Family Medicine in the Eastern Mediterranean Region

On behalf of the World Organization of Family Doctors (WONCA), I acknowledge the patronage of this conference by His Highness Sheikh Hamdan Bin Rashid Al Maktoum, Deputy Ruler of Dubai, Minister of Finance and President of the Dubai Health Authority.

I thank our Conference President, the WONCA Regional President for the East Mediterranean Region, Dr Mohammed Ibrahim Tarawneh from Jordan.  I thank Scientific Program Chair, Dr Mohammed Farghaly from the UAE, and all the members of the Scientific Program Committee.  I thank Organising Committee Chair, Dr Wedad Al Haj Al Maidoor from UAE and all the members of the Conference Organising Committee. And I thank our Conference General Secretary Dr Oraib AlSmadi from Jordan, our sponsors, and our conference organizer Meeting Minds – experts.  I acknowledge all the members of the Family Medicine Section of the Emirates Medical Association, our WONCA member organization in the UAE.  And I acknowledge the representatives from all our WONCA member organisations from across the East Mediterranean Region, and from around the world. I am told there are over 700 delegates from 42 countries from not only this region, but from around the world.

I have been asked to speak about new opportunities and challenges for Family Medicine in the East Mediterranean Region.  I am going to outline some of the recent activities of WONCA around the world and in this region, and hope to inspire you all become involved in our important work.

I also want to share with you some images developed by young family doctors around the world.  This one provides the words that we use to describe a family doctor in many different languages and celebrates our global contributions.  These are examples developed by groups of young doctors from this region, from Egypt, in Jordan and in Tunisia. How we describe ourselves is one of our challenges.  When I use the term family doctor, I mean you. Whether you call yourself a general practitioner, or a family physician, or a primary care doctor. Whatever you call yourself, and whatever your patients call you, when I say family doctor I mean you, my sisters and my brothers in family medicine.  The language we use to describe who we are differs from place to place.  What matters is the common work that we do, the vision that we share, the outcomes that we achieve for our patients and their families and our communities.

The WONCA East Mediterranean Region is WONCA’s newest region, but family medicine has been in this region for a very long time as we have seen from the writings of Ancient Egypt. As a frequent visitor to this region over the past years, I am very proud of the work our WONCA member organisations are doing in this part of the world, and I am going to share some examples with you as I outline some of the ways family medicine is ensuring both quality and equity in global health, with the support of WONCA and our member organisations.

I pay tribute to your inaugural regional president, Professor Nabil Kurashi from Saudi Arabia, for his great advocacy and his work in bringing the family doctors of the region together.  Family doctors led the development of this region in 2007 by coming together and advocating for a separate voice within WONCA.  Nabil must be very proud today to see this second regional conference happening with so many delegates.  I also pay tribute to our current regional president, Mohammed, who has been a tireless voice for this region since becoming regional president almost two years ago, working continually to strengthen family medicine in each nation.

I am especially delighted that we are joined today by my good friend Dr. Sameen Siddiqi from the Eastern Mediterranean Region of the World Health Organization, the WHO.

WONCA works closely on health system strengthening with the World Health Organization, both at a global level, and in each of the regions of the world.  The WHO Director General Dr Margaret Chan is a staunch supporter of the importance of family medicine.  At a meeting in Hong Kong a year ago Dr Chan stood up and proclaimed “I love family medicine”, which didn’t please the members of the other medical specialties in the room!

The Eastern Mediterranean Regional Organization of the WHO, called EMRO, led by Regional Director, Dr Ala Alwan, has a very special focus on the contributions family medicine can make to universal health coverage in each of the nations of the WHO’s Eastern Mediterranean Region.  Indeed Dr Alwan and the WHO EMRO is leading the world in this focus on strengthening health services through family practice.

At a recent WHO meeting held in Cairo, Dr Alwan, reminded delegates from the 22 nations of the region that “Universal health coverage needs to focus on the provision of quality health services to all people” and how “Family practice is one of the principle service provision aspects of universal health coverage …  offering person-centred integrated health services.”

The WHO has been working with our WONCA member organisations to identify the current status of family practice in the 22 countries of the EMRO region.  Professor Waris Qidwai from Pakistan has led a review by WHO EMRO on the status of family medicine training programs in the nations of the region. WONCA is now supporting a new initiative of the WHO to assist the roll out of new family medicine education and training program developments in countries including Morocco, Sudan and Tunisia.

In February the World Health Organization regional office for the Eastern Mediterranean Region released its new report on Strengthening service provision through a family practice approach: towards universal health coverage in the Eastern Mediterranean Region. This is a landmark document from a WHO region, with lessons for all nations, and I commend it to you.

WONCA is committed to working with our WHO colleagues on continuing to strengthen health service provision in each of the nations of the Eastern Mediterranean Region through a family practice approach. This is essential if we are to achieve universal health coverage for the people of this region.  This region is unique with its range of low, middle and high income countries, and countries in crisis.  The lessons learned during implementation of these reforms in this region will inform developments in many other nations, especially low income nations, in other regions of the world.

The greatest privilege of being WONCA president is that I am invited to visit family doctors in their clinics in countries all around the world to gain insights into the challenges that each of us faces in providing the best possible care to the people of our local communities. 

WONCA was founded in 1972 by 18 colleges and academies of general practice and family medicine from around the world; 18 organisations with members sharing a commitment to improving the quality of life of the peoples of the world through fostering high standards of care in general practice/family medicine, and through respect for universal human rights.

Our very first WONCA president, was the Australian Monty Kent Hughes, who said at the very first WONCA world council held in 1972: “the future of our professional discipline will depend on our ability to work together in the service of humanity.” 

Forty-three years later WONCA’s mission remains the same and WONCA, through our member organisations, now has a membership of over half a million family doctors in 141 countries around the world. The 500,000 family doctors represented by WONCA each year, and it includes all of us here today, have over 2 and a half billion consultations with our patients.  Two a half billion.  That’s the scope of our current work and our influence.

But we need to do more. WONCA is an inclusive organization.  We need to work to ensure that every family doctor, every GP, every primary care doctor, joins us in our commitment to deliver high quality primary care to our patients and communities.

WONCA is playing our part in supporting quality and equity in global health, and we have set ourselves three main challenges. First, we are committed to better understand the strength of each of our member organisations in each region, and to expand WONCA’s influence by supporting the development of new member organisations in more low- and middle-income nations, including all nations of this region, to ensure that all people have access to high quality family medicine.  WONCA’s East Mediterranean region extends from Morocco in the west to Afghanistan in the east and includes over 20 countries. Not all the countries in this region have family doctor organisations as members of WONCA, but there are plans underway and I know there are doctors here from Morocco and Algeria and Sudan and Libya and Tunisia and other nations of the region and I am looking forward to discussing membership of WONCA with you all over the next few days.  We also have with us today members from WONCA’s newest member organization in Qatar, and members of WONCA’s newest academic member organization in Kuwait. 

WONCA’s second challenge is recognizing the importance of the next generation of family doctors, and our commitment to supporting the next generation through the development of young family doctor movements in all seven regions of the world, and through the appointment of a young family doctor to represent the world’s young family doctors on the WONCA executive. Over the past 12 months we have seen young family doctor movement established in all seven regions of the world. In this region young family doctors can become involved with WONCA through the Al Razi Movement, established by young family doctors in this region in 2013, and led by Dr Nagwa Nashat Hegazy from Egypt. The Al Razi Movement is of course named after the great physician and teacher from Persia who is credited with several medical "firsts", most notably describing for the first time the clinical distinction between smallpox and measles. 

WONCA’s third big challenge is our commitment to strengthen our work with the World Health Organization at global and regional levels to expand the role of family medicine in strengthening primary health care in all countries and supporting universal health coverage, and to ensure that each country has a well-trained and supported family medicine workforce.  And Sameen will speak more about this shortly.

So why do we do all this?  We do it because family medicine is important. 

Because the evidence is clear that health systems based on strong primary care, which includes strong family medicine, are the most efficient, equitable and cost-effective.

Because strong primary care is the best way to improve the health of individuals, families and communities. 

Because we believe every family should have a family doctor who the members of that family can trust for their medical care and advice.  As Nabil has said so many times, “A family doctor for every family”.

Because family doctors and the members of our primary care teams are part of the social fabric of our societies and we work together to keep the fabric of health care together.

We are seeing some great developments in global family medicine.  Our WONCA World Council meeting in 2013 endorsed WONCA’s new global standards for postgraduate family medicine education, developed by our working party on education.  These standards provide a benchmark for those developing training programs for family doctors around the world, and WONCA has developed a system to accredit family medicine training programs against our global standards.

Last year the Shanghai Medical College of Fudan University became the first Family Medicine Training Program in the world to receive accreditation against the WONCA Global Standards for Postgraduate Family Medicine Education. This is a wonderful achievement and I was honoured to present a certificate of accreditation to representatives of this training program in the presence of the WHO Director-General, Dr Margaret Chan.  We hope that many of the family medicine training programs in this region will step up to the challenge of meeting WONCA’s global accreditation standards, like our colleagues in China.  Our CEO and I are keen to talk with the leaders of family medicine training programs in this region who might like to be among the first programs in the world to receive WONCA’s global accreditation.

One of the biggest health care challenges facing the world is providing health care to people living in rural regions. Last year, WONCA’s working party on rural practice released our new Rural Medical Education Guidebook, which reinforces our commitment to ensuring we meet the health care needs of the 50% of the world’s population living in rural areas, as well as those in urban areas.  I commend it to you.  We need to ensure family medicine is available to all the people living in rural communities in this region.

While our clinics may be different from country to country, and from urban to rural to remote locations, what is important is the way we are the same – through our commitment to comprehensive, continuing, coordinated whole person care. Through care that is person-centred, and family and community-oriented.  Through first-contact care, acute care, chronic disease management, prevention and health promotion.  And through our shared understanding of the interplay between population health and the health of individuals in our communities.

Recently, WONCA’s working party on environmental health launched a new publication on Family Doctors in the Field.  The book contains stories from family doctors from across the globe.

WONCA takes environmental health seriously.  We are committed to supporting the leadership role family doctors can play as part of the global transformation towards environmental sustainability that must take place over the coming few years.

As family doctors we see the direct links between the environment and the health of our patients and our communities every day.  We also appreciate that what is good for the environment is good for our patients’ health, including access to clean water, clean air, fresh locally grown food, and the benefits of physical activity, such as walking and cycling, rather than relying on motorized transportation.  Our work in tackling obesity among our patients can have a positive impact on the environment as well.

As family doctors we also need to lead by example.  We know that, in addition to our clinical responsibilities, we have social responsibilities.  We are credible public health advocates and there are times when we need to be vocal for the sake of the health of our communities, to speak out for what is right, to say “this is not OK”.  As family doctors we can be advocates for the health of our planet as well as the health of our patients. 

WONCA has been working with the WHO and the International Commission on Occupational Health looking at the health of workers and their families, especially in developing parts of the world.  Last year WONCA participated in a WHO meeting held in Iran on the health of workers.  We recognise that health and safety are threatened by poor working conditions, which are a daily reality for many workers around the world.  We are also aware of the poor health of many migrant workers based in countries where they may have no access to health services.  And we recognize that most health care and preventive services for workers and their families is provided in primary care settings by family doctors like you and me.

There are those who say that family medicine has no real role to play in low and middle-income countries.   Well WONCA has blown that idea out of the water. 

In 2013 Dr Margaret Chan launched WONCA’s new guidebook on the contribution of family medicine to improving health systems.  The guidebook includes a chapter from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many nations, including the nations of the Eastern Mediterranean Region, led by Sameen and his colleagues.  And there is a chapter outlining the remarkable work that is underway across Africa to strengthen family medicine, especially involving WONCA member organisations within Africa supporting developments in neighbouring nations. 

What these developments demonstrate is the need to strengthen the whole primary health care workforce, including family doctors, community nurses, community health workers, and traditional birthing assistants, and support us working together to deliver appropriate care to all people.  People in low income countries still want and deserve access to health care for themselves and their family members, access to caring clinicians, access to life saving medications.

A particular challenge for some of the nations in this region of the world is rebuilding their health services following emergency situations. This includes natural disasters such as earthquakes, like the tragedy which affected our friends and colleagues in Nepal over the weekend.  Our hearts go out to the people of Nepal.  The Ebola crisis has had a devastating effect on the populations and the health services in the affected nations of West Africa.  Emergency situations can also be due to armed conflicts and civil unrest as we have seen unfolding in some of the nations of this region, including Iraq and Syria and Libya and Afghanistan.  Regardless of the cause of emergency situations, a cascade of human suffering is often the result including large scale displacement with refugees moving across borders, shortages of food and clean water and sanitation, disease outbreaks and human rights abuses.  The WHO has been working to address the mental health consequences of emergency situations and has produced an excellent report on Building Back Better Sustainable Mental Health Care after Emergencies.  It documents work underway to support rebuilding of more sustainable mental health services in countries and areas like Afghanistan, Iraq, Jordan, Somalia and the West Bank and Gaza Strip.  WONCA works closely with the WHO on the intregration of mental health into primary care services.  We need to re-energise this commitment and work together to ensure that the entire primary health care systems in these nations are strengthened after conflict and catastrophe.  It is only through strong primary care that each of our nations will have the resilience to withstand future crises and be able to support our people at their times of greatest need.

2015 is a landmark year in global health as we come to the end of the Millennium Development Goals.  In 2000 the United Nations adopted the Millennium Development Goals, called the MDGs; eight aspirational goals, agreed by all the world’s countries, which aimed to halve extreme poverty rates by the end of 2015, provide primary school education to all children, empower women, reduce infant and maternal mortality, combat HIV, tuberculosis and malaria, and ensure the sustainability of our environment.

The MDGs have galvanized unprecedented efforts across the globe to meet the needs of the world’s poorest people, including in this region of the world.  And progress has been impressive with rates of extreme poverty halved, and significant reductions in infant and maternal mortality and HIV infection rates in many countries, with millions of lives saved through reductions in preventable deaths. 

It is clear that success in these areas has occurred only when there has been both national and local ownership to give the MDGs traction, and the importance of allowing the local adaptation of the MDGs to target local conditions.  And it is no surprise that this process has reinforced that developing countries want capacity, not charity – and that building self-reliance is critical; this is a key role for WONCA in our support through our member organisations for education and training for the members of the family medicine workforce in every nation.

The MDGs have also come in for criticism because of what is missing. They didn’t have a specific focus on rural communities, they didn’t tackle the need to strengthen the primary care basis of each country’s health system, or to tackle chronic disease or mental health, or to address the social determinants of health, or to ensure universal health care access for all people in both rural and urban areas. 

Each nation needs a strong system of primary care.  We have seen the terrible consequences when a nation faces a serious health challenge without well-developed primary care and the capacity to respond swiftly to health threats. This is exactly what happened during the recent Ebola crisis in West Africa. Those nations without strong established primary health care systems experienced the greatest challenges and significant loss of life.

Strengthening primary care must continue to be addressed beyond 2015. WONCA needs to ensure the clear voice of family medicine is heard on behalf of our patients and communities. We need to be clear about our role as family doctors in working with our patients and communities to increase life expectancy and achieve equitable health outcomes.

We are now facing a new set of global challenges.  The United Nation has developed the Sustainable Development Goals and targets, or SDGs, which will guide the global development agenda post-2015.

In his inspiring address to the United Nations General Assembly last December, Secretary-General Ban-Ki Moon, discussed “The road to dignity by 2030: ending poverty, transforming all lives, and protecting the planet” and he made a call to action to transform our world beyond 2015.  In his words “we are at a historic crossroads...  With our globalized economy and sophisticated technology, we can decide to end the age-old ills of extreme poverty and hunger.  Or we can continue to degrade our planet and allow intolerable inequalities to sow bitterness and despair.  Our ambition is to achieve sustainable development for all.”

He went on to state that the 1.8 billion young people on the planet need to be “the torchbearers for the next sustainable development agenda through 2030.  We must ensure this transition, while protecting the planet, leaves no one behind.”

The United Nations has adopted 17 Sustainable Development Goals.  There is only one health specific goal, number 3: “Ensure healthy lives and promote well-being for all at all ages.”  But each of the 17 new goals has an impact on global health and the health of individuals.

The Sustainable Development Goals are brought together into six integrated elements.  The element on People is to “ensure healthy lives, knowledge and the inclusion of women and children’.

These are bold ambitions, and as global citizens, family doctors must play our part.  People-centred care is a core component of universal health coverage, and there will be an increasing role for family medicine over the coming years in many countries to ensure this happens.  We need to support the focus on the social determinants of health and work to ensure marginalized populations, those groups of people in our communities most at risk of poor health, are not excluded from health care.  This is why last year, in a historic move, WONCA established a new working party on health issues for Indigenous people and minority groups.  This working party joins our WONCA working party on women and family medicine in focussing on equity concerns.  The East Mediterranean Region has strong representation on our women and family medicine working party, led by Dr Omneya Elsherif from Egypt, and Dr Sanaa Alkaisi from Iraq.

In order to provide universal coverage, our countries need to stem the costs of health care, and we can do so through increasing investment in community-based health services.  At the same time there must be a movement of funding from hospitals to the community, and especially to rural communities, rather then expecting more community-based care to be delivered with no increase in resources.

We need to continue our work with our global partners, the WHO, the World Bank and others to bring high quality primary care to the 1 billion people on this planet who currently have no access to any health care at all, many living in rural areas.

Every human being should be treated with dignity and respect.  And as health professionals we should be leading by example.

Something Iona Heath, former president of the Royal College of General Practitioners in the United Kingdom and a great advocate for health equity, said a few years ago really struck a chord with me, “I believe that general practice/family medicine is a force for good throughout the world.”  I agree with her.

Through my work as WONCA president, I have been impressed with the commitment of family doctors to human rights issues.  I am convinced that family doctors right around the world care about human rights; the basic expectations we all have about how we and our families and all people should be treated.  

I am pleased that during my time as WONCA president, our organization has established a new global group with a specific focus on health equity, bringing passionate family doctors from around the world together, through the marvels of the digital age, to share experiences and develop global policy which we can use in our advocacy with the WHO and the nations of the world.

The challenges we face also test our own resilience. While we continue to innovate within our practices to ensure that our patients receive the highest possible standards of care, it is critical that we also continue to find ways to support each other as well. 

Many family doctors work under very difficult conditions, often without the resources needed to do their jobs. We work long hours with arduous demands on our time and many of us feel unappreciated. And we don't often hear the words thank you.

This is why WONCA has established World Family Doctor Day, held on May 19 each year, to acknowledge the important work you do.  World Family Doctor Day recognises your commitment every day to providing the best quality health care you can to the people of your community.  The member organisations in this region have been very active in promoting World Family Doctor Day. 

Last year we had incredible support from Dr Alwan Dr Ala Alwan, Regional Director of WHO sent a message in English, Arabic and French: It is with great pleasure that the World Health Organization (WHO) joins the World Organization of Family Doctors (WONCA) and Member States in celebrating World Family Doctor’s Day. I would like to take the opportunity to underscore the importance of family practice programmes for delivering quality primary health care and accelerating progress towards universal health coverage in the WHO Eastern Mediterranean Region.

We also saw World Family Doctor Dat activities held in many countries including Egypt, Iraq, Jordan, Kuwait, Qatar and Saudi Arabia. 

So today, on behalf of the two and a half billion people around the world who benefited from your care and support over the past year I say thank you. Thank you for your commitment to being a great family doctor.  Thank you for the wonderful important work you do.  And thank you all for the health care you provide each day to the people who trust you for their health care and advice.  Together we are changing the world.