It’s been a long time without you, my friend

Feature Stories June 2021

June, 2021

Dear Barbara,

It has been 10 years since we last spoke. I miss the conversations during our many walks which I treasured. A lot has happened since then!

For instance, “population health” has become an approach many health care organisations worldwide embrace. Despite the fact that Obama was able to enact the Affordable Care Act the US health systems remain fragmented, many millions remain uninsured, and we remain a long way off from having a single-payer system as you favored. By the way, the term “managed care” has now migrated into “integrated care”. I actually like the evolution as it embraces more professions, sectors, and facets of care. Additionally, there has been increased focus on the role of community in the delivery of primary care. Integrated care is also more inclusive of the patient and the caregivers – a concept I know was close to your heart. All good.

The delivery of health care has arrived in the information age and “big data” has become the latest trend resulting in a tsunami of data. This has come about to a large extent due to “social media” which captures individuals’ every move whether they want it or not. Then there is the internet which enables armchair “doctor-wanna-bes” to offer treatments of questionable value. Patients arrive for a doctor’s appointment with a ream of information which necessitates a new role for family doctors to help patients discern what is valid advice from what is quackery.

There has also been an expansion in the use of eHealth solutions– electronic medical records, wearable vital sign monitors, use of computers for virtual consultations, cell phone apps which ensure patients are connected to their clinicians and the list goes on. The conundrum is that there is limited analysis done with this plethora of data and concerns remain regarding governance issues, such as who owns the data, data security issues as well as unanswered questions as to how such services will be remunerated. With that said, Hopkins finally formed the Center for Population Health Information Technology which conducts research on the increased sources of data. As a result, the ACG System has adapted and released a further three versions.

And now we find ourselves in the middle of a global pandemic… yes, exactly what you and I talked about. Yet, unfortunately, it didn’t turn out the way you and I envisioned. The pandemic exposed all the gaps in the system – and the lack of reliance on primary care to test, triage, coordinate follow-up care, and administer vaccines. People are getting their shots in drive-through vaccine centers like they would pick up a hamburger from McDonalds.

In most countries, there was limited or no coordination with public health efforts. Instead, individuals bypassed their primary care practice and were more likely to go straight to hospital. The avoidance of primary care practices also resulted in delayed visits for routine check-ups and well-child visits, not to mention the strain it put on the financial (and mental) well-being of family doctors. You would be exasperated as am I and as are many of our colleagues. There will be many uncomfortable conversations needed to secure the primacy of family doctors in the delivery of health care underscoring their role as the “first-contact”, and to involve them in the drafting of future pandemic plans. I trust that you have heard from your husband, Tony, regarding the absurdities of the Trump administration. Actually, Tony wrote an excellent commentary on this topic.

Despite the challenges, there has been progress in raising the importance of primary care ---

In recognition of the 40th anniversary of the signing of the Alma-Ata Declaration, the Global Conference on Primary Health Care took place in Astana, Kazakhstan in October 2018 and I had the honor to attend on behalf of the WHO.

To affirm the commitments to primary health care the Declaration of Astana was signed by member states. There was understandable frustration from the family doctors since they were not named explicitly. This was a result of the determination by signatories that it was better not to name professions and risk leaving someone out, however, I share family doctors’ understandable disappointment. To date this hasn’t proven to diminish their desire to continue to advocate for primary care.

I believe you would approve of the definitions of primary health care and primary care, which were drafted along with the declaration, since they were written with your words in forefront. It is now up to all of us to be consistent in using these definitions to ensure they become engrained in the ongoing vernacular.

In addition, the World Health Organization has set up a Special Program on Primary Health Care based on the premise - “PHC, because it is about how best to provide health care and services to everyone, everywhere, is the most efficient and effective way to achieve health for all.” (WHO website, accessed June 5, 2021). The WHO has also developed a PHC Monitoring and Evaluation Conceptual Framework along with associated indicators. Projects which I had the privilege to contribute to. It remains to be seen whether this will manifest a true impetus for primary care strengthening.

Speaking of assessing primary care, the PCATs are still alive and well. Our friends in Latin America have developed an Iberoamerica version (IA-PCAT) which harmonizes and updates the existing versions in use in the region. So, we are on our way toward a universal PCAT version.

There has also been an increased recognition that to achieve Universal Health Coverage (UHC) “which means that all people have access to the health services they need, when and where they need them, without financial hardship” (WHO website, accessed June 5, 2021), a strong, robust PHC approach is needed. To be sustainable and resilient, the house of health cannot be built on sand which shifts based on donors’ fancy, but stand on the holistic values of primary health care.

And you will be pleased to learn that WONCA World elected its first female president and the current president-elect is also a woman. (high-five).

Many individuals you are familiar with have risen to the occasion. They have been joined by many others from a new generation. All continue to shout out the need for a solid foundation to support the columns of vertical programs.

All said, primary care is more than just surviving, it is gaining strength. Sometimes those of us close to the fight don’t appreciate the progress that has been made. After all, it is a slow arduous journey and there remains much to be done. One thing which is needed is an increase in the voice of family doctors in critical health policy decision making with a goal to restructure health care systems such that family doctors are the first-contact a patient has with the health care system providing comprehensive care, the coordinators of patients’ care both within the primary care setting as well as across the health care spectrum, and the long-term companion of patients and their caregivers. I wonder what your thoughts would be to add a sixth “C” – “offering care in the context of the Community”?

I was blessed that Normalie stayed with me for many years. In the meantime, she has since retired and is doing fine. She said to say hello.

It has been an encouraging 10 years and there is so much more to share with you, but this letter is already long enough. I look forward to filling you in more fully next time.