Trends in Family Medicine in Latin America

1. Trends in Family Medicine in Latin America Adolfo Rubinstein M.D, MSc., PhD. Regional Presidente Wonca-Iberoamericana-CIMF . EURACT COUNCIL MEETING Turku, Finland, 4th-7th May, 2006

2. GLOBALIZATION, INEQUITY AND DISEASE IN THE WORLD % of total deaths in each group Source: Gwatkin y col. The burden of disease among the global poor. The Lancet 1998

3. There is a Relationship between Income and Life Expectancy But….is this relation accountable for everything? Life Expectancy

4. Global Health Chart Source: Karolinska Institute: www.whc.ki.se/index.php.

5. Aims of a Health Care system • To maximize population health applying state of the art available technologies and services • To minimize disparities for the health benefits reach all population subgroups equally

6. Our Region • Iberoamerica is a diverse Region with a wide heterogeneity regarding socio-economic development and health outcomes • Infant Mortality Rates range from more than 10% in some regions of Brazil and Bolivia to less than 1% in Cuba or Chile • Health Systems accross the Region are experiencing Reforms, many of them oriented to PHC

7. Distribution of Public Health Expenditures (PHE) and < 5 yr infant mortality in countries with similar per cápita GDP, 1995 *Relationship > 1 means higher PHE to poorer 20% of the population (B. Starfield 2005) Source: estimates from Karolinska Institute, Global health chart, www.whc.ki.se/index.php. Victora et al, Lancet 2003; 362:233-241. Castro-Leal et al, Bull World Health Organ 2000; 78:66-74. Carr. Improving the Health of the World's Poorest People. Population Health Bureau, 2004.

8. Selective PHC • Most of the initiatives and programs in PHC in Latin America failed due to: • Low/unsustainable Financing • Unqualified health Professionals • Poor training and equipment • Poor health care • “Primitive” rather than “primary”, particularly when PHC steategies were limited to the poor and only included basic services • Vertical Programs focused only on vulnerable groups

9. Systemic Attributes PHC regulation Financing Type of PCP % pf MD who are PCPs PCP/specialist payment ratio Co-payments in PHC Defined population in charge of a PCP Clinical Practice attributes First contact care Longitudinality Comprehensiveness Coordination Family approach Community Orientation PHC to all (PHC oriented health care systems) PHC as a central (not first) level of care

10. Argentina Brasil Chile Cuba Costa Rica México Dominican Republic PHC oriented Reforms in Latin American countries Plural and fragmented health care systems

11. Training Human Resources towards Family Medicine in LA • The demand of FP in the Region is increasing as a consequence of Health Care Reforms oriented to PHC • Low number of Specialists in Family Medicine • Few Residency Training Programs • Many GP´s without formal postgraduate training • Mismatch between what health services need and what health services and the Universities are producing in terms of undergraduate education and postgraduate training

12. PCP workforce in Latin America Source: Elaboración propia basados en HSR 29. OPS/OMS 2002

13. Family Medicine at undergraduate Education in Ibero America Source: Datos propios y HSR 29. OPS/OMS 2002

14. Residency Training Programs in FM in Iberoamérica Source: Documento Técnicos de Reunión IB Certificación Profesional y Acreditación de Programas de en MF. CIMF y OPS/OMS. Isla Margarita, Venezuela. Noviembre de 2003

15. Our Mission… • Since the beginning, almost 25 years ago, ICFM was created as a non-profit international organization devoted to the development and strengthening of Family Medicine and Primary Health Care in Iberoamerican countries. • At present, WONCA-Iberoamericana-CIMF is made up of 20 National Associations of Family and/or General Medicine of the Region • We are organized in four subregions: Andean, Southern Cone, MesoAmerica and the Iberic Peninsula

16. Our aims… • To provide a Regional forum to disseminate the principles and practice of Family Medicine in Ibero America • To implement technical cooperation with other international organizations, governments, NGO´s, academic institutions, and the private health care sector to foster and strengthen Primary Care Oriented Health Services Reforms in the Region, based on Family Doctors. • To promote and support the creation, development and empowerment of National Organizations of Family Medicine across the Region . • To promote, develop and coordinate high quality-academic initiatives in Education and Research in Family Medicine.

17. Our History… • ICFM was founded in Caracas, Venezuela in 1981 under the leadership of Prof. Julio Ceitlin and other regional leaders in the field of PHC • This first stage, that lasted 15 years, was characterized by the creation and organization of National associations, as well as for the sensitization of Health Care systems and services towards Family Medicine in the Region • In 1996 in Granada, Spain, the old ICFM became the Ibero American Confederation of Family Medicine, but in this second stage, formally integrating the National associations as its constituents and government body. • Today, in this third and last stage we are officially entering into the worldwide community of Family Doctors as its 6th Region, WONCA-IBEROAMERICANA-CIMF

18. Our Regional Initiatives…Buenos Aires, Argentina,November 1996 • Driven by the WONCA/WHO Conference held in Ontario in November 1994, academic and scientific regional authorities, as well as representatives of international organizations and governments of Ibero America met in Buenos Aires. • The aim was promoting the inclusion of Family Medicine into health services and Universities following the Reforms that were taking place in several countries. • The conclusions of this Conference were reflected in the “Declaration of Buenos Aires”.

19. Our Regional Initiatives…Seville, Spain, May 2002 • This First Ibero American Summit in Family Medicine, “Commited to Improve the Health of the Population”, was organized by CIMF together with PAHO/WHO and semFYC • 4 important issues were addressed: • Family Doctors, Health Systems and Demands of citizens • Quality Improvement in Family Practice and PHC • Undergraduate education and Postgraduate training of FP • The Summit concluded with the publication of technical documents framed in the “Declaration of Seville”, undisputable cornerstone for the elaboration of a regional agenda for our specialty

20. Our Regional Initiatives…Isla Margarita, Venezuela, November 2003 • Following the compromises adopted in Seville, experts in Medical Education and scientific representatives of Family Medicine, sponsored by CIMF/WONCA and PAHO/WHO, gathered to define regional standards for Quality Improvement in FP regarding patient care, addressing: • Accreditation of Residency Training Programs Accreditation of CME activities • Certification of Specialists in Family Medicine This initiative concluded with the publication of recommendations exposed in the Declaration of Margarita, “Improving the Professional Quality of Family Doctors in Ibero America”.

21. Our Regional Initiatives…Santiago de Chile, October 2005 The II IB Summit of Family Medicine was a meeting organized by Wonca IB, PAHO and the Chilean Government aimed to gather political and academic decision makers in LA to promote Family Medicine A document with 10 recommendations related to the integration of FM within health services called the “Compromisos de Santiago de Chile” were agreed and signed.

22. You are very welcome to come to Buenos Aires in October…our spring season!!!