Family Medicine in Health Policy: The Journey of AFPI from Advocacy to Act

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Dr Raman Kumar

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 practice. Family medicine is defined as a specialty of medicine which is concerned with providing comprehensive care to individuals and families by integrating biomedical, behavioural and social sciences. Family physician’s scope of practice 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 health care services with other specialists, as needed.

Historical evolution of family medicine
Internationally family medicine has developed from the historical tradition of general practice as a counter culture of the phenomenon of rapid fragmentation medical care into ever growing list of specialties and sub specialty during the period following 2nd world war in much of the developed world. In most countries family physicians function as first contact person in the health system and function as gate keepers of recourses and optimal utilization of expensive tertiary care facilities through a structured referral system. Family physicians form the backbone of any health care delivery system be it private insurance based eg US health system or public funded universal health coverage eg NHJS of UK.

Recognition of Family Medicine in India
That although “Family Medicine” is a recognized post graduate medical specialty by the Medical Council of India as a post graduate qualification (MCI PG Regulations 2000), departments of family medicine or general practice do not exist at medical colleges in India as it is not a mandatory requirement to start a MBBS course or medical college in India (Minimum Standards for Starting Medical College Regulation 1999). Interestingly family medicine is the ‘practicing discipline’ of majority medicine graduates such as general practitioners/family physicians private sector and GDMOs (general duty medical officers) in public sector is family medicine.

Academy of Family Physicians of India – Leadership for Change in Policy
That the “Academy of Family Physicians of India (AFPI), is a not for profit organization registered in New Delhi under society’s act 1860 with membership base spread over all India. AFPI is working towards establishment of a distinct academic discipline ‘Family Medicine or General Practice” for doctors pursuing primary care vocation within mainstream medical education system in India. Since inception in 2010, AFPI is providing academic forum for practicing and in-training primary care physicians. AFPI has organized several academic sessions of continued professional development (CPD) for primary care doctors at international, national and state levels. AFPI has so far organized 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 the inception AFPI has engaged with policy makers and the stake holders for upliftment of academic family medicine. Following is a brief background of policy related to family medicine discipline and outcomes of the advocacy on the behalf of the Academy of Family Physicians of India.

Family Medicine in Policy
Several policy documents of Government of India and WHO have strongly recommended establishment of family medicine training programs in India.

Mehta Committee Report
In 1983, “The Medical Education Review Committee” setup 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 practice outpatient unit in order to be exposed to multi-dimensional nature of health problems, their origins. The committee also strongly recommends that this specialty, which is already been approved by MCI, should be further developed so that an increasing number of students pursue higher study in area.

National Health Policy 2002 National Health Policy 2002 stated that in any developing country with in 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 to examine 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) Post graduate level (specialist level). The committee recommended following (1) Family medicine should be recognized 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 of 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 Woking Group 2007
In 2007 the working group of medical education under 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. Fifty percent of post graduate 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 Academy of Family Physicians of India, the Ministry of Health and Family Welfare (MOHFW) convened a high level meeting vide letter no. V. 11025/56/2010 ME (P1) under chairmanship of Union Health Secretary Government of India to discuss 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 post graduate 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 Health Care 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 Health Care” in Jakarta, Indonesia, 19-21 October 2011. The consultation came out with 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 recognizing 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 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 programs 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, and national boards etc. as per country needs. Distance education can be a cost-effective means of training large numbers in a relatively short period of time. (e) Standardize existing training programmes for family physicians and establish an accreditation system for the same. (f)Implement and institutionalize 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 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
That 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 came out with specific recommendation for Central Government, State Governments, universities, MCI etc towards implementation of government of India policy on family medicine. That in 2013, 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 & 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
That the several state governments in India have taken keen interest in family medicine training. The state of Kerala in its state health policy 2014 has mentioned family medicine as important area of intervention. That state of West Bengal has entered into a collaboration with Royal College of General Practice through ‘Institute of Health and Family Welfare Kolkata’ towards development of a course in family medicine called ‘Diploma Family Medicine’ program for which admission has taken place for the two batches. State of Bihar, Jharkhand and Chhatisgarh 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 Programs in Family Medicine and facilitate introduction of Family Medicine discipline in all medical colleges. This will not only minimize the need for frequent referrals to specialist and decrease the load on tertiary care, but also provide continuous healthcare for the individuals and families.

National Health Policy 2017
That the National Health Policy 2017 has emphasised on the need to popularize MD in family medicine or general practice in order to attract and retain medical doctors in rural areas. The policy recommends 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 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 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 development of academic discipline of family medicine / general practice for medical doctors engaged in primary care vocation as strategy towards strengthening of primary health care services across in India, broadly summarised below. (a) Creation of mandatory departments of family medicine or general practice and inclusion of this broad knowledge domain within 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 post graduate MD (family medicine/ general practice) seats or training programs and thereafter residency posts which are based in and spread over district hospitals, sub divisional hospitals, community health centres as an strategy towards augmenting provision of generalist medical services by skilled/ competent human resource leading to 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 preferential grant under Central Government Scheme of Strengthening/ upgradation 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 post graduate 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 rationalizing 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. Else creation of separate autonomous specialty board / college for family medicine and primary care on the lines of medical education regulatory system of 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 on the basis of data generated solely at academic tertiary care centres.

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 family medicine programme in India. The Supreme Court of India allowed liberty to approach Government of India and the Medical Council of India once again. As per the Supreme Court direction, fresh representations were submitted the to Ministry of Health and Family welfare and the Medical Council of India.

Reply from PMO:
In June 2018, the PMO provided following reply , which was in response to the memorandum submitted 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.”

National Medical Commission Act 2019
The National Commission Act 2019 passed in the Indian Parliament has mandated both under graduate and post graduate boards to facilitate family medicine courses in MBBS as well MD level.

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