|Year : 2020 | Volume
| Issue : 4 | Page : 1805-1810
Advocacy to act – Family medicine in health policy: A decade-long journey of the academy of family physicians of India
Founder and National President, Academy of Family Physicians of India, Regional President, South Asia, WONCA - World Organisation of Family Doctors
|Date of Submission||20-Feb-2020|
|Date of Decision||06-Mar-2020|
|Date of Acceptance||24-Mar-2020|
|Date of Web Publication||30-Apr-2020|
Dr. Raman Kumar
049, Crema Tower, Mahagun Mascot, Crossing Republic, Ghaziabad - 201 016, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The 'Academy of Family Physicians of India (AFPI)', is a non-profit organisation registered in New Delhi with a membership base, spread over all India. AFPI is working towards the establishment of a distinct academic discipline 'family medicine' for doctors pursuing primary care vocation within the mainstream medical education system in India. AFPI adopted a multi-pronged approach engaging political leadership, bureaucracy, higher judiciary and other stakeholders. In 2018, a public interest litigation was filed in the Supreme Court of India. In pursuance to the Supreme Court of India order, AFPI approached the ministry as well as the Medical Council of India. In 2018 we had received written assurance from the Prime Minister's Office - PMO that the family medicine discipline will be addressed in the NMC bill. Earlier family medicine was mentioned only as part of the National Health Policies (NHP 2002 and NHP 2017) and finally, it has become part of the act, the National Medical Commission Act 2019.
Keywords: Academy of family physicians of India, family medicine, health policy, medical education reforms, national medical commission, primary care, universal health coverage
|How to cite this article:|
Kumar R. Advocacy to act – Family medicine in health policy: A decade-long journey of the academy of family physicians of India. J Family Med Prim Care 2020;9:1805-10
|How to cite this URL:|
Kumar R. Advocacy to act – Family medicine in health policy: A decade-long journey of the academy of family physicians of India. J Family Med Prim Care [serial online] 2020 [cited 2021 Feb 26];9:1805-10. Available from: https://www.jfmpc.com/text.asp?2020/9/4/1805/283427
| Introduction|| |
Academy of family physicians of India – Leadership for change in policy
The 'Academy of Family Physicians of India (AFPI)', is a not-for-profit organisation registered in New Delhi under society's act 1860 with membership base spread overall India. AFPI is working towards the establishment of a distinct academic discipline 'family medicine or general practise' for doctors pursuing primary care vocation within mainstream medical education systems in India.
AFPI was founded to promote family medicine and primary healthcare. Family medicine is the practising speciality and academic discipline of the majority of Indian doctors. AFPI is an equivalent organisation to the American Academy of Family Physicians, College of Family Physicians of Canada, Royal College of General Practitioners and Royal Australian College of General Practise for India. AFPI is a full member of WONCA (World Organisation of Family Doctors). The academy currently has a membership base across India and functions through several state chapters. The members include family medicine specialists, practising family physicians, general practitioners and medical officers who provide generalist medical care across all age groups, genders and organ systems.
Since inception in 2010, AFPI has been providing academic forums for practising and in-training primary care physicians and engaged with several projects of advocacy, training and education. AFPI has organised several academic sessions of continued professional development (CPD) for primary care doctors at international, national and state levels. AFPI has so far organised four successful national-level academic conferences of family medicine (National Conference of Family Medicine and Primary Care) in 2013 (New Delhi), 2015 (New Delhi), 2017 (Kochi) and Bangalore (2019). Since its inception, AFPI has engaged with policymakers and the stakeholders for the upliftment of academic family medicine.
Prioritising rural health agenda in India
AFPI hosted the 15th World Rural Health conference (WRHC2018) from 26 to 29 April 2018 at India Habitat Centre, New Delhi. The theme of the conference was 'Healing the heart of healthcare'. The conference attracted more than a thousand delegates from 40 countries. The Vice President of India M Venkaiah Naidu inaugurated the conference in the presence of Ashwani Choubey Minister of State for Health and Family Welfare Government India. WRHC 2018 also hosted national consultation on strengthening rural primary healthcare in India in partnership with Niti Ayog, Public Health Foundation of India. Leading Indian and International universities participated in the event. The conference unanimously culminated in the adoption of Delhi declaration 2018 which calls for rural proofing of policy across the world, if countries are to achieve sustainable development goals by 2030. Delhi's declaration has been endorsed by the World Health Organisation (WHO).
Policy reforms and family medicine
Following is a summary of policy reforms related to family medicine discipline and outcomes of the advocacy on behalf of the AFPI.
| What Is Family Medicine?|| |
Family medicine is the internationally recognised nomenclature for the academic discipline, knowledge domain and medical specialty of primary care doctors. It has originated from the historic tradition of general practise. Family medicine is defined as a speciality of medicine that is concerned with providing comprehensive care to individuals and families by integrating biomedical, behavioural and social sciences. Family physician's scope of practise covers all organ systems, genders and age groups. A family doctor provides primary and continuing care to the entire family within the communities; addresses physical, psychological and social problems; and coordinates comprehensive healthcare services with other specialists, as needed.
Historical evolution of family medicine
Internationally, family medicine has developed from the historical tradition of general practise as a counterculture of the phenomenon of rapid fragmentation medical care into an ever-growing list of specialties and subspecialty during the period following World War II in much of the developed world. In most countries, family physicians function as a first contact person in the health system and function as gatekeepers of resources and optimal utilisation of expensive tertiary care facilities through a structured referral system. Family physicians form the backbone of any healthcare delivery system is it private insurance-based e.g. US health system or public-funded universal health coverage e.g. NHS of UK.
| Recognition of Family Medicine in India|| |
Although 'family medicine' is a recognised postgraduate medical speciality by the Medical Council of India as a postgraduate qualification (MCI PG Regulations 2000), departments of family medicine or general practise do not exist at medical colleges in India as it is not a mandatory requirement to start an MBBS course or medical college in India (Minimum Standards for Starting Medical College Regulation 1999). Interestingly, family medicine is the 'practising discipline' of majority medicine graduates such as general practitioners/family physicians in the private sector and GDMOs (general duty medical officers) in the public sector.
| Family Medicine in Policy|| |
Several policy documents of the Government of India and WHO has strongly recommended the establishment of family medicine training programmes in India.
| Mehta Committee Report|| |
In 1983, 'The Medical Education Review Committee' set up by Ministry of Health and Family Welfare GOI, under the chairmanship of Dr Shantilal Mehta recommended that 'the undergraduate (MBBS) medical students should be posted; in a general practise outpatient unit to be exposed to multidimensional nature of health problems, their origins. The committee also strongly recommends that this speciality, which has already been approved by MCI, should be further developed so that an increasing number of students pursue higher study in the area.
| National Health Policy 2002|| |
National Health Policy (NHP) 2002 stated that in any developing country within the inadequate availability of health services, the requirement of expertise in the area of 'public health' and 'family medicine' is markedly more than the expertise required for other clinical specialties. NHP 2002 recommended examining the possible means for ensuring adequate availability of personnel with 'public health' and 'family medicine' discipline, to discharge the public health responsibilities in India.
| WHO SEARO Meeting on Curriculum of Family Medicine 2003|| |
A WHO SEARO Regional Scientific Working Group Meeting on Core Curriculum of Family Medicine held in Colombo, Sri Lanka, from 9 to 13 July 2003 devised core curriculum of family medicine for the (a) Undergraduate level (b) Intermediate level and (c) Postgraduate level (specialist level). The committee recommended the following (1) Family medicine should be recognised as a separate specialty in medicine. (2) Immediate steps should be taken to incorporate the recommended core curriculum in family medicine into the existing basic medical curriculum (3) Departments of family medicine should be established whenever and wherever possible for undergraduate and postgraduate training. (4) Provision should be made for training teachers for family medicine. (5) Appropriate structures and cadres should be developed for incorporating general practitioners and trained family physicians within the national health system.
| Recommendations of National Knowledge Commission Working Group 2007|| |
In 2007, the working group of medical education under the Prime Minister's National Knowledge Commission (NKC) stated that any successful development process must have a pyramidal structure with a strong horizontal base. In terms of medical education, it has to be a strong base of basic scientists and clinical generalists/family medicine specialists, who are the backbone and stability of the system. The working group further stated that family physicians of yesteryears are no longer widely available. This needs to be urgently addressed. Around 50% of postgraduate seats should be for them to form the base, protect the public and provide and provide appropriate care to the community/masses at primary and family levels, as envisaged in the National Health Policy 2002.
| Ministry of Health and Family Welfare Meeting on Family Medicine 2010|| |
In 2010, in response to a representation given by the AFPI, the Ministry of Health and Family Welfare (MOHFW) convened a high-level meeting vide letter no. V. 11025/56/2010 ME (P1) under the chairmanship of Union Health Secretary Government of India to discuss the following: (a) Initiating of MD family medicine at government medical colleges (b) Employment of DNB family medicine qualified doctors within NRHM. Subsequently considering the merit of the issue, the Ministry of Health and Family Welfare (MOHFW) communicated with all state governments vide letter No. 11025/56/2010 MEP 1 dated 1.11.2010 requesting to start postgraduate courses in family medicine and also offered financial assistance for the development of infrastructure and faculty for any government medical college.
| WHO SEARO Consultation on Role of Family Physicians in Primary Healthcare 2011|| |
In 2011 the WHO Regional Office of South Asia (SEARO) Regional called a consultation on 'Strengthening the Role of Family/Community Physicians in Primary Healthcare' in Jakarta, Indonesia, 19–21 October 2011. The consultation came out with the following recommendations for the member states should: (a) Strengthen national health policies to articulate clearly the roles and responsibilities of family physicians/general practitioners as providers and promoters of PHC. This includes recognising this category of health personnel as an integral part of the national public health system. (b) Include the education, placement, retention and career development of family physicians within the appropriate strengthening of national human resources for health policies and strategies. (c) Consider establishing departments of family medicine in medical colleges in consultation with medical councils, and work towards including family medicine as a subject in the undergraduate curriculum. (d) Consider training courses/diplomas and degree programmes to develop or enhance the capacity of primary care physicians in family medicine both in the government and private sectors. These could be implemented by universities, professional bodies, national boards, etc., as per country needs. Distance education can be a cost-effective means of training large numbers in a relatively short period. (e) Standardise existing training programmes for family physicians and establish an accreditation system for the same. (f) Implement and institutionalise continuing medical education programmes for family physicians/general practitioners. (g) Conduct operational research to inform policy for expansion of numbers, roles and responsibilities of family physicians.
| Working Group Recommendation 12Th Plan – Planning Commission 2012|| |
According to the working group of the planning commission for the 12th plan (2012-2017) estimated the projected need for specialists in family medicine (family physicians) as 15000 per year for the year 2030.
| National Consultation of Family Medicine Programme 2013|| |
In 2013, a national consultation was convened by National Rural Health Mission (NRHM) Ministry of Health and Family Welfare (MOHFW) in partnership with Academy of Family Physicians of India that came out with a specific recommendation for central government, state governments, universities, MCI, etc., towards the implementation of the government of India policy on family medicine. In 2013, the Ministry of Health and Family Welfare again communicated with the state governments.
| Letter from Union Health Secretary to All States 2013|| |
The Union Health Secretary Government of India vide Letter No. D.O. V 11025/MEP -1 communicated with all Principal Secretaries of Medical Education. Health and FW of all State/UTs. In his letter, the Union Health Secretary wrote:
'Twelfth Plan seeks to expand the reach of healthcare and work towards the long term objective of establishing a system of Universal Health Coverage (UHC). This requires strengthening of human resources in health particularly at primary and secondary level. There is a need for an integrated generalist approach to diagnosis and treatment and the family physicians are best positioned to deliver this integrated approach to diagnosis, treatment and complete healthcare management of an individual and a single post graduate in Family Medicine can meet the requirement of a Surgeon, Obstetrician and Gynaecologist, Physician and a Paediatrician in a CHC, besides taking care of Public Health need of the community. In the view of the foregoing, while I would once again reiterate that the Medical College in your State should be encouraged to start the course in MD (Family Medicine) should also be started in large government hospitals and MD (Family Medicine/DNB (Family Medicine) be made a desirable qualification for the posting at CHCs and sub district hospitals'
| Family Medicine and Health Policies of State Governments- State Health Policy Kerala 2014|| |
Several state governments in India have taken a keen interest in family medicine training. The state of Kerala in its state health policy 2014 has mentioned family medicine as an important area of intervention. That state of West Bengal has entered into a collaboration with the Royal College of General Practise through the 'Institute of Health and Family Welfare Kolkata' towards the development of a course in family medicine called 'Diploma Family Medicine' programme for which admission has taken place for the two batches. State of Bihar, Jharkhand and Chhattisgarh through state NRHM have sponsored their medical officers for completing PG Diploma in Family Medicine conducted by CMC Vellore. In 2011, NRHM provided funds to Bihar and other states to start DNB family medicine departments at district hospitals.
92nd report of the department related parliamentary standing committee on health and family welfare on the 'Functioning of the Medical Council of India' has emphasised the need for PG in family medicine, 2016
The committee report has noted that 'the medical education system is designed in a way that the concept of family physicians has been ignored'.
The committee recommends that the Government of India in coordination with State Governments should establish robust PG programmes in family medicine and facilitate the introduction of family medicine discipline in all medical colleges. This will not only minimise the need for frequent referrals to specialists and decrease the load on tertiary care, but also provide continuous healthcare for individuals and families.
| National Health Policy 2017|| |
The National Health Policy 2017 has emphasised on the need to popularise MD in family medicine or general practise to attract and retain medical doctors in rural areas. The policy recommends the creation of a large number of distance and continuing education options for general practitioners in both the private and the public sectors, which would upgrade their skills to manage the large majority of cases at the local level, thus avoiding unnecessary referrals.
| Memorandum by AFPI to Prime Minister's Office (Pmo) 2017|| |
The registration no PMOPG/E/2017/0548340 a detailed memorandum was submitted by AFPI to the PMO with following demands.
A detailed memorandum attached as PDF File Respected Sir Subject: Time-bound implementation of recommendations of the National Health Policy 2002, National Health Policy 2017 and the 92nd report of the parliamentary standing committee on health and family welfare towards the development of the academic discipline of family medicine/general practise for medical doctors engaged in primary care vocation as a strategy towards strengthening of primary healthcare services across in India, broadly summarised below. (a) Creation of mandatory departments of family medicine or general practise and inclusion of this broad knowledge domain within the MBBS curriculum at all medical colleges of India by amending 'Establishing Medical College Regulation 1999' of Medical Council of India. (b) Creation of 15,000 postgraduate MD (family medicine/general practise) seats or training programmes and thereafter residency posts which are based in and spread over district hospitals, sub-divisional hospitals and community health centres as a strategy towards augmenting provision of generalist medical services by skilled/competent human resource leading to the prevention of unnecessary referrals resulting into overcrowding at tertiary medical facilities and large teaching/non-teaching hospitals. By amending and rationalising 'Medical Council of India Post Graduate Medical Education Regulations 2000' and by a preferential grant under Central Government Scheme of Strengthening/up-gradation of State Government Medical Colleges for starting new PG courses/creating PG seats (c) Issuing GO (government order) by central and state governments towards making postgraduate DNB (Family Medicine) or MD (Family Medicine) as a desirable qualification for posting at CHC and sub-divisional hospitals. (d) Removal of regulatory restriction on primary care doctors from becoming medical teachers in India by amending and rationalising Medical Council of India Minimum Qualifications for Teachers in Medical Institutions Regulations 1998. (e) Creation of separate family medicine departments with faculty qualified in family medicine at newly established AIIMS institutes under PMSSY (f) Mandatory representation of primary care doctors on regulatory bodies of medical education such are (i) Medical Council of India and (ii) National Board of Examinations by amending Medical Council of India Act 1956 which are at present exclusively controlled and monopolised by specialist doctors and hospitalists. Furthermore, the creation of separate autonomous speciality board/college for family medicine and primary care on the lines of the medical education regulatory system of the USA, UK and other developed countries. (g) Preferential research grants by ICMR (Indian Council of Medical Research) for primary care research. Presently all treatment protocols are developed based on data generated solely at academic tertiary care centres. A detailed memorandum attached herewith with relevant.
| AFPI Public Interest Litigation in the Supreme Court of India 2018|| |
In 2018 the Academy of Family Physicians of India Supreme Court of India filed a PIL in the Supreme Court of India for implementation of a family medicine programme in India. The Supreme Court of India allowed liberty to approach the Government of India and the Medical Council of India once again. As per the Supreme Court direction, fresh representations were submitted to the Ministry of Health and Family Welfare and the Medical Council of India.
| Reply from Prime Minister's Office|| |
In June 2018, the following reply was received in response to the memorandum submitted to the PMO in 2017.
'Under the National Medical Commission Bill, 2017, the Post Graduate Medical Education Board has been mandated to promote and facilitate post-graduate courses in family medicine. Further, under the said Bill the Under- Graduate Medical Education Board has been mandated develop competency based dynamic curriculum for addressing the needs of primary health services, community medicine and family medicine to ensure health care in such areas'.
| Representation to AFPI on the Specialist Board in Family Medicine by the National Board of Examinations|| |
In 2018, the Specialist Board in Family Medicine was reconstituted by the National Board of Examination and the Academy of Family Physicians of India was given representation along with other experts. A series of meetings have taken place at NBE and the Ministry of Health and Family Welfare to revamp the existing DNB Family Medicine Programme. The revised modular DNB FM programme is likely to be announced soon along with the new family medicine curriculum.
| National Medical Commission Act 2019|| |
The National Commission Act 2019 passed in the Indian Parliament has mandated both undergraduate and postgraduate boards to facilitate family medicine courses in MBBS as well as MD level. As per the provision of the NMC Act 2019 under section 24 (1) (c), the Under Graduate Medical Education Board is mandated to develop a competency-based dynamic curriculum for addressing the needs of primary health services, community medicine and family medicine to ensure healthcare in such areas. Similarly, under section 25. (1) (j) the Post Graduate Medical Education Board is mandated to promote and facilitate postgraduate courses in family medicine.
High-level group on health sector report to the 15th finance commission of India 2019
The 15th finance commission set up by the Government of India has recommended strengthening the role of family medicine specialists in India. The high-level group on the health sector noted and recommended that 'family medicine physicians are required in India; however, there are not enough opportunities for family medicine specialists. There is a need for a good family medicine programme at the district level and proper cadre needs to be in place'. The HLG has further recommended that the MOHFW may be requested to create a suitable ecosystem for family medicine specialists. There should be proper family medicine departments in all medical colleges with full-time faculty and effort should be made to increase opportunities after pursuing family medicine. Finally, a model centre for family medicine has been recommended to be created at AIIMS New Delhi to guide other healthcare institutions in developing the speciality.
The Academy of Family Physicians of India: Leading the path of primary care in India
The vision of AFPI is to transform the healthcare delivery system in India through an enhanced level of community-based high-quality services and the mission is to improve the health status of communities both in urban and rural areas by building up an environment of change and reform by promoting education, training of skilled primary care physicians and their integration in healthcare delivery system. AFPI will continue to work towards the betterment of healthcare for the people of India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Regional Consultation on Strengthening the Role of Family/Community Physicians in Primary Health Care Jakarta, Indonesia, 19-21 October 2011. Available from: https://apps.searo.who.int/PDS_DOCS/B4831.pdf.
[Last accessed on 2020 Feb 20].
National Consultation on Family Medicine Programme 2013: Report and recommendations convened by National Health System Resource Centre (NHSRC) National Health Mission (NHM) MHOFW (Ministry of Health and Family Welfare) Government of India. J Family Med Prim Care 2016;5:197.