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Development of family / community practice in low income countries

In a primary health care perspective, first line health services are the cornerstone of health systems. But presently they do not play their role in low income countries, for several reasons.

First line health services / health centres are underutilised. Geographical and financial constraints are well known obstacles to utilisation (topic 1), while quality and comprehensiveness of care, although quite important, aren’t much mentioned in the scientific literature.

In many health centres in low income countries, health care focuses on disease-control interventions and highly standardised curative solutions for a few diseases (topic 4). First line facilities are often staffed by non-physician clinicians or nurses. The professional self-esteem of staff is low, because of bureaucratic control, emphasis on technical standards and oversimplification of the definition of their responsibilities, at the cost of their autonomy in practice and the underutilisation of their knowledge acquired during studies.

Our assumption is that a combination of family and community practice in first line health facilities can drastically improve quality and acceptability of care.

This combination has the following features:

  • patient-centeredness
  • bio-psycho-social care
  • integration of individual care and public health activities (such as prevention and disease control) into one practice. This type of practice can be implemented by family doctors, but also by non physician clinicians.

Unger JP, Van Dormael M, Criel B, Van der Vennet J, De Munck P (2002). A plea for an initiative to strengthen family medicine in public health services of developing countries. International Journal of Health Services 32;4(799-815). (ref 3.1)

Van Dormael M, Unger JP (2002). First line facilities and support for providers have to be improved. [Letter] British Medical Journal 325 (976) (ref 3.2)

Unger JP, Ghilbert P, Pip Fisher J (2003). Doctor-patient communication in developing countries. [Letter] British Medical Journal 327(450) (ref 3.3)

Dugas, S, Van Dormael M. La construction de la médecine de famille dans les pays en développement. Antwerpen: ITGPress, 2003: 352 pp. (ref 3.4)

We observed the development of family medicine in Mali and in Costa Rica.
In Mali, a growing number of so-called community doctors work in rural first line services. This is a consequence of an increased production of medical doctors, strong demand from community health centres to hire a medical doctor, and an incentive package provided by their professional association, with the support of an NGO. The incentive package includes material support to improve living and working conditions, as well as professional support (initial professional training, continuous training, mentoring and co-mentoring, and an exchange programme).
The professional association plays an important role in the development of a professional identity of community doctors, distinct from hospital practice. It also encourages professionalism and intrinsic motivation for quality practice. Training activities and increased awareness of their professional role contribute to attitudinal changes of doctors, improved social integration in their community, and retention in rural community practice (topic 2). The professional group gained legitimacy in the community, as well as among authorities and health professionals themselves. In 2007, 15 % of the Malian rural first line facilities were staffed with a community doctor.

Coulibaly S, Desplat D, Kone Y, Nimaga K, Dugas S, Farnarier G, Sy M, Balique H, Doumbo OK, Van Dormael M. Une médecine rurale de proximité: l'expérience des médecins de campagne au Mali. Education for Health 2007; 20(2):1-9.

Van Dormael M. L’introduction des sciences sociales dans une expérience de formation continue des médecins de campagne au Mali [Abstract]. Colloque International AMADES : Anthropologie et Médecine : confluences et confrontations dans les domaines de la formation, des soins et de la prévention, Marseille, 25-27/10/2007.

Van Dormael M, Dugas S, Diarra S (2007) North-South exchange and professional development: experience from Mali and France Family Practice 2007 24: 102-107. doi: 10.1093/fampra/cml070)

Van Dormael M, Dugas S, Kone Y, Coulibaly S, Sy M, Marchal B and Desplats D Appropriate training and retention of community doctors in rural areas: a case study from Mali. Human Resources for Health 2008, 6:25.

In Costa Rica, the government has strongly supported the development of and access to primary health care in an integrated way, leading to service delivery by basic health teams (EBAIS) with certain characteristics of family and community medicine. These basic health teams are evaluated by national social security fund on targets and indicators for a number of programmes (so-called management commitments). The effects of these management commitments have been: a focus of attention of providers towards the indicators at the cost of other problems presented by patients and at the cost of a patient-centred approach; an increase in time spent on paper writing at the cost of patient communication. Doctors feel constrained in their professional autonomy by the evaluation system (topic 2). One can conclude that the intervention of management commitments has had negative effects on the professional development of family medicine in Costa Rica. Knowing that pay for performance techniques amount, in practice, to such management commitments in combination with performance related incentives for professionals, these consequences might be even more severe in those low income countries applying pay for performance. The effects of these tools on the professional development in different contexts needs further examination.

Werner Soors, Pierre De Paepe & Jean-Pierre Unger. Primary care management commitments in Costa Rica, an assessment. Submitted for publication