News from WONCA South Asia - July 2023

Front-Line Warriors: The Evolving Role of Primary Care Physicians in South Asia

Authors:
Dr. Tariq Aziz, President WONCA South Asia Region (SAR)
Dr. Hina Jawaid, Chair WONCA SAR Primary Care Research Network
Dr. Ramakrishna Prasad, Editor WONCA SAR Journal

Compassion, competency, team-work, patient safety and equity are the fundamental pillars of primary care. In order to improve skills and knowledge of primary care physicians (PCPs) and overall quality of work structured training of PC Physicians is essential. Furthermore, to achieve universal health coverage in low middle-income countries, the existence and maintenance of robust primary care (PC) system is a must. Multiple efforts are taking place on a day to day basis in our region to contribute towards strengthening of PC system. Significant contributions by family physicians in research and academic activities along with defining recommendations and advocacy strategies for primary care have been shared in this section.

Continuing Medical Education Activities held in South Asia Region

1- Primary Care Research Network (PCRN) South Asia (Chair: Dr Hina Jawaid, Secretary: Dr Rama Krishna Prasad) arranged an online session on

(i) Leadership & Governance Training For Family Medicine Residents: Lessons from South Africa by Dr Klaus Von Pressentin, Associate Professor & Head Division of Family Medicine, University of Cape Town, South Africa on Saturday 24th June 2023

The main take home message of this session was the family physicians to act as agents of change and must be included in District Health Management to improve district health indicators of the country.

2- Educational activities conducted by Dr Basharat Ali, Academic secretary WONCA SAR. These were face-to-face sessions held in cities of Lahore & Gujranwala, Pakistan. The purpose of these sessions was to provide current, evidence-based clinical information to family physicians.

(i)- A 2- day workshop on “Hospital Acquired Infection Prevention and Control” by Dr Basharat Ali held on 3rd & 4th May and again on 22nd & 23rd June, arranged by Mercy Corps Pakistan at local hotel

(ii)- A lecture on “Importance of Research in General Practice in a conference in Lahore on 21st May 2023

(iii)- A presentation on TB diagnosis, management and prevention for Family Physicians in a local institution on 9th June 2023


3- Case- based discussions in Family Medicine, are on-going online educational activities held on 2nd June then 9th June 2023 by the department of Family Medicine at University of Health Sciences Lahore, Pakistan. These sessions provide a platform for practicing general practitioners (GPs) and trainees to discuss complex cases and difficulties in consultations or patient management.

4- A good number of practicing family physicians are regularly contributing in print media. Newspaper columns by Family Physicians Dr Hina Jawaid, Dr Abdul Jalil Khan, Dr Naseem Amin Dhedhi and Dr Naureen Kazim are as follows:

1- Providing Healthcare Cover - Universal Health Coverage: are we heading in the right direction? published 18th June 2023
2- Managing Measles
3- Typhoid Troubles
4- Understanding Monkey Pox
5- The Vital Vitamin

In this issue of the WONCA South Asia Report, we highlight two important policy engagements by the Academy of Family Physicians of India (AFPI) held recently in Hyderabad, India.

Future of Family Medicine in Telugu states: Relevance of State
Policies and Possibilities of Quality Medical Education

Moderator:
Dr. V. Sreenivas, Dean, College of Family Physicians of India, Academy of Family Physicians of India (AFPI)

Panelists:
Dr. Santosh Kumar Kraleti, Member, National Medical Commission, India
Dr. Raman Kumar, Family Medicine Physician & National President, Academy of Family Physicians of India (AFPI)
Dr. Raghu Ram, OBE, Renowned Surgeon, Padma Shri Awardee, and B. C. Roy Awardee
Dr. Malleswaramma, Family Medicine Physician & Deputy Civil Surgeon, Community Health Centre, Vempalli, YSR District, Andhra Pradesh

Introduction:

Recently, the two Indian states of Andhra Pradesh and Telangana have introduced different policies for citizens' health and wellness.

In Telangana state, demonstrating its commitment to the people, has launched National Health Mission (NHM) initiatives in the areas of reproductive and child health, institutional deliveries, introduction of new childhood vaccines, and the opening of several new public sector medical colleges, one in each district, and the opening of Basthi (settlement) dawakanas and Palle (Village) dawakanas in a few districts, among other things. However, some challenges and misdirections are also noted such as unnecessarily prioritizing the acquisition and construction of physical infrastructure (such as multi-storeyed healthcare buildings) and a relative inattention to human resources. Without enough medical professionals, such as doctors and nurses, these initiatives, while laudable, are nonetheless somewhat poor and insignificant. A large focus on investing public funds in high-rise hospital structures is often believed to be counterproductive and unrelated to the immediate requirements of people because people's health requires rapid attention and care.

In Andhra Pradesh, the government recently launched the Family doctor programme. This is a positive, unique and first of its kind initiative at scale in independent India. The government has recruited more than 1000 MBBS level doctors to implement this family doctor programme. While the government's focus is on health, the way the policy is being translated into practice needs to be re-examined. The major caveat with this programme is that the doctors recruited have neither studied or achieved accreditation in family medicine nor undergone any training in family medicine. It is observed that without scientific training, it is futile to implement family medicine and treat patients across the districts of the state.Thus it is feared that the state's health initiatives may become counterproductive, inadequately people-centric, and fail to stem the soaring out of pocket expenditure on health that is both marginalizing people and pushing families into poverty.



Against the above backdrop, the Moderator Dr V. Sreenivas, Dean Academics AFPI, posed two questions to the panelists regarding: 1) The purposefulness of the newly proposed Family doctor programme of Andhra Pradesh, a unique first of its kind programme in independent India, which is employing MBBS doctors who have not been trained in Family Medicine; and 2) The employment prospects of about 8500 MBBS doctors who will be graduating soon in Telangana, and the quality of medical education with regard to their preparedness and skills to provide competent primary care.

Dr.K Santosh Kumar, NMC member from Telangana, emphasized the training of the faculty of all disciplines, as well as the training of the family doctors who are employed in Andhra Pradesh, and explained the successes of the US in promoting Family Medicine as a distinct clinical speciality. He also suggested an exclusive round table conference with the NMC members to discuss the prospects of Family medicine in India be organized. He extended his full support to the cause of Family medicine.

Dr. Raghuram, a renowned Oncologist, cited the experience of the NHS in the UK, and explained how the general practitioners are providing health care services in a significant way. He criticized the present specialist driven health care system in India. He upheld the role of the family physician as the gatekeeper and the first contact in the health care delivery. He stressed the need for special training to be given to the MBBS doctors, so that they can render comprehensive, continuous and coordinated care.

Dr. Raman Kumar, AFPI National President, explained the need for building robust Family medicine services to improve the health care of India. This included the introduction of Family medicine into the undergraduate MBBS curriculum, on par with all the basic subjects, and thus preparing the future doctors to tackle diseases with a sound base of Family medicine. He also focussed on the need to create Family medicine departments at the undergraduate level and also starting Family medicine post graduate courses in all medical colleges. Only then can Family medicine can be recognised as a speciality with a broader base. He brought to the notice of the panelists that he had filed a Public Interest Litigation (PIL) in this context, and that this struggle will have to go forward until the goal is reached.

Dr Malleswaramma, Deputy Civil Surgeon, CHC from Andhra Pradesh, narrated her experiences in rendering specialized Family Medicine care in the Community health center (CHC) setting as a family physician, how she diagnoses complex diseases with her family medicine PG training, how she outnumbered the cases of tubectomies and C-sections of all other specialists of her area, and how she conducted various procedures. But even after her NMC recognised PG qualification in Family medicine, she is not given her due promotion as a specialist. She said that this should be corrected.
Additional themes and issues that came to light during the panel discussion are listed below.

Current Health Policies and Practices	Is this huge spending necessary when the conditions of PHCs and CHCs are appalling? What should be the government’s priority in the context of sustainable development goals planned to be achieved by 2030? What lessons the governments have learnt from COVID 19 experiences? How have these lessons been incorporated into the design and implementation of the current policies?
Status of Medical Education	Hundreds/thousands of medical students will graduate soon from the newly established medical colleges that are currently very poor in terms of infrastructure and having quality doctors and professional nurses. In such a case how do we ensure the quality of medical education and also their employability?
Quality and people centric Family Medicine	Many countries in the world have a family medicine residency programme. Only after completing three years of rigorous competency based training, they start functioning as family physicians, family doctors, general practitioners and primary care physicians. When this is the worldwide experience, why are we failing to learn from the above?
Involvement of Regulatory Bodies	In Telangana, due to restrictive rules of National Board of examinations various institutions like Apollo, Yashoda, KIMS,Care, Duddu shehwar and DDH haven’t reapplied for accreditation of DNB Family Medicine courses. As a result, currently, only one institute - Kamineni hospital is offering DNB programme, while in Andhra Pradesh (AP) - only Puttaparthi, Bathalapalli and Nandhyal institutes are offering DNB Family Medicine and NRI Guntur is offering MD Family Medicine.
Participation of people, doctors, nurses, and other professionals in policy formulation.	What are gaps between State health policies and real life conditions of people?
Future of Medical Education and Family Health	With regard to DNB and MD Family Medicine courses the situation is not encouraging. Though the NBE started a 2 year regular course - Diploma in Family Medicine (DipFM), Telangana does not even have a single seat yet. In such a situation, how do we address basic needs of people and establish standard medical education and deliver quality health care for people?

After these thorough discussions, Dr Sreenivas concluded that the perspective of giving competency based extra training in Family medicine to the MBBS doctors, before they can cater to the needs of the community as family doctors, has been stated by all the panelists. Family medicine specialists must be recruited as specialists into the primary and secondary levels of the health care system. Thousands of MBBS graduates coming out of Telangana medical colleges must be given the opportunity to pursue DFM and DNB/MD Family medicine courses and subsequently recruited into the public health system at various levels. All the panelists felt the need to increase the investments in primary care.

Keynote address by Honorable Former Chief Justice of India (CJI) Shri N. V. Ramana (Full text of speech)

Full text of the inaugural address delivered by Shri Justice N V Ramana, former Chief Justice of India at the two-day first joint conference of Academy of Family Physicians of India (AFPI) of Andhra Pradesh and Telangana.
Hyderabad

24 June 2023

It is truly an honour to stand before you today and address such a distinguished gathering. It is indeed a pleasure for me to be with distinguished and eminent doctors. Perhaps your’s is the only profession which follows Gandhiji’s principle- “service to man is service to God”.

At the risk of annoying other professionals, including those in my own profession, I venture to say that no other professional is capable of rendering the services as valuable as those offered by doctors. This decade is defined by the healing touch and the sacrifices made by our doctors. While the world was reeling under the devastating impact of COVID, our doctors were tirelessly and selflessly fighting against the deadly pandemic. No amount of medical training or experience can ever prepare anyone to go through the psychological ordeals of the pandemic.

But, time itself is a testimony of your healing touch. When thousands of physically and emotionally vulnerable patients stood isolated in their hospital wards, it was the doctors who kept hope alive even in the times of despair. My salute to you all. You are the real life heroes. I pay my humble tributes to the memory of all those medical professionals who lost their lives while dealing with the pandemic.

Medical professionals, who despite playing a crucial role in preserving human life, endure many challenges on a daily basis. The life of a doctor as of today has become more troublesome compared to what it was, 30 years back. I know many of the doctors today do not want their children to be doctors. Majority of the youth are not interested in taking up this profession.

There are many reasons for that

- Long years of study;
- High costs;
- Comparatively less remuneration;
- Very harsh lifestyle calling for sacrifices;
- Need for heavy investment in case one wishes to start own practice;
- Long wait for years together to establish oneself as a good practitioner;
- Highly competitive field etc.

It is saddening to see that doctors in India face an alarming rise in cases involving violence and assaults. These dedicated individuals, who have devoted their lives to healing, find themselves in the cross-hairs of angry and frustrated patients and their families. The physical and emotional well-being of doctors is compromised as they deal with verbal abuse, threats, and even physical attacks. Such acts of violence not only pose a direct threat to doctors but also create an atmosphere of fear, hindering the delivery of medical services. Unfortunately, the professional bodies are not strong enough to protect their own members.

We must recognize that these ordeals not only affect individual doctors but also have far-reaching consequences for our healthcare system as a whole. When doctors face hostile environments, their motivation and morale are impacted. It leads to burnout resulting in diminished quality of care. Less and less number of medical professionals will be willing to work under such conditions. Ultimately, it is the patients who suffer the most, as access to quality healthcare becomes increasingly challenging.

As a society, it is our responsibility to address these issues and create an environment that fosters collaboration, trust and respect between doctors and patients. We must advocate for stricter laws and stricter enforcement against violence towards medical professionals ensuring their safety within healthcare institutions. We must also introspect as to why doctors, who were once treated equivalent to god, are now faced with these types of situations.

Coming to the theme of this conference, "Preventive Care in Clinical Practice and the Role of a Family Physician", I am sure it will lead to meaningful and productive deliberations on important aspects of healthcare. I thank the Academy for this opportunity to speak on a subject that is of utmost importance in the field of healthcare. We live in a world where medical advancements and technological breakthroughs are transforming the way we approach healthcare. Yet, the significance of preventive care cannot be overstated. Preventive care involves taking proactive measures to maintain good health and prevent the onset of diseases.

It is a cornerstone of healthcare, emphasizing the importance of healthy practices in day to day lives, early detection and intervention to prevent illness or minimize its impact. One of the primary pillars of preventive care is the role of a family physician. A family physician is a healthcare professional who provides comprehensive and continuous medical care for individuals and families. They are the first point of contact for most patients and play a crucial role in promoting preventive care and guide individuals on course of treatment.

We grew up in a time when every family would consult a particular doctor who would be thorough with the medical history of the entire family. In other words, the family doctor would have a complete picture of the health status of the family and would adopt a holistic approach in deciding the course of treatment.

Family doctors offer personalized care that takes into consideration the physical, psychological, and social aspects of health. However, in recent years, several factors such as technological advancements, corporatization and commercialization of medicine have contributed to the decline in the prominence of family doctors. The role of family doctors as primary caregivers and trusted healthcare providers is diminishing, posing significant challenges to the delivery of comprehensive and patient-centered care.

It is unfortunate that the corporatization of medical service has overshadowed the private practitioners and family physicians which is very dangerous and harmful to society. Due to the rise in technological advancement, we often see people trying to replace family doctors with Doctor Google. The patient himself is trying to become half a doctor by acquiring half-baked knowledge on the internet. Only after complicating matters for himself with self-diagnosis and self-treatment, the patient is approaching the true medical professionals.

The role of family physicians in preventive care is multi fold. They build long term relationships and trust with patients. They offer personalized care. They encourage patients to schedule routine check-ups and visits to assess their overall health, monitor risk factors and detect any early signs of illness and identify potential health concerns before they escalate into major problems.

Family physicians also play a critical role in promoting vaccinations and immunizations. They act as educators, imparting valuable knowledge and guidance on healthy lifestyle choices. Family physicians help patients with chronic conditions such as diabetes, hypertension and heart disease through regular monitoring and guidance, minimizing the complications associated with chronic illnesses. They can identify early signs of mental health issues, provide counseling, and refer patients to appropriate mental health professionals when needed. Family physicians act as coordinators of care, working closely with other healthcare professionals to ensure comprehensive and seamless preventive care.

Preventive care goes beyond individual patient interactions. Family physicians also have a broader impact on community health through their involvement in health promotion and disease prevention programs. They participate in community health campaigns, conduct awareness programs, and actively engage in public health initiatives to educate the general population about preventive measures and encourage healthy behaviors.
Active assistance from family physicians will also have a positive impact on the financial health of individuals and society. In my growing up years, I hardly came across the incidents of families going bankrupt on account of huge costs incurred on medical treatment. Of late, we get to hear about many poor and middle class families suffering massive financial hardships on this account. Perhaps, the early detection and preventive cure by family physicians might have helped in the good old days. Such preventive health care also unburdens public exchequer. There will be less stress on the public health care system. Added benefit is the contribution of enhanced productivity of healthy individuals for all round development of the society and the nation.

In conclusion, preventive care is the foundation of a healthy society, and family physicians are the frontline warriors in this battle against diseases. Over drugging or unnecessary drugging, misuse of antibiotics, steroids, unnecessary surgeries and interventions, unnecessary exposure to radiation and prolonged stay in hospitals are some of the issues that are virtually ruining the physical and financial position of people. This can be prevented if family physicians stay updated with the dynamic changes taking place in treatments, medicines and new inventions. What we say in Telugu, “ఆరోగ్యమే మహాభాగ్యం”(Aarogyame Mahabhaagyam) is said in every language. Health is Wealth. It is the universal truth. Any investment is justified to acquire this wealth because only a healthy nation can become a wealthy nation. As Mahakavi Gurajada garu said : “ఈసురోమని మనుషుల ుంటే దేశమేగతి బాగుపడునోయ్?” (Eesuromani manushulunte deshamegati baagupadunoi?) A nation cannot progress unless its people are healthy.

As we move forward in our journey towards a healthier nation, let us recognize and appreciate the vital role played by family physicians in preventive care. Let us support their efforts and work together to build a healthcare system that prioritizes prevention, ultimately leading to a healthier and happier society.

I thank Dr. Kiranmai, Organising Chairperson and the Academy of Family Physicians of India for hosting me and for honoring me with the privilege of inaugurating this first two-day joint state conference of Telangana and Andhra Pradesh. Spread over five sessions, the highly qualified professionals are going to discuss subjects that impact the lives of millions.

I hope and believe that your deliberations will lead to quality research and concrete steps in addressing public health issues. I wish the conference all success. Thank you for your attention, and may we all embrace the power of preventive care in our lives.

Namaskar.

Two studies celebrating and documenting the contributions of Pioneering Family Medicine physicians in establishing Family Medicine in Southern India published in PLOS Global Public Health

Around the world, countries are introducing family medicine to strengthen primary health care, however, the process has been slow. Understanding the implementation of family medicine in a national context is complex but critical to uncovering what worked, the challenges faced, and how the process can be improved.

The first study explored how family medicine was implemented in India and how early cohort family physicians supported the field’s emergence. In this qualitative descriptive study, several family physicians who were among the first in India and recognized as pioneers, were interviewed. The methodology included using Roger’s Diffusion of Innovation Theory to describe and understand the roles of family physicians, as innovators and early adopters, in the process of implementation. Additionally, Greenhalgh’s Model of Diffusion in Service Organizations was applied to identify barriers and enablers to family medicine implementation.

This research identified multiple mechanisms by which pioneering family physicians supported the implementation of family medicine in India. Notably, the study showed that pioneering FPs were: a) innovators who developed the first family medicine training programs; b) early adopters willing to enter a new field and support spread as educators and mentors for future cohorts of family physicians; c) champions who developed professional organizations to bring together family physicians to learn from one another; and d) advocates who pushed the medical community, governments, and policymakers to recognize family medicine’s role in healthcare.

Facilitators for implementation included the supportive environment of academic institutions and the development of family medicine professional organizations. Barriers to implementation included the lack of government support and awareness of the field by society, and tension with subspecialties. The study concluded that, in India, the implementation of family medicine has primarily occurred through pioneering family physicians and supportive educational institutions. However, for family medicine to continue to grow and have the intended impacts on primary care, government and policymaker support are needed.

Citation and link: Gupta A, Prasad R, Abraham S, Nedungalaparambil NM, Bhattacharyya O, Landes M, et al. (2023) The emergence of family medicine in India–A qualitative descriptive study. PLOS Glob Public Health 3(5): e0001848. https://doi.org/10.1371/journal.pgph.0001848

The second paper, aimed to understand the mechanisms by which family physicians strengthen primary health care (PHC). The premise of this study was that; a)Improved primary care and primary health care play an integral role in overcoming health disparities and b) Family medicine is a subset of primary care—delivered by family physicians, characterized by comprehensive, continuous, coordinated, collaborative, personal, family and community-oriented services—and may be able to fill these gaps.

In this qualitative descriptive study, the Contribution of Family Medicine to Strengthening Primary Health Care Framework was used to understand the potential mechanisms by which family medicine strengthens primary health care. Iterative inductive techniques were used for analysis. This research identified and highlighted multiple mechanisms by which family physicians strengthen primary health care in India including: 1) By being skilled primary care providers themselves; 2) Supporting mid and low-level health care providers’ ongoing training and capacity building; 3) Developing relationships with specialists, ensure appropriate referral systems are in place; 4) When necessary, work with governments and organizations to access the essential resources needed to deliver care; 5) Motivating the workforce and change how care is delivered by ensuring providers’ skills match the needs of communities and engage communities as partners in healthcare delivery. These findings strongly support the need for investments in postgraduate training in family medicine and integrating family physicians into the primary care sector, particularly the public sector, could address health disparities.

Citation and link: Gupta A, Prasad R, Abraham S, Nedungalaparambil NM, Landes M, Steele Gray C, et al. (2023) Pioneering family physicians and the mechanisms for strengthening primary health care in India—A qualitative descriptive study. PLOS Glob Public Health 3(6): e0001972. https://doi.org/10.1371/journal.pgph.0001972

Note: Both the papers above were part of Dr. Archna Gupta 's PhD thesis. Many thanks and congratulations to her and all the co-authors for leading these insightful and important studies. Felicitations are also due to all the study participants (each of whom has contributed significantly to the field), the Academy of Family Physicians of India (AFPI), the National President of AFPI, and other leaders of Family Medicine for having created a platform for enabling engagement and advancement of much needed work like this.