Actions speak louder than louds, but words are a start!

Amanda Howe

Editor's note

In October 2018, 22nd WONCA World Conference of Family Doctors was held in Seoul, the capital of South Korea. At this meeting, general practitioners and family medicine researchers from around the world gathered together and launched Seoul Declaration. Over the last decade, family medicine has developed rapidly in Asia pacific region. WONCA decided to hold the 22th World Conference in Seoul, which showed the recognition of general practitioners about the development of family medicine in Asia. Another example is at the conference.Chinese general practitioners held an independent sub-forum, which fully demonstrated the progress of China's family medicine in the last decade. Today, family medicine still faces many challenges, such as the shortage of medical resources in developing countries and the unbalanced medical expenses in developed countries. However, people around the world are cooperating to face these challenges, as Seoul Statement highlighted: “WONCA reaffirms that investment of resources in the Primary Health Care sector will achieve comprehensive personalized primary care that responds effectively to people’s health needs in every community in the world.” Therefore, FMCH invited professor Amanda Howe, the president of WONCA, to write this special editorial, so as to explain the background, connotation and influence of the Seoul Declaration.

Any major conference is a huge amount of work, and takes years of effort on the part of many. When the meeting finally occurs, those who have led the process are always hoping that the event itself will be a success—and that it will leave a legacy. For participants, this legacy is often of exciting places, new people, new ideas and new learning. For those who lead, it may also be a chance to make a major impression—on their own country and its leaders, as well as those who visit from overseas. And it is a chance to bring together key strategic messages, to emphasise these in a powerful collective setting.

The World Organization of Family Doctors(WONCA) links family doctors across the world and holds its global conference every 2 years. It also has regional conferences, and working parties and special interest groups.At all levels, there are times when official statements are put forward.1The Host Organising Committee for the conference in 2018 in South Korea proposed to follow this model and launch the ‘Seoul Declaration’ at the conference.2Working with the WONCA Executive, it was agreed that some of the text should align with the upcoming statement likely to be issued by the member states of the world to mark the 40th anniversary of the Alma Ata Declaration.3This work was led by the WHO and Unicef, and WONCA in our capacity as a registered‘non-state actor’ was already trying to influence this important event. The opportunity to pick up the theme of strengthening primary healthcare (PHC) for universal health coverage (UHC) was taken, and the opening paragraphs of the Seoul statement show this theme.

The Seoul Declaration also highlights three key areas which WONCA is always championing—the need for equity in healthcare, the importance of family doctors for an effective and efficient health system, and the need for countries to invest in the primary care sector to deliver fullscope UHC. The wording and style of the Declaration is short and sharp, but covers key points. For example:

WONCA urges countries to invest in the training of skilled Family Doctors -through the development of academic capacity starting at the medical school level, effective recruitment and retention policies, postgraduate training programs, and continuous professional development. This investment will need to be matched by support for training of all members of the primary health care workforce; primary health care reform to aim for high quality and safe clinical services; and relevant research and new technologies which will underpin high quality clinical care. Working conditions, including remuneration, must also be made attractive for family doctors and their teams.

So what is the value of this statement? At the time, it provided a ‘feel good factor’ for those at the conference to rally around an explicit statement both of our value to the world’s healthcare, and to see our own needs and expectations highlighted. It attracted the attention of the Korean press and provided a focus for their outputs about the conference. It can be used by any national member organisation for similar purposes and to educate others about the core functions and importance of family medicine at this stage in history.

But as we know, words in themselves change nothing.The Astana Declaration had a process of countries signing up to commit to its implementation, with the potential for them to be held to account. Even then,such outcomes require countries to understand what UHC and stronger PHC should actually mean in practice, to increase investment into all those aspects that can preserve health and well-being, and to prioritise the primary care sector over what is often an uncontrolled development of the hospital sector. This requires political will, the stability and resources to make consistent changes, the agreement of other powerful players, and making the right practical choices. None of these more practical steps are specified in either Declaration, and family doctors were not specifically mentioned in the Astana Declaration (This was in spite of WONCA’s efforts—nursing and other health professional categories were also not specified, but the worry is that such high-level general statements risk subsequent action missing key components in an effective strategy). WHO has produced many background and technical documents which if consulted can provide very useful guidance.4WONCA commented on some of these when in draft and is gratified by the frequent mention of the family doctor workforce—but we need our member organisations to familiarise themselves with this debate,ensure that they are actively in touch with their ministries and decision makers, and educate and support all political decision makers as they (hopefully!) reconfigure the primary care workforce.

We know from prior experience of active advocacy at the country, region and WHO levels that there are still many players who simply do not understand what family doctors with a modern training can offer. We also know that there are areas of covert opposition—sometimes from other specialists who think their livelihood will be threatened, or from governments who fear that fully trained specialists will be too expensive. The option to retain doctors with no postgraduate training or proper continuous professional development, or to substitute doctors with nurses, remains a risk in many countries.If modern family medicine does not already exist in a country, the vision of the full impact of family medicine can often only be delivered by showing evidence from other countries and settings: so the process of ensuring that decision makers are familiar with the evidence base is another task we must undertake. To summarise—all professional leaders in family medicine need to get themselves into situations where they are listened to by key decision makers, to be able to explain what the Seoul Declaration means and how this can meet the aspirations of the Astana Declaration, and then to ensure that changes occur and are sustainable over time.

The advocacy literature is helpful here.5Being clear that successful advocacy involves specific key steps enables us to turn our passions and beliefs into practical strategic action. Being analytic about the problem and its possible solutions; gathering relevant evidence and opinions; then deciding on the key issue to aim for, building relationships with potential allies, setting agreed goals, deciding how these may be achieved and also how to identify the people whose voice is most likely to be ‘heard’ will all strengthen the effectiveness of any practical campaign (see Box 1 for an example).

Box 1. Example of how a national family medicine organisation might advocate for the key steps of the Seoul Declaration

?Agree a programme of work is needed, who will lead and work on it, and how it will report.

?Collate some of the key literature and existing messages on why family doctors can contribute to primary care that can deliver cost-effective care in a person-centred way. This could include case studies from their own and other countries.

?Decide what the next key issue(s) is for our country to achieve or strengthen equitable healthcare (accessible, affordable and a range of services that achieve the same ends for all).

?Discuss whether this view is shared with others and also how to achieve it: these others might include other specialties, other health professional groups and their professional representative bodies,patients and the public, health service funders and providers, and local or national public service sectors.

?Agree specific targets that are feasible but also ambitious-for example, ‘we shall double the numbers of family doctors in training in the next 3 years: this will be possible if…’.

?This may then need another round of discussion with partners to ensure they agree!

? Decide how to ‘sell’ this message publicly or to key decision makers-for example, it may be better to say ‘Based on previous evidence, we could increase population screening coverage by x,reduce hospital admissions by y, and save the country z if we had twice as many specialist trained family doctors doing the first line of medical care in 3 years time…’ than to say ‘The College of Family Doctors wants more family doctors’. Another option is the patient voice: ‘Since I had a family doctor I can xxxx’. These kinds of messages and case studies can then be disseminated through social media, press and professional circles.

?Of course any programme of work may need regular review, and this will be needed until the goals are achieved or the timeline of the initiative has run its course. Then it is time to take stock, learn from the experience and consider the next steps!

lN CONCLUSlON

More than 2000 people attended the Seoul conference,but many more have heard about the Seoul Declaration, and the ideas in it will be familiar to most family doctors in the world. If everyone who reads this article contacts their WONCA member organisation to check what they are doing to take this forward, we shall build momentum that will help countries to achieve UHC and strengthen PHC. The need to deliver family doctors to the world is a key objective. The Seoul conference and Declaration are part of that campaign. But we all need to take action to see this goal achieved.

AcknowledgementsThe author would like to thank all those who contributed to the excellent conference in Seoul, to the Seoul Declaration and to all members of WONCA.

FundingThe authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

DisclaimerThe author is a member of WONCA World Executive at the time of the editorial publication, and also a member of the WHO International Advisory Group for the Astana meeting, but has written this in a personal capacity; the views do not necessarily reflect WONCA or WHO policy.

Editor's noteIn October 2018, 22nd WONCA World Conference of Family Doctors was held in Seoul, the capital of South Korea. At this meeting, general practitioners and family medicine researchers from around the world gathered together and launched Seoul Declaration. Over the last decade, family medicine has developed rapidly in Asia pacific region. WONCA decided to hold the 22th World Conference in Seoul, which showed the recognition of general practitioners about the development of family medicine in Asia. Another example is at the conference. Chinese general practitioners held an independent sub-forum, which fully demonstrated the progress of China's family medicine in the last decade.Today, family medicine still faces many challenges, such as the shortage of medical resources in developing countries and the unbalanced medical expenses in developed countries. However, people around the world are cooperating to face these challenges, as Seoul Statement highlighted: “WONCA reaffirms that investment of resources in the Primary Health Care sector will achieve comprehensive personalized primary care that responds effectively to people’s health needs in every community in the world.” Therefore, FMCH invited professor Amanda Howe, the president of WONCA, to write this special editorial, so as to explain the background, connotation and influence of the Seoul Declaration.

Competing interestsNone declared.

Patient consent for publicationObtained.

Provenance and peer reviewNot commissioned; internally peer reviewed.

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