing to promote gender equity in Some have started and experiences can be shared. between regional and world conferences. 2. Asia Pacific Family Medicine,our constant 9. ASEAN region primary care. In one of the issues forum for convergence and sharing. Support for the of Asia Pacific Family Medicine, Professor Richard journal can be shown through submission of more Hays mentioned the need for the central hemisphere articles, writing letters to editors on what to improve to develop family medicine not only in practice but and nominating peer reviewers. also in education [14]. The central hemisphere or Table 3 Twinning Opportunities, Asia Pacific Region Best Practices Significant Problems Needs for Possible Assistance � Community–based practice/community oriented primary care � Recognition/Status/Prestige � Research issues � Conjoint examination � Lack of funds � Networking � Training programs � Antagonism � Improvement of training programs � On-line teaching � Member participation � Trained teachers � Availability of consultants � Role of family physicians in health care � Collaboration with Wonca � Organized Teachers Group � Website not sustained � Legislation on Family Physician’s role � Primary Care policy of the government � Migration � Regional recognition of programs Leopando Asia Pacific Family Medicine 2010, 9:7 Page 7 of 7 http://www.apfmj.com/content/9/1/7 ASEAN has 10 countries with economic and cultural medicine statesmen in our region led by Professor Wes links. A political partnership through a constitution Fabb who continues to inspire and provide us with guid- similar to EU is rapidly gaining ground. Mutual ing light. The pathways have been paved through the recognition agreements have been signed for various cumulative efforts of Wonca leaders in the region. With professions. ASEAN region primary care (ARPAC) many of us already raring to make giant strides, there conference has been held and plans for collaboration remains only one option- that is making Professor on many issues are forthcoming. Fabb’s dream for family medicine excellence for Wonca Asia Pacific come true. Additional action points Acknowledgements 1. Revitalization of Regional Committees on Classifi- To the respondents of my survey for their support in participating in the cation, Quality, and Informatics with region wide activ- survey. To officials of the University of the Philippines Manila for giving me ities. Database on consultants, useful resources, protected time in preparing the oration. researches, and family medicine development projects To Maria Leticia Sapina, Cynthia Villamor and Nelson Cayno for their are needed. The Regional Executive and Council mem- assistance in writing the original oration paper. To Professor Leothiny Clavel for his valuable comments and for diligently bers should ensure a favorable environment to further going through the written version of this oration. push projects such as Classification, Quality and Infor- matics across member organizations. Competing interests The author declares that she has no competing interests. 2. Developments include expanding the involvement of women and young family physicians. Young women Received: 24 October 2009 Accepted: 26 March 2010 have met in Singapore and will meet here in Melbourne Published: 26 March 2010 to address various issues and concerns and how to do References so. Young men have issues and concerns too. The Raja- 1. Fabb WE: The Exciting Future of Family Medicine- Insights into the kumar Movement will be launched here in Melbourne. Emerging Roles of Family Physicians. Hong Kong Practitioners 1990, This is the start of collaboration among registrars/resi- 12(6):887-893. 2. Fabb WE, Chao DV, Chan CS: The Trouble with Family Medicine. Family dents and other trainees in Family Medicine. The Practice 1997, 14(1):5-11. women and the youth are clamoring for improved train- 3. Fabb WE: Conceptual Leaps in Family Medicine. Are there more to ing conditions and smoother transition from training to come. Asia Pacific Family Medicine 2002, 1:67-73 [http://www.apfmj-archive. com/afm1.2-3/afm_034.pdf]. practice. This can be possible if Wonca Asia Pacific can 4. Leopando ZE: Championing Family Medicine:- Regional Wonca Growth ensure that countries can lobby for stronger primary Maturity. Asia Pacific Family Medicine 2002, 1(1):5-6 [http://www.apfmj- care, grant specialty status to Family Medicine, guaran- archive.com/afm1.1/afm_008.pdf]. 5. Goh GL, Fabb WE: Family Medicine Development in the Asia Pacific tee that all families will have family physicians. Perhaps, Region. The Singapore Family Physician 2001, 27(3):31-36. strengthening relations with regional offices of WHO 6. Making Medical Education More Relevant to Health Care Needs. The can be a key element in this regard. Contribution of Family Doctor. World Health Organization and World Organization of Family DoctorsBoland M, Boelen C 1994, 3-10. 3. New activities which may be introduced are the 7. Ostergaard D: Making Medical Practice and Medical Education More formation of Asia Pacific Family Medicine Network of Relevant to Health Care Needs. The Contribution of Family Doctor. Academic Departments which can champion not only Toward Unity for Health WHO 2000, 28-29. 8. Leopando ZE: Triennial Report of Regional Vice President for Asia Pacific. resource sharing and faculty and student exchanges but Agenda Papers for Wonca World Council 1998, 28-42. also a core training program for family medicine with 9. Leopando ZE: Triennial Report of Regional Vice President for Asia Pacific. heightened learning experience in community-based Agenda papers for Wonca World Council 2001, 121-131. 10. Mc Whinney IR, Pickles William, Lecture: The Importance of being family medicine because this best simulate the practice. Different. Br J Gen Pract 1996, 46:433-436. Thetimeisripe for theconduct of aRegionalWork- 11. Starfield B: Primary care and health. A cross-national comparison. JAMA shop on definition of Family Medicine and role of family 1991, 266:2268-2271. 12. Goh GL: Primary Care in Asia Pacific, Making it Survive. Asia Pacific Family physicians in health care. Last but not least, a Regional Medicine 5 [http://www.apfmj-archive.com/afm5_2/afm42.pdf]. standards and International accreditation of residency/ 13. Leopando ZE, Olazo R, Gan Goh Lee, Editors: Core Curriculum for vocational training programs are necessary because we Residency/Vocational Training in Family Medicine/General Practice. World Organization of Family Doctors 1995, 35-38. are seeing health migrations not only of patients but 14. Hays R: The Central Hemisphere: The Potential of Academic Family family physicians. Medicine in the Asia Pacific Region. Asia Pacific Family Medicine 2003, 2:5-7 [http://www.apfmj-archive.com/afm2.1/afm_042.pdf]. Conclusion doi:10.1186/1447-056X-9-7 The journey to convergence in the midst of diversity Cite this article as: Leopando: Fourth Wes Fabb Oration Diversity of primary care in Asia Pacific: pathways to convergence. Asia Pacific Family started many years ago. We have most of the pieces in Medicine 2010 9:7. place. We have dedicated advocates of family medicine who are willing to work and help. We have family http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Fourth Wes Fabb Oration Diversity of primary care in Asia Pacific: pathways to convergence

Asia Pacific Family Medicine , Volume 9 (1) – Mar 26, 2010

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Copyright © 2010 by Leopando; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Asia Pacific is one of the 6 regions of the World Organization of Family Doctors (Wonca). It is a region with 16 full and 2 associate members coming from 14 countries. One of the main activities in the region is the regional con- ference highlighted by the Wes Fabb Oration. This Fourth Wes Fabb Oration has a historical perspective and three main parts: the results of a cross sectional sur- vey done among member organizations and three countries not affiliated yet with Wonca which show Family Medicine as to status, practice, education and research; the regional initiatives and activities which indicate conver- gence; and, suggested action points which can further promote family medicine development, collaboration, and convergence. Introduction education. Thus, being webmaster of Global Family One of the great events in the World Organization of Doctor after his retirement as chief executive officer Family Medicine (Wonca) Asia Pacific Region is the and establishing the Journal Alert was not a surprise. establishment of Professor Wes Fabb Oration in 2001, Retiring as webmaster, he continued as one of its medi- an initiative done to honor Wes and his contribution to cal editors. the development and strengthening of family medicine Professor Fabb’s guiding principle is that “Wonca is around the world. Wes served Wonca for more than a inclusive,” a principle he infected us with, and is con- quarter of a century, first as honorary secretary and at tributory to the growth of Wonca. He is consistent with the time of his retirement in 2001, he was chief execu- his belief in what family medicine and Wonca stand for. tive officer. The Wes Fabb Oration also honors Asian Reading through articles he has written in more than family physicians who have personified what Wes stands 30 years, what stand out are his advocacies for optimum for and who have similarly contributed to family medi- quality and comprehensive care in family medicine and cine growth and the improvement in health and well high standard of family medicine education [1-3]. being of patients. In what way did Professor Fabb influence my career It is a great honor to deliver the Fourth Wes Fabb and advocacies in family medicine? As regional presi- Oration in the birthplace of Professor Fabb and dent (then called regional vice president) for Asia Paci- Wonca, after three previous orators who are giants of fic, reaching out to member organizations through family medicine - Professor Fabb himself, and former personal visits and constant communications at the time Wonca world presidents Dr. Peter CY Lee and Dr. MK when the internet is not that popular yet, I would say, Rajakumar. I thank the Royal Australian College of brought the member organizations closer to Wonca. In General Practitioners and Wonca Asia Pacific Region addition, we were able to have our own structure as a for this honor. region, with its own set of regional executives and I had the privilege of working closely with Professor bylaws like Europe. Member organizations were encour- Fabb, whom I consider to be one of my mentors. His aged to join forces with governments and medical love for family medicine and Wonca is a lifelong com- schools bringing with them the “Core curriculum for mitment, similar to his belief in lifelong medical family medicine residency“ and the London Ontario pro- ceedings on “Making health system more relevant to Correspondence: dfcmdada@yahoo.com people’s needs: the contribution of family doctors.” Department of Family and Community Medicine, University of the Strengths of each member organization and needs of Philippines Manila, Manila, Philippines © 2010 Leopando; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Leopando Asia Pacific Family Medicine 2010, 9:7 Page 2 of 7 http://www.apfmj.com/content/9/1/7 others were matched to facilitate collaboration. Work- region are so diverse in geographic size, population, reli- shops were institutionalized in the promotion of high gion, economics, politics, culture, and health care. standards of family medicine education, research work- If we group the member organizations according to shops and contests were held and the foundation for hemisphere of location, northern hemisphere will have Asia Pacific Family Medicine, the official scientific pub- organizations from China, Hongkong, Japan, Macau, lication of Wonca Asia Pacific, was laid down. Thus, by Mongolia, South Korea, and Taiwan. Central hemi- 2001 when my term as regional president ended, we had sphere will be the ASEAN region currently with organi- scheduled regional conferences up to 2008, called for zations from Indonesia Malaysia, Myanmar, the submission of papers to Asia Pacific Family Medicine, Philippines, Singapore, Thailand and Vietnam. Southern instituted the journal’s peer review process, and hemisphere has organizations from Australia, Fiji and approved the Wes Fabb Oration. New Zealand. (See Figure 1) The inspiration from Wes and the theme of the con- Wonca Asia Pacific has 16 full and 2 associate mem- ference motivated me to choose the topic “Diversity of bers. (See Figure 2) primary care in Asia Pacific: pathways to conver- Primary care in Asia Pacific is anchored on family gence” for this Fourth Wes Fabb Oration. medicine and general practice. The training and practice of primary care is diverse due to varying influences from Historical perspective the United Kingdom and United States of America. Asia Pacific is one of the 6 regions of the World Orga- Established in 1972, the Wonca has worked tediously nization of Family Doctors (Wonca). Serving 2.07 billion in hastening the development of Family Medicine. people, it is the only region that extends from the Through the efforts of its members, Wonca was able to northern to southern hemispheres. Countries in the conduct educational workshops which formulated the Figure 1 Map of Wonca Asia Pacific Region. Leopando Asia Pacific Family Medicine 2010, 9:7 Page 3 of 7 http://www.apfmj.com/content/9/1/7 Figure 2 Member organizations of Wonca Asia Pacific Region. core curriculum for family medicine, as well as the core still very relevant and I quote: “to meet people’sneeds, content of examination. Research workshops gave way fundamental changes must occur in the health system, in to the publication of several journals, including the Asia the medical professions, and in medical schools and Pacific Family Medicine [4,5]. In addition, Wonca, both other educational institutions. The family doctor should globally and regionally, has undertaken activities that have a central role in the achievement of quality, cost- guide countries in developing, strengthening, and enhan- effectiveness, and equity in health systems. To fulfill this cing primary care. Global activities include the 1994 responsibility, the family doctor must be highly compe- Wonca - WHO strategic meeting in Canada, Global tent in patient care and must integrate individual and Family Doctor website, 2002 Guidebook, and 2003 community health care [6].” I am thankful that when I Research Workshop. Among the regional activities in became Regional President for Asia Pacific, I had the Asia Pacific were regional conferences, regional struc- London Ontario document with its 14 vision statements ture and bylaws, the struggling Asia Pacific Family Med- on optimal medical care, optimal medical practice, and icine journal and family medicine education workshops. optimal medical education; and 21 specific recommen- WONCA has worked closely with the World Health dations which set the direction on how I would function Organization (WHO), which in 1978 identified primary in my office and in how I would lead the member health care approach as the strategy to attain the organizations toward the Wonca goal of excellence global target of “Health for All by the Year 2000.” With and relevance in family medicine practice and education. family physicians and general practitioners at the fore- The action points derived from the 1994 joint Wonca - front of care, Wonca supported the initiative. In the WHO strategic forum on the “Contribution of the WHO-Wonca conference on contribution of family doc- family doctor,” were monitored in the Asia Pacific tors, the executive summary was very challenging and Region from 1995 to 2001. Twinning between Leopando Asia Pacific Family Medicine 2010, 9:7 Page 4 of 7 http://www.apfmj.com/content/9/1/7 organizations was encouraged, and more frequent regio- care and only 37% affirmed its presence. All 7 with nal conferences were held, thus bringing member orga- mandate reported finishing a medical degree with nizations closer to Wonca and with each other [7-9]. license to practice as requirement. Only 3 identified WHO’s focus on family medicine was further intensified board qualified and/or trained family physicians as pre- in the late 1990s through the “Towards unity for health” requisite to practice. Of the 10 with no mandate, 8 have campaign, which integrated individual health with popu- no plan to work for a policy. But do we need a policy? lation health and clinical medicine with public health. Barbara Starfield in her studies showed that countries giving greater emphasis on primary care spend less on Diversity in status of primary care and family health care and have better outcomes. Primary care phy- medicine development sicians provide first contact, comprehensive care and An internet cross-sectional survey of all member organi- entry into the health delivery system is one of the char- zations in Asia Pacific and non member organizations in acteristics [11]. countries like Brunei, Laos and Cambodia was done to Multiple answers on locus of care showed that family determine the status of family medicine development. physicians provide continuity of care geographically. All There was a response rate of 86.4%. Respondents were answered community-based clinic followed by home distributed as follows: 6 from northern hemisphere, 10 care. More than 50% answered hospital-based clinic/sur- from central hemisphere and 3 from southern gery and industrial/occupational clinic. These are con- hemisphere. siderations in training family physicians because The 19 respondents included national office bearers, different areas have unique needs. Wonca council members, and academic department The predominant level of care provided is primary heads and three respondents from organizations not yet care at the outpatient level, sometimes with inpatient affiliated with WONCA. Table 1 shows summary of component or at secondary level of care. Family physi- results. (See Table 1) cians have mixed sector affiliations working with both the government health centers and the private sector for 1. Specialty status a fee. Less than half are with national health insurance Family Medicine is recognized as a specialty according or private health maintenance organizations (HMOs). to 13 respondents and recognition was given mainly by 52.6% answered no patient registration while 36.8% the national medical organizations, policy makers on mentioned that patient may either be listed with a medical education, and the departments of health. (See family physician or a health facility. About 52% of Table 1) In the 1960s, Professor Ian Mc Whinney, respondents indicated the presence of formal referral explaining why family medicine is a specialty, empha- policy and mechanism while 36.8% have none. sized its distinct core knowledge, unique field of action, In the 1990s, most countries underwent health sector training which is intellectually vigorous, and active area reforms, which included health financing through social of research [10]. insurance. More than half answered selective health insurance scheme, while a third answered that there is a 2. Practice of Primary Care national health service with universal coverage. Another On the role of family physicians in health care, 52.5% of third said there is free public sector at health center and respondents revealed the absence of law or policy man- fee for service private sector, indicating combination of dating family physicians to be the entry point of health ways by which health care is financed. Professor Goh Lee Gan mentioned in an article that improvement of payment scheme for primary care physicians is an Table 1 Specialty Recognition of Family Medicine in Asia important issue for survival [12]. Pacific, 2006-2008. Organization Giving HEMISPHERE TOTAL 3. Academic development Recognition Around 68% of organizations confer academic recogni- Northern Central Southern tion to members. However, terminologies for ranking National Medical Organization 4 6 3 13 are varied with the title of fellow as more commonly used. Majority (14/19) have certifying specialty examina- Policy making body of Medical 56 2 13 Education tion, and another majority (13/19) have no system of Department of Health/Ministry 25 3 10 recertification. of Health Compared to the 1992 survey on academic programs, General Medical Council 3 3 3 9 the recent survey revealed that there are more countries National Health Insurance 3 2 2 7 offering undergraduate program in family medicine. Pre- (n = 19) sently, there are 16 countries offering residency or Leopando Asia Pacific Family Medicine 2010, 9:7 Page 5 of 7 http://www.apfmj.com/content/9/1/7 vocational training. There were only 10 in 1992[13]. respondents are: Obstetrics and Gynecology, Mental Also available are continuing professional development Health and Psychiatry, and Emergency Medicine. and/or graduate programs. (See Table 2) Evaluation of trainees is both formative and summa- When asked to characterize family medicine under- tive. Feedback of the evaluation is an important feature. graduate educational program, it is noted that: Formative assessment covers observational rating scale for marking, review of portfolio and processing of video � Fourteen have family medicine course, thirteen tapes. Summative evaluation is done through written have clinic rotation and Family Medicine is offered and practical examinations which use multiple choice in all medical schools in eleven. questions, objective structured clinical examinations � Ten offer Family Medicine with Community Medi- (OSCEs) and long cases. In addition, graded case report cine but is offered as solo subject in 9. and thesis are reported. Evaluation of training programs � Eight respond that Family Medicine integrates clin- is done through accreditation and trainees’ feedback ical medicine, behavioral science and public health. evaluation of their experiences. Program accreditation is done by the Ministry of Sixteen reported having residency/vocational training Health at the national or provincial level, certifying in Family Medicine. Learning objectives include board, and the national accrediting committee. Accredi- expected competencies and characteristics of family phy- tation is conducted every 1 - 6 years using set criteria sicians (68.8%), preparation for practice of family medi- and standards. cine (37.5%), and domain (3/19). The guiding principles used in selecting the learning 3. Research and quality activities strategies are: adult learning, problem-based learning, Quality activities are important to family medicine. Pro- and learning by doing. Strategies include learning with fessor Fabb has promoted this since 1990, and Wonca patients such as: hospital and practice postings, bedside has a world committee for this. Of the 9 respondents rounds, direct observation or review of video tapes of answering this question, 8 identified the following activ- consultation. Learning with supervising physicians dur- ities: practice standards in family medicine; quality activ- ing conferences entails: case discussion/presentation, ities such as evidence-based medicine, utilization of lectures and workshops done either as monthly intensive clinical practice guidelines and medical audit. Six men- courses, modules, or weekend sessions. Self-directed tioned that physicians are required to participate in learning includes learning portfolio and its review, dis- quality activities with 4 reporting actual engagement in tance learning, and learning contracts. quality projects. Mechanism of practice review through Importance is also given to evidence-based medicine, peers/experts visit for assessment based on standards is quality assurance and research, with chart review, medi- mandatory in 3 but optional in 2. cal audit, critical appraisal of the literature, mortality Research is an important component of family medi- and morbidity review. cine as a specialty. Activities for research capability The venue for clinical training is mixed hospital and building include research writing workshop, research practice based clinic in the community. proposal making workshop, and research consultants The most popular rotations for the residency training assisting members. Other research-related activities have are: 94% each for Internal Medicine, Pediatrics, and Sur- something to do with research funding, technical and gery, which are higher than the combined Family Medi- institutional review, and practice based research cine/Primary Care/Health Center rotations. Considering network. that we are in family medicine, we would expect 100% Research dissemination activities include research pre- inclusion. Other rotations given by more than 50% of sentation in annual scientific assembly topping the list Table 2 Available Family Medicine Academic Program/s in Asia Pacific, 2006-2008 Training Program HEMISPHERE TOTAL Northern Central Southern Undergraduate Program (Medical curriculum) 5 9 2 16 Residency/Vocational training 6 8 2 16 Continuing Professional Development Program 5 5 3 13 Graduate degree (Master) 4 6 2 12 Diploma Course 3 5 1 9 (n = 19) Leopando Asia Pacific Family Medicine 2010, 9:7 Page 6 of 7 http://www.apfmj.com/content/9/1/7 followed by submission of abstracts to Wonca confer- 3. Primary care research network has started but ences and research contests. participation in face-to-face meetings and virtual dis- Nine reported that papers are submitted to Asia Paci- cussions has not included all member organizations. fic Family Medicine. Only 9 each have their own peer To start collaboration, the region has chosen “Family reviewed journal or give out awards to outstanding life cycle in Asia Pacific,”“Chronic disease manage- researchers. ment strategies” and “Teaching related research” as the priority research agenda. 4. Best Practices and needs lead to twinning 4. Family Medicine education workshops have opportunities (See Table 3) been done in conjunction with most regional confer- Table 3 shows twinning opportunities of areas with best ences. During the Training of Trainors (TOTs) practices with significant problems and needs for assis- workshop held in Vietnam, it was agreed that TOTs tance. The best practices make it easier for Asia Pacific will be held in areas where they are most needed. to establish a database on resources available. Thirteen This is easy because there are available experts in reported on their best practices, which included com- the region waiting to be tapped. munity based practice or community oriented primary 5. There is a clamor for a common regional exami- care; RACGP conjoint examination; training programs, nation. At present, three countries have conjoint including teacher training; on line teaching; and orga- examination with RACGP. Will RACGP examination nized tutors group. Significant problems and frustrations be the regional examination or will it be the gold cited by 14 respondents include: recognition/antagon- standard? ism, lack of funds, member participation, role of family 6. Twinning is happening between Singapore and physicians in health care, and migration. Needs for assis- Myanmar, Thailand and Cambodia, Hongkong and tance expressed were on research issues, networking, China, the Philippines and Vietnam, Australia and improvement of training programs, trained teachers, col- Fiji, and Korea and Mongolia. laboration with Wonca, legislation on family physician’s 7. WONCA Rural Health emanated from Australia, role, and regional recognition of programs. and its conferences have been held in China, Malay- sia, and Melbourne. There is a need to encourage Pathways to convergence rural doctors to be active in the Working Party. The pathways to convergence in the midst of diversity, Many counties are not yet integrated into the party. as indicated by the results of the above cited survey, In addition, we need to ensure that rural health start with what we already have and what we in Asia stream will be included in all regional and world Pacific can tread on. conferences. 8. WONCA Working Party for Women and Family 1. WONCA 2007 Resolutions on “Support to Medicine has championed Gender Equity with HER Hamilton Equity Recommendations (HER) Statement Statements and 10 Point Ways. Three sessions are and gender equity“, “A family physician for every included in this conference, but there is a need to family“ and “Family Medicine taught in all medical ensure that sessions on women are sustained. More schools“ are good starting points to review what the important to anticipate is what each member organi- member organizations can collectively advocate. zation will be doing to promote gender equity in Some have started and experiences can be shared. between regional and world conferences. 2. Asia Pacific Family Medicine,our constant 9. ASEAN region primary care. In one of the issues forum for convergence and sharing. Support for the of Asia Pacific Family Medicine, Professor Richard journal can be shown through submission of more Hays mentioned the need for the central hemisphere articles, writing letters to editors on what to improve to develop family medicine not only in practice but and nominating peer reviewers. also in education [14]. The central hemisphere or Table 3 Twinning Opportunities, Asia Pacific Region Best Practices Significant Problems Needs for Possible Assistance � Community–based practice/community oriented primary care � Recognition/Status/Prestige � Research issues � Conjoint examination � Lack of funds � Networking � Training programs � Antagonism � Improvement of training programs � On-line teaching � Member participation � Trained teachers � Availability of consultants � Role of family physicians in health care � Collaboration with Wonca � Organized Teachers Group � Website not sustained � Legislation on Family Physician’s role � Primary Care policy of the government � Migration � Regional recognition of programs Leopando Asia Pacific Family Medicine 2010, 9:7 Page 7 of 7 http://www.apfmj.com/content/9/1/7 ASEAN has 10 countries with economic and cultural medicine statesmen in our region led by Professor Wes links. A political partnership through a constitution Fabb who continues to inspire and provide us with guid- similar to EU is rapidly gaining ground. Mutual ing light. The pathways have been paved through the recognition agreements have been signed for various cumulative efforts of Wonca leaders in the region. With professions. ASEAN region primary care (ARPAC) many of us already raring to make giant strides, there conference has been held and plans for collaboration remains only one option- that is making Professor on many issues are forthcoming. Fabb’s dream for family medicine excellence for Wonca Asia Pacific come true. Additional action points Acknowledgements 1. Revitalization of Regional Committees on Classifi- To the respondents of my survey for their support in participating in the cation, Quality, and Informatics with region wide activ- survey. To officials of the University of the Philippines Manila for giving me ities. Database on consultants, useful resources, protected time in preparing the oration. researches, and family medicine development projects To Maria Leticia Sapina, Cynthia Villamor and Nelson Cayno for their are needed. The Regional Executive and Council mem- assistance in writing the original oration paper. To Professor Leothiny Clavel for his valuable comments and for diligently bers should ensure a favorable environment to further going through the written version of this oration. push projects such as Classification, Quality and Infor- matics across member organizations. Competing interests The author declares that she has no competing interests. 2. Developments include expanding the involvement of women and young family physicians. Young women Received: 24 October 2009 Accepted: 26 March 2010 have met in Singapore and will meet here in Melbourne Published: 26 March 2010 to address various issues and concerns and how to do References so. Young men have issues and concerns too. The Raja- 1. Fabb WE: The Exciting Future of Family Medicine- Insights into the kumar Movement will be launched here in Melbourne. Emerging Roles of Family Physicians. Hong Kong Practitioners 1990, This is the start of collaboration among registrars/resi- 12(6):887-893. 2. Fabb WE, Chao DV, Chan CS: The Trouble with Family Medicine. Family dents and other trainees in Family Medicine. The Practice 1997, 14(1):5-11. women and the youth are clamoring for improved train- 3. Fabb WE: Conceptual Leaps in Family Medicine. Are there more to ing conditions and smoother transition from training to come. Asia Pacific Family Medicine 2002, 1:67-73 [http://www.apfmj-archive. com/afm1.2-3/afm_034.pdf]. practice. This can be possible if Wonca Asia Pacific can 4. Leopando ZE: Championing Family Medicine:- Regional Wonca Growth ensure that countries can lobby for stronger primary Maturity. Asia Pacific Family Medicine 2002, 1(1):5-6 [http://www.apfmj- care, grant specialty status to Family Medicine, guaran- archive.com/afm1.1/afm_008.pdf]. 5. Goh GL, Fabb WE: Family Medicine Development in the Asia Pacific tee that all families will have family physicians. Perhaps, Region. The Singapore Family Physician 2001, 27(3):31-36. strengthening relations with regional offices of WHO 6. Making Medical Education More Relevant to Health Care Needs. The can be a key element in this regard. Contribution of Family Doctor. World Health Organization and World Organization of Family DoctorsBoland M, Boelen C 1994, 3-10. 3. New activities which may be introduced are the 7. Ostergaard D: Making Medical Practice and Medical Education More formation of Asia Pacific Family Medicine Network of Relevant to Health Care Needs. The Contribution of Family Doctor. Academic Departments which can champion not only Toward Unity for Health WHO 2000, 28-29. 8. Leopando ZE: Triennial Report of Regional Vice President for Asia Pacific. resource sharing and faculty and student exchanges but Agenda Papers for Wonca World Council 1998, 28-42. also a core training program for family medicine with 9. Leopando ZE: Triennial Report of Regional Vice President for Asia Pacific. heightened learning experience in community-based Agenda papers for Wonca World Council 2001, 121-131. 10. Mc Whinney IR, Pickles William, Lecture: The Importance of being family medicine because this best simulate the practice. Different. Br J Gen Pract 1996, 46:433-436. Thetimeisripe for theconduct of aRegionalWork- 11. Starfield B: Primary care and health. A cross-national comparison. JAMA shop on definition of Family Medicine and role of family 1991, 266:2268-2271. 12. Goh GL: Primary Care in Asia Pacific, Making it Survive. Asia Pacific Family physicians in health care. Last but not least, a Regional Medicine 5 [http://www.apfmj-archive.com/afm5_2/afm42.pdf]. standards and International accreditation of residency/ 13. Leopando ZE, Olazo R, Gan Goh Lee, Editors: Core Curriculum for vocational training programs are necessary because we Residency/Vocational Training in Family Medicine/General Practice. World Organization of Family Doctors 1995, 35-38. are seeing health migrations not only of patients but 14. Hays R: The Central Hemisphere: The Potential of Academic Family family physicians. Medicine in the Asia Pacific Region. Asia Pacific Family Medicine 2003, 2:5-7 [http://www.apfmj-archive.com/afm2.1/afm_042.pdf]. Conclusion doi:10.1186/1447-056X-9-7 The journey to convergence in the midst of diversity Cite this article as: Leopando: Fourth Wes Fabb Oration Diversity of primary care in Asia Pacific: pathways to convergence. Asia Pacific Family started many years ago. We have most of the pieces in Medicine 2010 9:7. place. We have dedicated advocates of family medicine who are willing to work and help. We have family

Journal

Asia Pacific Family MedicineSpringer Journals

Published: Mar 26, 2010

References