Radhika Arora (India), Felipe Rojas Lopez (Chile), Leen Jille (The Netherlands) & Sushma Krishna (India): Students MPH 2013-14, Institute of Tropical Medicine Antwerp

Radhika Felipe ROJAS LOPEZ Leen Dr. Sushma

“The general practitioner is a licensed medical graduate who gives personal, primary and continuing care to individuals, families, and a practice population, irrespective of age, sex and illness. It is the synthesis of these functions which is unique. He will attend his patients in his consulting room and in their homes and sometimes in a clinic or hospital… He will include and integrate physical, psychological and social factors in his consideration about health and illness.” Leeuwenhorst definition, 1974

Recently, a group of international public health students at the Institute of Tropical Medicine in Antwerp had the opportunity to observe the provision of primary health services in Belgium. As part of this group, we the authors of this post were impressed by the role that the general practitioner (GP) held within the local health system here. We noticed GPs had time to spend with their patients; often, they knew about the social background of their long-standing patients. GPs provided home-visits to the elderly and others without the capacity to travel to a health centre, impressed by the patient centeredness of care that this system of primary health care encouraged. However, it also pushed us to reflect upon the significance of GPs as providers of primary care in our home countries and in the health systems in countries such as India, Chile and Mozambique, where we had worked.

The definition of a GP varies in different settings, but the essence of the role of this healthcare provider remains largely the same everywhere – as one who provides holistic, primary healthcare services to a community. In many of our contexts the presence of the GP is gradually fading. There was a collective expression of nostalgia of a time when the GP or the family doctor  – we use the terms general practioner, family doctors, family physicians interchangeably –  made house calls when a member was unwell; a doctor who knew the medical history and family of his patients intimately and often had social ties within the community he served in.  This daily town tour done by the GP in the past is currently nothing but a memory of the days gone by; the visits are now more and more restricted to those unable to visit a health centre. The decline in the change in home visits could also perhaps be attributed to the fact that fewer medical graduates chose to work as general practitioners. Even in Belgium, we are told, general practice as a career choice in medicine is being traded in for practice in specialised medical fields. And so, at a time when effective management of health workforce towards providing primary health services, both in the global South and North, is one of the key challenges facing the health system, we asked ourselves, what happened to the general practioner? We juxtaposed this with settings in Mozambique and India, which have a shortage of qualified physicians so acute that being visited by a Community Health Worker (CHW), trained in the absolute basic of health care services is considered a luxury. As essential primary health providers, the GP’s role is crucial in providing preventive, curative, palliative and informal care. For both low-middle- and-high income countries this can mean reducing the burden on specialists. GPs provide crucial preventive and curative services for ailments that require less specialised care. Often GPs can practice with fewer years of medical education than it requires to practice as a specialist, thereby giving the opportunity to produce more trained physicians within a relatively shorter time. With the demographic transition and the burden of chronic diseases in the North and also increasing in the South, the GP’s multifaceted role becomes even more relevant and indispensable.

We realised that there are lessons to be shared between the global North and South. For example, many countries in low-resource settings employ task-shifting to make more efficient use of available resources – a lesson which could be relevant to the North. The role of nurses and midwives could be expanded from that of ‘support’ staff, to expanding the type of services they can provide. Lessons in task-shifting from the South where nurses take over certain routine procedures for chronic patients, where midwives at first level can deal with antenatal care, family planning, counselling, etc. is an option open to both high and low-income countries. For example, at a not-for-profit health centre in Antwerp, we noticed nurses being trained to provide routine care and counselling services to diabetic patients, thus freeing up the GP’s from that service. This, of course requires the support of both, the state and health providers, as well as investment in developing appropriate medical education strategies for the future. This is also relevant in areas with an inequitable distribution of workforce. For example, in Mozambique which already has a low health worker-population ratio, physicians are often located at distances inaccessible for most people. Here nurses and nurse-practitioners often run the first line health care services and provide essential health care services to the community.

Providing adequate and quality primary health services is, from a human rights perspective, a permanent matter of concern. Under this frame, human resources play a paramount role. Even as Belgium has 3.8 doctors per 1,000 people, Chile has 1, there are 0.6 in India and only 0.03 in Mozambique, there are shortages of general physicians in Belgium, especially in underserved areas. Currently in countries with adequate health care professionals, those choosing a career as primary health care providers (such as GPs and family doctors) are reducing. A common complaint, noticed during our visits was “we don’t have enough staff”, particularly GPs. And so, while impressed by the amount of time doctors and nurses had with their patients in Belgium, as compared to settings with chronic health worker shortages, we noticed that in both settings the doctors at the primary or community level were outnumbered and outgunned.

But why, one might ask, is there such a shortage of medical professionals interested in primary health care? Could it be financial remuneration and associated prestige (in comparison with their peer doctors)? In the North, for example, in the OECD countries, particularly Belgium, the Netherlands and Austria, GPs earn less than half that of specialists. In the United States, they are the lowest earning medical doctors. Even in the South, where the qualified medical practitioners are woefully short of WHO’s recommended figure of 23 health workers per 10,000 people , and inequitably distributed between urban and rural areas, specialisation is preferred over the provision of primary health services among the medical fraternity. A nationwide campaign demanding more seats in medical colleges for specializations took off in mid-2013 in India. The country produces 46,000 medical doctors and 22,000 specialists every year,  as almost 99% of undergraduate students indicated an interest in pursuing a specialization after their basic medical training, indicative of a reluctance to work as primary health care providers, certainly in rural areas with less attractive living conditions?. Conversely, the Netherlands and Chile have witnessed the production of more specialists than the health system can absorb, but clearly, in most settings there is a strong preference towards working as a specialist rather than as a general, primary health care specialist.

Although there is a difference in the magnitude of the human resources constraints facing countries in the North and South, each presents its challenges in their individual contexts. There is a need to share experiences towards encouraging qualified professionals (and finding ways to produce more qualified health professionals) who are motivated to provide primary health care services to the community. Strategies such as task-shifting are quite popular in low-resource settings. Affordable health technologies are gaining ground as they provide a more efficient use of resources in diverse settings in providing primary health care. For example, mHealth initiatives are being used for drug adherence for antiretroviral therapy and also to improve the coordination and productivity of CHWs in low-resource settings.  In India, trials are underway for a new kind of baby incubator which requires little or no electricity – essential in countries with limited resources and weak health systems.  Belgium’s Impulseo I which offers financial incentive to physicians who chose to work in areas with a low doctor-patient ratio is  just as pertinent to the needs of the country, as India’s own initiatives to incentivise physicians to provide primary health care in rural areas.

It is time to once again look at ways to resurrect the family physician’s role in the provision of primary health care services whether in India, Belgium or Chile to find ways to ensure that the role of GP’s as primary providers is insured by mechanisms to develop structured referral systems, encourage people to see the benefits of developing links with their family doctors, as well as, ensure a more equitable status. Whether it’s in countries like Mozambique with an overall shortage of health workers or in Belgium with its inequitable distribution of health workforce, the use of the skills of trained nurses, midwives and other allied health care professionals, has the potential to bridge the gap, and provide quality public and primary health services to people.



Author information

Leen Jille: Originally from The Netherlands, Leen has worked in the area of Procurement and Supply Chain Management for medicines and medical supplies in several LMIC since 2003, most recently in Mozambique. leenjille.wordpress.com

Felipe Rojas Lopez: A midwife from the University of Valparaiso, Chile with a diploma in Family Health, University of Chile, Felipe has four years of experience in primary health services in Chile. And four years of humanitarian experience with MSF and IRC. pubhealthnoob.wordpress.com

Radhika Arora: Has lived and worked in India for most of her life. Her initial training and work was as a features journalist. She worked with the Public Health Foundation of India, before joining ITM as a student of public health. radhikaarora.wordpress.com

Sushma Krishna: worked as a Medical Doctor, Lab Microbiologist and was faculty at University Teaching hospital in India before starting MPH at ITM, Belgium. sushmakrishna.wordpress.com

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5 Responses to Mind the GP! The role of the general practioner in the Belgian system: sharing lessons from low-and-middle-income countries and vice versa

  1. David Hercot says:

    Dear Colleagues,

    I want to congratulate you to put this discussion to the front. I agree with you that more link can and should be made between North and South human resource policy in the healht sector. Particularly with regards to the role of the first line care providers, which includes GPs. I agree with your arguments that Belgian GPs are underpaid compared to specialists and do not feel attracted to work in rural areas with current incentive schemes.
    Beside this, I would like to add that the amount of money doctors get at the end of the month is increasingly only a part of the equation. The quality of life is becoming an important criteria, especially for younger graduates. Working in a hospital setting or sharing a practice with other doctors are ways to improve these.
    Talking of task shifting, many GPs and specialist alike are still reluctant to embrace reforms that might reduce their responsibilities and hence their power or capacity to make themselves unavoidable in a system. A reaction I have also noticed in “the South” in very different settings where doctors did not want to allow adequately trained nurses to perform emergency C-section even in the absence of a doctor although this could save the life of the mother and the child. It might not be a deliberate decision but I am convinced it does play a role.
    Quality of life and power are two aspects we should not loose from sight in the debate of defining who should do what in health care.

    All the best.

  2. Chenai says:

    An interesting read. i have a few comments to make.
    1) perhaps it is time to inquire further into the reasons why people train to become medical doctors- their motivations. Medical schools should also take these motivations into account before enrolling new students. In my experience, many people trained to be doctors for the prestige, and for simple reason that doctors are the better paid in country, and they are never out of a job. So, of course, the more specialties you get, the more money you earn- why should I want to be a GP?
    2) unfortunately I don’t see that many people will want to be GP- unless this financial difference is resolved in some way.
    -we should also take into account that due to competition for patients, this current situation may actually be what some GPs find ideal (not necessarily in Belgium)
    3) from the consumer perspective- would you rather be consulted by a GP or by a specialist? Sometimes it is the consumer who drives this change. Maybe it is worth it to try to promote the GP among the population (this can start by governments actually recognizing their importance and increase their remuneration)
    4) task shifting- yes, it is done, and sometimes quite successfully, but it is not the sustainable solution. In my experience, it leads to burnout and disorientation of the staff who are shouldering the burden (e.g nurses). Task shifting is often also associated with some loss in quality. The staff taking over these ‘extra’ roles also have their normal duties to perform in the health system…who will do them? In the end, I see us accepting that nurses can do Cesarean Section (for example)- and we will justify it by provided a short training on surgery! We must be careful how far we take task shifting.
    These are general comments but i feel they should be ‘pondered’ upon. We have a real concern because with many new health problems emerging- each member of the health team really needs to be focusing on doing their own job- not trying to cover for another.

    • joseph Adrien Emmanuel Demes says:

      I think that task shifting is a valuable strategies if we want to go to universal acess. The human ressource aspect is very challenging. In Haiti, for instance, there is not enough doctors. So there is experience, in the HIV program where nurses do job that doctors suppose to do: there is not a problem in terms of quality of services. Actually in Haiti with the support of University of washington/ITECH, they train specialized nurse in the field of HIV. In Congo Where i used to work as an expatriate, nurses have been trained to do cesarian section. The quality is good. And that have a huge impact on acess to care for millions of women who otherwise will no be able to get the care they need due to shortage of doctors and OBGYNs specialists. The task shifting and task delegation should no be taken in isolation. It should be part of an holistic package: supervision, continous training, on the job training, human resources development, good health information system, governance etc…i think there is hope that task delegation could work in our countries. Dr Adrien Demes (Haiti)

      • Chenai says:

        Dr Adrien, I agree with you about task shifting helping to improve access especially in low resource settings. It is also the strategy we are using in Zimbabwe for HIV/TB programs. Our primary health care system is manned by nurses. However- my question still remains- are we now looking at a future were we have specially trained nurses to do the work traditionally designed for a medical doctor? Task shifting is not solving the problem of less and less GPs; it is still a temporary solution, and I am curious how far we will go this way.

  3. Totally agree! Nice post and good reflections. Congratulations Leen, Felipe, Radhika and Sushma!

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