Merry Tiyas A, dr

The universal challenges to optimal health care delivery in health care systems are the result of the dream and reality struggle. The dream is the desire of the different stakeholders policy makers, health professions, academic institutions, health care managers, and communities to meet their subsystem goals of quality and equity in each stakeholders perspective. The reality is that such a system will not be sustainable.

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interim results are well-known:

limited health budget, rapidly rising costs as moreunprevented disease burden takes its toll, inequitable distribution of resources between need and want, and inefficiencies in delivery of care as different stakeholders work towards a subsystem optimum.

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reality is the need for relevance and costeffectiveness.

solution A balance is needed between quality and equity on the one hand and relevance and cost-effectiveness on the other hand.

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do people need from the health care delivery system has been addressed in a WHO-Wonca Working Paper, Making Medical Practice and Education More Relevant to Peoples Needs: The Contribution of the Family Doctor, the result of the 1994 Ontario, Canada Conference and subsequently by WHO Europe in 1998 in its paper Framework for Development of FP/GP.

Family Medicine, by the nature of its work and core values, can help health systems to meet peoples needs which are to:

Address common health problems Improve access to care and equity Integrate prevention and care, physical and psychological, acute and chronic diseases Collaborate and co-ordinate care with the health care team more efficiently and cost-effectively Integrate care of individuals, families and communities.

Family medicine is the bridge and not the solution. The 1994 Ontario, Canada Conference Paper alluded to earlier had this to say: To meet peoples needs, fundamental changes must occur in the health care system, in the medical profession and in medical schools and other educational institutions. The family doctor should have a central role in the achievement of quality, cost effectiveness and equity in health care systems.

The family doctor is a good bridge between hospital care & public health; he is able to help save costs through being a five star doctor, a model conceptualized by Dr Charles Boelen, a WHO staff who is now a healthcare consultant. The five star doctor is onewho is:

Care provider, Decision maker, Communicator, Community leader, and Manager of healthcare resources.

How does a family doctor help to save costs? Some examples illustrate the possibilities:

Treatment of acute problems timely and appropriately, getting things right the first time particularly in children and the aged prevents death and disability. Encouraging appropriate lifestyle to control chronic diseases will reduce disease burden and truly save costs to the individual, family, community, and nation. Diet, exercise and weight control (DEW) together they will prevent or reduce the prevalence of hypertension, heart disease, diabetes mellitus, hyperlipidemia and the downstream consequences from strokes, heart disease and the long term complications of diabetes mellitus. Smoking respiratory consequences of chronic obstructive lung disease, cancer of the lung and ischaemic heart disease are prevented or reduced. Sexual behaviour sexually transmitted infections including AIDs are prevented.

How does working towards unity for health work?

The common vision of reduction of disease burden, and promotion of health will place the use of limited healthcare budgets to achieve the greatest impact on health status. The activities among the stakeholders will not be divergent. There will be self-care by patients motivated to keep themselves healthy and to avoid unnecessary use of health resources; appropriate level of use of services and not more healthcare and in particular, hospital care; primary care doctors not just doing gatekeeping and the denial of care but to encourage the appropriate use of resources where appropriate. The outcome of such healthcare reforms in the minds of the stakeholders will be health systems that meet peoples needs.

Critical Success Factor in Introducing Family Medicine into the Singapore Health Care System: Link Up with Stakeholders

Ministry of Health wanted a vocational training programme; is supportive. College of Family Physicians, Singapore saw the opportunity to promote Family Medicine through Wonca. The University had sympathetic supporters on adoption of Family Medicine as a discipline. An external change agent was available. In Singapores case, a Family Medicine expert was invited to meet up with the various stakeholders to discuss the place of family medicine, training requirements and organizational matters. The Hospital specialists were convinced of the importance of well-trained primary care doctors who were individually willing to contribute their efforts towards training the doctors.

The introduction of family medicine in Indonesia as family medicine oriented primary care has three reasons to make it succeed:
There is a critical mass of primary care leaders, university teachers, and insurance providers, as well as Ministry of Health primary care leaders who have been exposed to the concepts and understanding of the role that family medicine can play in the health care delivery system. Indonesian needs family medicine oriented primary care doctors to be effective gate keepers in the health care delivery system. The project between Singapore International Foundation (SIF) & Indonesian Ministry of Health allowed the transfer of skills and knowledge on the organization and development of a family medicine programme.

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Stakeholders who are positive for its introduction are:

Ministry of Health Indonesian Association of Family Physicians Indonesian Medical Association Universities Ministry of Education Insurance providers

Invitation of Singapore Medical Association and Myanmar Medical Association (MMA) was the entry point for in-depth introduction of family medicine learning and teaching strategies into Myanmar. Reason for entry of family medicine into Myanmar Health Care Delivery System GP as primary care provider is recognized to be important. Prior exposure of medical leaders to the concepts and the role of the family doctor is again important. Family Medicine Workshop & interaction with MOH & MMA as the means to transfer of technology