State of Family Medicine around the world — A more detailed view by region (Supplement)
Arya Gibson Ponka Hansel Dahlman Rouleau Haq
with assistance of …
Family medicine around the world is variable in terms of form and practice but also in training, recognition and institutional support. This site provides more regional and country-specific information than the CFP print article allows.
Information is sometimes confusing and contradictory and our informants and personal contacts, whether programme, governmental, or administrative, each may have biases and limited information. We have tried to validate information through looking at the literature, confirming facts with personal contacts and using data from two larger studies. We shall be pleased to update information with intelligence from the readership on the Besrour website.
We are preparing a WikiTable at https://docs.google.com/spreadsheets/d/1Hqxwi9_ZKvk5IBmpG9ZdRzcAJD7UcjIaLOl-vOmSTGc/edit?usp=sharing with information on Family Medicine Training, History, Recognition by the Health System and (eventually) Health Systems Performance.
Resources-Articles and Websites of Note
Haq C, De Maeseneer J, Markuns J, Montenegro H, Qidwai W, et al. Kidd M, editor. The Contribution of Family Medicine to Improving Health Systems: A Guidebook from the World Organization of Family Doctors. 2nd ed. London: WONCA and Radcliffe Health Publishing, 2013.
Haq C, Ventres W, Hunt V, Mull D, Thompson R, Rivo M, Johnsson P. Where there is no family doctor: the development of family practice around the world. Acad Med. May 1995: 70(5):370-80. Available from: http://journals.lww.com/academicmedicine/Abstract/1995/05000/Where_there_is_no_family_doctor__the_development.12.aspx
The World Organization of Family Doctors (WONCA) was founded in 1972 and now claims 118 Member Organisations representing some 500,000 family doctors in over 130 countries and territories around the world. It has seven regions – Africa, Asia Pacific, Eastern Mediterranean, Europe, Iberoamericana-CIMF, North America, and South Asia. We hope to use WONCA contacts to develop this web resource.
From Erika Baum -Health Systems Interesting Health systems dates for Europe can be taken from the Euro Health consumer index: http://www.healthpowerhouse.com/files/EHCI_2016/EHCI_2016_report.pdf
Britain is seen by many as the birthplace of universal health care with the NHS though in larger centres such as London a parallel private system exists. The UK has the shortest post grad GP licensure in Europe of three years with 12 to 18 months spent in outpatient general practice. This is following the system of foundation years one and two FY1 and FY2, usually consists of two years of 4 x 6 months (may also be four months each), changed in 2005 from junior and senior house officer training After that they apply for Speciality Training and for General Practice that lasts for 3 years – half of which is GP based and half hospital, using an e portfolio to log everything with a dedicated educational supervisor. The Royal College is proposing an immediate increase to four years with two years in General practice. Also see http://www.rcgp.org.uk/ (courtesy Steve Adams, reviewed by Alice Shiner)
The Dutch College of General Practitioners is the scientific society of Dutch general practitioners (GPs) and represents 95% of the GPs in the Netherlands (approximately 11,000), with the mission to improve and to support evidence-based general practice. https://www.nhg.org/ The training is 3 years (medical school is six years divided into a three year bachelor’s and three year master’s degree) beginning after medical school. A total of two years is spent in general practice (the first and third years) with six months ER, three or six months geriatrics or chronic health-nursing home and three months psychiatry ( or six months OB). The general practitioner in the Netherlands is ‘the gatekeeper’ of the health system. (with assistance Jennifer Young, Annemiek Griffioen).
In Spain the Sociedades de Medicina de Familia y Comunitaria formed in 1982 three years after the first residency programme began and now has almost 20,000 members. https://www.semfyc.es/es/ Spain also contributes to the development of family medicine in Latin America.
In France le Collège National des Généralistes Enseignants http://www.cnge.fr/ was created in 1983 to encourage development of general practice as a scientific and teaching discipline.. But despite governmental interest in establishing a gatekeeping role, this has not taken hold.
The German College of General Practitioners and Family Physicians ” Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin” (DEGAM) was founded in 1966. It promotes primary care practitioners as gatekeepers, defining the discipline in 2002 as, concerning “the provision of basic health care to all patients with physical and mental health problems in the form of emergency, acute and long-term care. It also plays an important role in the areas of prevention and rehabilitation.” (http://www.degam.de/what-we-do.html) More GPs are organized in the Hausärzteverband which functions as a trade union.. Entwurf für die Novellierung der Musterweiterbildungsordnung Stand 2013″-http://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/pdf-Ordner/Weiterbildung/MWBO.pdfp 23-25
As in other specialties training is 5 years, normally 18 months in an in hospital internal medicine setting, 18 months open but involving direct patient care and two years in ambulatory general practice-this could include six months in pediatrics, internal medicine or outpatient surgery. Though work in a university department of General Practice/Family medicine can be credited for up to 24 months there is tremendous variation between states and universities. 80 hours are spent in basic psychosomatic care and communication (including 30 hours with Balint groups). More information may be found at: http://www.degam.de/weiterbildung.html.
There is some mandatory teaching of family medicine at the undergraduate level ( two weeks, further 14 hours teaching) and an option to spend four months in general practice during the final year of medicine. Other education provided by GPs through Departments of General Practice include elective courses, mandatory sessions on geriatric preventive care for example. Thus though there are many departments at universities there are few residency programmes run by universities. At local level there are voluntary residency programmes offered by various players in the system. http://www.degam.de/allgemeinmedizinische-universitaetsabteilungen.html
Data from Kassenärztliche Bundesvereinigung (KVB) official organisation for the care of our insured patients (over 90% of the population). http://www.kbv.de/html/
In chart (with assistance of Julia Romberg, Erika Baum)
Greece (courtesy Rania Skoufi)
For decades two organizations have been officially recognized by the Greek government and doctors within and outside Greece-ELEGEIA (Greek Company of General Medicine Doctors) & ENOSI ( Greek Union of Medicine General Doctors).
Problems exist in applying the right to Primary Health Care including health structures (physicians tenured within public structures and non permanent), pilot programs which went nowhere, payment structure -salary (not satisfying physicians-those working in the governmental sector are restricted to working 7 hours per day which is to be “complete and exclusive employment” ), fee for service (sometimes fraud so more expensive and per capita (also in other countries)-normally between 500 and 2000 patients. Currently there is insufficient recognition of differences related to remoteness (eg. islands, age, morbidity etc.) The government wants to establish a 24 hour call system.
In Russia and Central and Eastern Europe (CEE) the fall of Communism a quarter of a century ago was accompanied by rapid changes in health policies including privatization of healthcare provision and disintegration of polyclinics into separate, smaller outpatient clinics. For those CEE countries aspiring to join the European Union (EU), EU directives on medical education, primarily intended to promote the free movement of doctors, was a further driver of reform.
However, there is still much variation in the region. For example, in the CEE countries duration of training varies from 3 to 5 years, and not all universities have department of family medicine(Seifert). In Russia, at least 15 family medicine training sites have been established (notably in St. Petersburg and the Far East), but new graduates find integration into a system still defined by “old attitudes and infrastructures of the Soviet era frustrating” (Rese, Christianson). In several countries, such old attitudes mean the creation of separate “family doctors” for adults and children.
Estonia and Slovenia may be among the most advanced with recognition, scientific conferences journals There are also doctorate family medicine as public health or social medicine called PhD programmes in Estonia, Slovenia, Poland and Latvia 2013. Some countries avenues for certification after practice with CPD and recertification but in most not enforced. (Oleszczyk et al,) Ask Joachim Gross)
In the former Yugoslavia, however, family medicine was created in several institutions with assistance from Canada in the form of CIDA funding and the involvement of the Department at Queen’s University) in a post-conflict situation, with very little initial infrastructure, using a more radical approach. This presented different challenges, but avoided some engrained of the conflicts mentioned above.
(Verified Dr. B. Seifert)
Christianson CE, Bistrovsky VF, Kogut BM. Family Medicine in the Russian Far East. Family Medicine. December 2007, 39(10): 742–45. Available from: http://www.stfm.org/fmhub/fm2007/november/charles742.pdf
Krztoń-Królewiecka A, Švab I, Oleszczyk M, Seifert B, Smithson WH, Windak A. The Development of Academic Family Medicine in Central and Eastern Europe since 1990. BMC Family Practice .2013, 14:37:1471-2296-14-37. Available from: http://www.biomedcentral.com/1471-2296/14/37
Rese A, Balabanova D, Danishevski K, McKee M, Sheaff R. Implementing general practice in Russia: getting beyond the first steps. BMJ. 2005 Jul 23;331(7510):204–7. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1179768/
Seifert B, Svab I, Madis T, Kersnik J, Windak A, Steflova A, et al. Perspectives of family medicine in Central and Eastern Europe. Fam Pract. 2008 Apr 1;25(2):113–8. Available from: http://fampra.oxfordjournals.org/content/25/2/113.full
Oleszczyk M, Švab I, Seifert B, Krztoń-Królewiecka A,Windak. Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia BMC Family Practice. 2012, 13:15 doi:10.1186/1471-2296-13-15. Available from: http://www.biomedcentral.com/1471-2296/13/15
Tomasik T. We don’t know if health system changes in Eastern Europe have improved quality. BMJ. 2012 Jan 25;34(4)(jun25_1):e3923. Available from: http://www.bmj.com/content/344/bmj.e3923
El Centro Internacional para la Medicina Familiar (CIMF) was founded in Caracas in 1981 is a federation of societies colleges and associations of Iberoamerica to promote the development of family medicine in the Americas. At the WONCA World Conference in 2004, CIMF joined forces with WONCA and became the 6th WONCA region named Iberoamerica-CIMF.
FROM WONCA REPORT The establishment of a standardized curriculum for post-graduate courses of Family Medicine (Argentina, Brazil, Chile, Colombia, Peru) the development and implementation of a community and family model of health delivery with Family Doctors included in the basic teams (Colombia, Costa Rica, Nicaragua) the progressive positioning of Family Medicine in public and private institutions (Puerto Rico) the government initiative ensuring every child has a family doctor (Portugal) the support to FM residents and young doctors in the Waynakay Movement as well as introducing them to the scientific associations of FM (Chile, Colombia, Costa Rica, Paraguay, Uruguay) the development of parameters and initiatives for the certification/recertification process in Family Medicine (Argentina, Bolivia, Chile, Costa Rica, Paraguay) the publication of national policies for the medical undergraduate curricula giving Primary Care and Family Medicine a minimum of 30% of course time an increase in the number of FM Residency Programs as well as an increase in the coverage of the Health Family Strategy to 60% (Brazil) the increasing influence and participation of the FM Associations and/or representatives of FM in influential positions and/or as advisors on themes and issues related to health policies and health systems organization (Chile, Costa Rica, Panama, Paraguay, Spain, Uruguay) significant improvement in recognition of Family Medicine as the key to deliver Primary Care, with the establishment of an economic incentive for Family Physicians who work in the public health system (Chile)
Editor Maria Sofia Cuba Fuentes
Until recently, clinical primary care training at the Catholic University of Chile has been divided into two adult and child residency streams, partly related to a model in Spain when the programme started where general pediatricians performed much primary care adult and pediatric (this also occurred in Eastern Europe) and difficulties with Chilean referral system. Recently efforts to integrate the two consistent with prevailing global understanding has been underway in collaboration with external bodies from North America and Europe. (Conversations with faculty (October 2014) and with representatives of the Chilean MOH (December 2014, Nicolas Barticevic). Several schools in the country have Master’s programmes, the Catholic University in UCL also has several Master’s, most distance Diploma programmes 320 hours comprised of forty hour courses including one in class. These are at Catholic University, Concepcion, Valparaiso and Frontera, This is to be transformed into an accredited ‘in practice programme. The Catholic University also offers a similar length advanced course with twice as class time.
In Argentina termed as Atencion primaria de la salud APS, programmes continue but trainees seem to have less interest in primary care. (Del Carmen Gayol, Carrera, Mancia)
Bolivia has 400 trained family medicine specialists, each doctor working in the public health system, managing a team which cares for a population between 2500 to 10000. Bolivia has residency programs based in several schools, Ministry of Health, social services and hospitals (Ruiz Guzman 2007).
Colombia has six institutions with family medicine programmes and about 200 graduates. (Colombian Ministry of Health)
Paraguay‘s three year programme graduated about four to five residents a year since 1981, and has had a society of family medicine since 1990 which also has organized conferences every four to five years and assisted in recertification. Since 1998 programmes have expanded to four schools a couple accepting twenty residents per year, with more support in teaching at an undergraduate level. Within th the last five years efforts have been made to make a virtual course increasing numbers by orders of magnitude. (Szwako Pawlowicz) with 240 doctors certified and recertified by the licensing body médicos certificados y recertificados por la SPMF http://www.observatoriorh.org/sites/default/files/webfiles/dialogos/dgo_medfam/DianaYuruhan_paraguay.pdf
In Uruguay, the Ministry of Public Health created Family and Community Medicine Residency in 1997, with recognition of the specialty by the Faculty of Medicine and specialist qualifications (2003). In 2006 Uruguay’s Universidad de la Republica reoriented its curriculum to align it with the concept of the social accountability of medical schools, integrating Family and Community Medicine teaching in the undergraduate and postgraduate curriculum at a number of locations throughout the country, founding a Department in 2007 and conducting collaborative research on practice in partnership with Sherbrooke University (Fac Med). (will ask Anahi Barrios) Will see also http://www.observatoriorh.org/?q=node/611
Peru Family medicine residency training began in Peru in 1989; currently there are more than 600 family doctors and 21 residency programs, with training spots for 70-90 annually. Family medicine has not been inserted in undergraduate training. Undergrad teaching concentrates more on community than family medicine and perhaps four of 21 universities have family doctors teaching. The inclusion of family medicine in the health system has also been slower and more complicated than expected. Peru has a mixed health system with multiple insurers and providers and 20% of the population remain without coverage. While a Master’s Maestría en Medicina Familiar y Atención Primaria de Salud at the Universidad Peruana Cayetano Heredia (UPCH) continues, the number of residency positions fell from 70 in 1989 down to 2 in 2001 back to 70 in 2007. Even the family medicine society recognizes multiple challenges, There are few specific jobs for family medicine specialists and trainees are much more interested in other residencies. In the future Peru must consolidate the specialty by improving the training settings and developing a unique health system. (With Dra. Maria Sofia Cuba Fuentes)
With the Revolution, Cuba lost half of its doctors and soon decided it needed to promote rural practice through salary and advancement incentives, working with Health Units and promoting Vertical Primary Health Care campaigns. By 1964, a Comprehensive Polyclinic model was adopted involving community participation keeping family records; focusing on population groups with disease oriented programs (tuberculosis, venereal diseases, infant mortality, acute diarrheal diseases), immunization programs and health education. (Rojas Ochoa) Now about 500 such polyclinics exist each dealing with 30-60,000 people, 20-40 family doctor and nurse offices, and having accredited research and teaching centres for medical, nursing and allied health sciences students. Said one policymaker “We were conscious that prevention had to be a cornerstone of our system, and that people had to be understood in all their dimensions: biological, psychological and social [and] as individuals, within families, and within their communities.” (Bulletin of the WHO) Society of Family Doctors of Cuba. la Sociedad Cubana de Medicina Familiar (SOCUMEFA) con la Medicina Familiar y la Atención Primaria de Salud (APS), Overall Cuba each person has their own family doctor and primary care nurse team and 36,000 family doctors in 3000 clinics provide 100% coverage of the population of 11 million people including rural areas and making housecalls. The Cuban model has now been promoted as an example of a national integrated approach resulting in improved health status first by medical personnel sent throughout Latin America and Africa and now, through the Latin American Medical School (ELAM), training thousands of doctors to return to at-risk communities in countries throughout Latin America and also in Canada and the US. (Keck and Reed) Now family medicine training is almost compulsory with 97% of medical graduates spending an internship year and two residency years in training in family practice, before being eligible to apply for another residency. (There is a fast track for such specialities as vascular surgery) There are also more than 20 000 Cuban physicians living abroad, mostly in Africa and Latin America. WHO Bulletin (verified by Mena Ramos)
Venezuela is considered to have had Family Medicine active society and a scientific journal with nine two year ambulatory-based residency programs established in the early 1980s (after internship) and two years of practice and similar to COPC family home visits, a 40-hour course titled “Family Dynamics and Counseling”, working with a health care team, completion of a community-based and health-related research project, and structured courses of theory in areas such as public health, behavioral medicine, and research methodology. (Thompson et al, Mejía et al,, Ledesna-Solaeche)
Brazil, began programmes to train general practitioners (GPs) in the late 1970s and the Brazilian National Committee of Medical Residency recognized “general and community medicine” in 1981 (changed to “family and community medicine” (FCM), in 2001). The National Curricular Guidelines for Medical Education highlighted professional competencies about PHC and FCM,. Blasco credits the formation of an academic society in 1992 to “establish the proper basis and scientific methodology for family medicine.” In the early 90s the government also created a Family Health Programme to combat popular and professional bias and to enhance teaching of humanistic medicine- communication, social accountability and empathy in undergraduate medical education .(Blasco, 2008) In the last two decades 30,000 Family Health Teams were established throughout the country, each caring for up to 4000 community members, with patients determined by geographic catchment area. Interestingly, only roughly 5000 of these teams included a trained family physician, with most including a generalist physician not specifically trained in family medicine. (Demarzo 2010) There are now 35000 teams while 60000 teams are required to cover the entire population. http://www.observatoriorh.org/sites/default/files/webfiles/dialogos/dgo_medfam/ThiagoGomes_brasil.pdf
Since health care falls under the oversight of municipalities and given Brazil’s rich diversity, support for family medicine varies greatly across the country. In Rio, a beacon of family medicine innovation, an accelerated increase in the number of family health teams over the past 5 years has been paralleled by an increased number of family medicine residency training positions from 30 in 2012 to 100 in 2014. In an effort to support quality of care and of training, generalist physicians recognized for the quality of their skills have been hired as faculty in this new training program and are provided with continuing medical education according to a well established and coordinated program.There are now more than 100 Family Medicine residency programs that provide around 1,600 residency positions each year.
Even within the same institution, at the University of the West Indies, located in 4 different countries and offer four slightly different training programmes ranging from more public health oriented diploma and Master’s programmes (in Jamaica for instance, both of these are offered with continuing education format with physicians completing modules while in independent practice and coming together periodically to receive a core curriculum and mentorship. Trinidad and Tobago’s Postgraduate Diploma in Primary Care and Family Medicine concentrates training on for example, ethics, evidence-based medicine and communication skills. (Maharaj) (KATHERINE TO CHECK)
In the late 1980s and early 1990s In Central America several family medicine residency programmes were reported as in development (Slater, Davis). But in most such training has diminished- for example Costa Rica now trains a couple of residents per year so that there are more teachers than residents. Most now favour Master’s programmes, certificates or more community medicine training. Since 2009 a four year Specialization with Master’s outside of San Jose Family and Community Medicine in Guanacaste including fieldwork clinic and hospital. http://www.odi.ucr.ac.cr/boletin/index.php?option=com_content&task=view&id=835
In El Salvador family physicians still struggle for recognition by training bodies and in terms of financial compensation. Now support from the Ministry of Health has led to formation of new programmes such as the 320 hour Master’s at the Dr. “José Matías Delgado” University (Universia) A residency program in family medicine emerged at the Salvadoran Social Security Institute (Instituto Salvadoreño del Seguro Social (ISSS)) in the 1980s, but with little support and low demand, soon closed. In the last decade the ISSS reopened programmes at the Amatepec Hospital in San Salvador, the Social Security Hospital of Sonsonate; but this time a Ministry of Health institution, Dr. Jose Antonio Saldaña National Hospital, in San Salvador in academic collaboration with the University of El Salvador (UES) also participated. The National Hospital also has a residency involved with UES. Recently the first two schools closed. leaving only the Saldaña/ UES programme with five to six residents per year. Prior to 2010 all specialists were diploma-based but since then, graduates obtain a degree. The programme is based on models from primarily Argentina, Cuba, Canada and Spain but also the United States and England. Over the years, models of family medicine have been influenced by the US (market-based) and Cuba (Latin American social medicine based on “social determination” and revolutionary theory), depending on orientation of the government at the time.
Family medicine remains poorly understood in El Salvador. Some see family physicians as general practitioners with three more years of studies, others as mini-internists but most don’t know who they are or what they do and some may be dealt with as such. Thus while some are lucky enough to be engaged by the ISSS as a GP, or as an internist by the Ministry of Health, whose health reforms demonstrate openness to the family doctor, others are unrecognized in private practice, by the general public and rest of the medical profession. There is also little training at an undergrad level at UES. The AMEFAES (Association of Family Physicians of El Salvador) began in 2011 and has had congresses (information courtesy Dr, María José Mejía de Chavez and William Ventres)
Mexico family medicine since 1971 http://www.observatoriorh.org/sites/default/files/webfiles/dialogos/dgo_medfam/MiguelFernandez_mexico.pdf 1981 certification then advanced now; for a country of 117 million approximately 39,000 family doctors, 1200-1400 entering residency every year of whom 17% from CEMFMG. Each family doctor looks after about 500-600 families or 2000 to 2500 patients Curso de Especialización para Médicos Generales (México) Programas de Formación Acelerada de Especialistas (Estados Unidos y Colombia) Programas de Reconversión (Especialización de Médicos en ejercicio) Educación Continua y prácticas clínicas (Argentina, Chile, Perú) Virtual Especialistas en Medicina Familiar (Paraguay y Argentina) Reconversión, Otros especialistas a Medicina Familiar + 400 hrs de EMC en MF y APS (Europa) Residencia Médica Cursos de Posgrado Posgrados paralelos (Especialidades y Maestrías) Rep. Dominicana, Bolivia, México.
Guyana has just begun a programme in the last year in collaboration with the University of Ottawa while French Guyana and Surinam lack programmes at present.
Blasco P, González P, Levites MR, Janaudis MA, Moreto G, Roncoletta GFT, et al. Family Medicine Education in Brazil: Challenges, Opportunities, and Innovations. Academic Medicine. July 2008; 83(7): 684–90. doi:10.1097/ACM.0b013e3181782a67. Available from: http://www.sobramfa.com.br/artigos/2008_jun_fm_education_in_brazil.pdf
Carrera LI, Enria GT, D’Ottavio AE. Primary care and medical specialization: Complementary or mutually exclusive categories? Educacion Medica. October- December 2004; 7(4):1575-1813. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1575-18132004000600010
Colombian Ministry of Health http://www.minsalud.gov.co/Paginas/Boyaca-le-apuesta-a-la-Atencion-Primaria-en-Salud-y-a-la-medicina-familiar.aspx
Davis WL, Haggerty J, Filion-Laporte L. The McGill-Costa Rica Project- Training in family and community medicine. Can Fam Physician. May 1992; 38: 1150–1154. Available from: http://www.odi.ucr.ac.cr/boletin/index.php?option=com_content&task=view&id=835
Del Carmen Gayol M, Tarres MC, D’Ottavio AE. Primary Health Care Medical Curricula Reflections and Proposals from the Present Argentinean Reality. Actual Med. 2011, 96(784):036-040. Available from: http://www.academia.edu/8861764/Curr%C3%ADculos_m%C3%A9dicos_y_Atenci%C3%B3n_Primaria_de_la_Salud
Demarzo D, Piva MM, Gusso GDF, Anderson MIP, Chalegre de Almeida RCC, Belaciano MI. Academic Family Medicine: New Perspectives in Brazil. Family Medicine. August 2010; 42(7): 464–65. Available from: http://www.stfm.org/fmhub/fm2010/July/Marcelo464.pdf
Facultad de Medicina: Departamento de Medicina Familiar y Comunitaria [Internet]. Vignolo JC. Available from: http://www.medfamco.fmed.edu.uy
Gunes, E. and Yaman, H. Evrim Didem Gunes and Hakan Yaman. Transition to Family Practice in Turkey. Journal of Continuing Education in the Health Professions 28(2):106-112. 2008
Guzmán JR. . LA MEDICINA FAMILIAR EN AMÉRICA LATINA: La medicina familiar en Bolivia Aten Primaria. 2007; 39(3):157-9. Available from: http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=13099564&pident_usuario=0&pcontactid=&pident_revista=27&ty=109&accion=L&origen=zonadelectura&web=zl.elsevier.es&lan=es&fichero=27v39n03a13099564pdf001.pdf
Ledesna-Solaeche FM, Romero NE, Atencio CM, Pineda F, Fernandez MA. International family medicine certification exam in Venezuela: the physician’s experience. Rev Invest Clin. 2006 Nov-Dec; 58(6):561-6. [Spanish]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17432287
Maharaj R, Sieunarine T. The Postgraduate Diploma in Primary Care and Family Medicine at the University of the West Indies. West Indian Med J. 2002 Jun;51(2):108-11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12232930
Mancia: Profesionales de la Salud [Internet]. Manica.org c200-2007 [updated July 22, 2011]. Buenos Aires y la Atencion Primaria de la Salud: Generalidades y precisiones para una perspectiva local. Available from: http://www.mancia.org/foro/articulos/83853-buenos-aires-atencion-primaria-salud.html
MEDICC Review [Internet]. MEDICC- Medical Education Cooperation with Cuba c2004. Ochoa FR. Origins of Primary Health Care in Cuba. Available from: http://www.medicc.org/publications/medicc_review/1104/pages/cuban_medical_literature.html
Mejía MA, Quintero OM, D’Avila MC, Silva CC. La Medicina Familiar en América Latina. Situación actual de la medicina familiar en Venezuela. “[Current situation of family medicine in Venezuela].” Aten Primaria. September 2007; 39(9):495-6. Available from: http://zl.elsevier.es/es/revista/atencion-primaria-27/la-medicina-familiar-america-latina-situacion-actual-13109501-series-2007
Nasmith, L. Focus on Cuba’s Accomplishments. Canadian Family Physician. June 2006, 52:6813–14. Available From: http://www.cfp.ca/content/52/6/813.full.pdf+html
Pawlowicz SAS. Desarrollo de la medicina familiar en Paraguay (Family medicine in Paraguay). Medwave. 2013 Ene/Feb;13(1):e5612 doi: 10.5867/medwave.2013.01.5612. Available from: http://www.medwave.cl/link.cgi/Medwave/Enfoques/SaludFamiliar/5612
Thompson R, Gruber F, Marcano G. Family Medicine training in Venezuela. Fam Med. 1992 Mar-Apr; 24(3):188-90, 238. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1577210
Universia El Salvador [Internet]. Universia El Salvador c2015. Diplomado en Medicina Familiar y Comunitaria. Delgado JM. Available from: http://estudios.universia.net/elsalvador/estudio/ujmd-diplomado-medicina-familiar-comunitaria
World Health Organization [Internet]. [Updated 2015]. Bulletin of the WHO. Cuba’s primary health care revolution: 30 years on. Available from: http://www.who.int/bulletin/volumes/86/5/08-030508/en/
Slater RG. New Family Practice Residency Programs in Nicaragua and Costa Rica. The Journal of Family Practice. April 1989; 28(4): 468–72.
Brazil approves Competency Based Curriculum for Family Medicine Residency. http://www.observatoriorh.org/index.php Conference 2014 http://www.observatoriorh.org/?q=node/607 Residencies Residencias médicas en América Latina. Serie Nro. 5: La renovación de la atención primaria de salud en las Américas 2011
At the 2009 World Organization of Family Doctors (WONCA) Africa conference South Africans Bob Mash and Steve Reid coordinated an intensive process that engaged over 250 stakeholders and local practitioners leading to a Statement of Consensus on Family Medicine in Africa. They recommended that family physicians be the clinical lead for a health care team, with a goal to ensure continuous, comprehensive, holistic, high-quality and personalized care to individuals, families, and communities. (Mash and Reid)
Family medicine is most established in South Africa with post graduate programmes in primary care in 1968 at the University of Pretoria and being community based since 1998. (Hugo ) By 1997, all eight departments of family medicine formed FaMEC (Family Medicine Educational Consortium), a network for communication and consultation, to share and exchange expertise, form a core curriculum and standardize examinations and develop appropriate assessment systems.(Training) However it wasn’t until 2007 that South Africa’s accrediting bodies formally recognized Family Medicine as a specialty.(Hellenberg) journal nash http://www.phcfm.org/index.php/phcfm African Journal of Primary Health Care & Family Medicine (PHCFM)
Within West Africa family Medicine training programs that focused on meeting the significant needs of the marginalized rural populations first began in Nigeria in the early 1980s. Though beginning in church hospitals, once the positive impact of these training programs was recognized these quickly spread to the government hospitals. Recently three separate 18 month part-time family medicine Diploma programmes have begun in Nigeria in the North, East and Southwest Zones. Groups meet one weekend per month on Friday afternoons and Saturdays on for lectures, practicals and demonstrations. Ghana also has had family medicine training since 1999, with two programs currently enrolling students. (2010 article).
Uganda‘s three year family medicine training at Makerere University (Kampala) based at the tertiary care University teaching site at Mulago, and using rural teaching sites in the final year began in 2002 and now has had over 50 graduates. Another three-year programme developed at Mbarara University of Science and Technology (MUST) with an initial cohort of ten students training in Integral Medicine starting in 1999 and another five that started in 2002 using a referral hospital in Rugazi for training in the last year. Lack of tuition support, especially after a partner institute in Germany that had provided research and living expenses pulled out, has hampered this programme. Family medicine specialists have been recognized and paid by the Ugandan Ministry of Health as specialists New programmes including The International Health Science University (IHSU) beginning in 2012 in Kampala, geared towards private, urban practice and the Kampala International University in Ishaka also aspire to family medicine development. Issues still include lack of faculty, recent development of undergrad curriculum (courtesy Cindy Haq and Innocent and article Development of Family Medicine in Uganda Jane Namatovu Cynthia Haq WONCA E Update Regional NewsAfrica March 2016 February, 2016 http://www.globalfamilydoctor.com/News/DevelopmentofFamilyMedicineinUganda.aspx
Approximately 35% of Kenya’s health care is provided in rural, church-affiliated hospitals. The Institute for Family Medicine (INFA-MED) was formed in 1996 from this base to support family medicine training in Kenya and with three of the church hospitals, approached Moi University in 2000 to pioneer the first Family Medicine training that started in 2005. “Family Medicine becomes viable and relevant when the specialty is defined and developed collaboratively with local citizens from community to national (MOH) levels” (Pust) One measure of the Moi programme’s success in that the County Hospital training site and the Department are now run by local graduates. Additional family medicine training programs have started: Aga Khan University in Nairobi (began 2002), Maseno University in western Kenya (2014), Kabarak University in central Kenya (2015) and Kenyatta University near Nairobi (2015). Kenya is unique in that the Ministry of Health has adopted an official Family Medicine Policy (2009). The Family Medicine Coordinating Committee, chaired by the Ministry of Health, is meant to champion the specialty’s growth and development in education and practice. “Together with the District Health Management Team, the Family Physician will be responsible for the implementation of the Kenya Essential Package for Health in their catchment areas.” ( Kenya MoH 2009 Family Medicine Policy, p. ii) (Also Bruce Dahlman). The Kenyan Association of Family Physicians (KAFP) began in 2002 and had been providing CME to its members through Practice-based Small Groups and advocacy for the specialty within the country.
Rwanda‘s programme, assisted by the University of Colorado, took residents from 2008-2010 but was suspended with changes at the Ministry of Health, and perhaps in response to external funding priorities.
Tanzania‘s programme began in 2004 at Aga Khan University (AKU) in Dar Es Salaam but has suffered from lack of recognition and support from the Ministry of Health and of rural training opportunities. This led to migration of trainees and staff to Kenya, but now encouraging changes seem on the horizon.
Gezira University in central Sudan, in the city of Wad Madani to develop both a 1-year diploma using online modules from NextGen U and a 2-year Master of Science (MSc) in family medicine with specialists mentoring on the ground in order to develop family medicine specialists able to enrol more than 100 at a time and graduate them quickly trainees at a time and graduate them.
In 2013, Ethiopia, with the support of the University of Toronto and the University of Wisconsin, developed a programme based at Addis Ababa University. As of February 2015 the program includes 19 residents in 3 cohorts. The Ethiopian Ministry of Health has expressed its support for the development of family medicine in Ethiopia and two additional training programs are set to begin in Gondar and Jimma in the coming year. (Philpott)
Malawi A residency is being developed at Mangochi and Nkhoma under the leadership of John Parks. (from Mena Ramos)
Hellenberg D, Gibbs T. Developing family medicine in South Africa: a new and important step for medical education. Med Teach 2007; 29: 897–900.
Hugo J, Allen L. Doctors for Tomorrow. 1st ed. South Africa: NISC, 2007.) (Training in Family Medicine and Primary Health Care in South-Africa and Flanders: report of a study visit. Belgium; September 1997. Report No.: Projectnr. ZA.96.11.)
Pust, R., Dahlman, B., Otsyula, B, Armstrong, J, and Downing, R. Partnerships Creating Postgraduate Family Medicine in Kenya, Family Medicine, 2006, Oct) 38 (9), 661-666.)
The Middle East and North Africa (MENA) is a diverse region and includes countries in the geographic areas of Western Asia, the Arabian Peninsula and Persian Gulf, the Levant and North Africa. MENA countries face several social and health challenges that have impacted the uptake and development of Family Medicine. The economic diversity found in the MENA region means that some of the richest in the world (Gulf countries such as Qatar, Kuwait, UAE) are found alongside some of the poorest (Yemen, Gaza). The region is characterized by low government spending on healthcare (on average 8.2% between 2006 – 2011 vs. 18% on education) and high out of pocket expenditures (40% or more), creating high levels of inequity in terms of access to services and health status within countries and perception of low quality of care (World Bank Fairness). The education and health status of women are low relative to economic wealth and violent conflict in several countries has had a devastating impact on years of investment and development in health systems. Conflicts in several countries of the region are resulting in thousands of deaths, disability and suffering, perpetuating large-scale refugee crises, and eroding decades of development and progress in health not only in terms of damaged infrastructure but also in accelerating the brain drain of health professionals.
Health challenges in the Middle East include a double burden of communicable diseases in poorer countries alongside a growing prevalence of NCDs in nearly all countries of the region; low-, middle- and high- income. The burden of NCDs will present one of the most complex challenges in the Middle East in the coming decades as the region has high rates of obesity (four MENA countries – Egypt, Bahrain, UAE, Kuwait- have among the highest rates of obesity in the world), Type 2 diabetes (a 2001 study showed 25% of all UAE nationals suffer from diabetes as opposed to a global average of 5-7% and affects 40% of the population aged 60+) (Mourshed and Lambert) and is projected to have one of the highest relative increases in the burden of diabetes in the world by 2030 (Shaw Sicree & Zimmet). In such a context family medicine’s emphasis on prevention and longitudinal care for a defined population is particularly relevant.
The Gulf countries import large numbers of expatriate health professionals from varying educational backgrounds to staff their health services, presenting challenges to developing unifying concepts and approaches to primary health care. The majority of physicians staffing primary care clinics are GPs with limited training beyond medical school, leading to general perception of low quality of care and patient preference for specialists.
Many family medicine programmes in the region have few graduates per year in relation to the need for family physicians. There is also limited continuing professional development and few research opportunities, though an effort in 2003 by the Lebanese Society of Family Medicine to introduce a 2-year structured CME program for primary care physicians in remote areas covering a variety of topics is noteworthy. (Saab)
Some countries are developing new programmes and searching for evidence for family medicine/health. The United Nations Relief and Works Agency (UNRWA) providing health services to Palestinian refugees in the region is introducing the Family Health Team (FHT) Approach to improve the quality of care and integrate services, particularly in NCD prevention and control (UNRWA, 2013. Health Department Annual Report 2012, UNRWA). The reform aims to reorient services from the traditional vertical polyclinic model, where each clinician is responsible for one type of service, to one of holistic, family and person-centered care, with teams of providers ensuring continuity and longitudinal care. Significant community involvement and consultation has been a hallmark of UNRWA’s reform. Results to date have been positive; staff report more equitable workload distribution and enhanced professional satisfaction for caring for patients in a more comprehensive manner, and patients perceive services as more organized and less crowded, and appreciate having a personal doctor for their family. Improvements in the quality of services are also noted by UNRWA, including a decrease in the average number of physician consultations per day, increase in consultation time, and a decrease in antibiotic prescription rates. This model is being discussed on the national level in Palestine with the MoH and other stakeholders for its applicability in the government-run PHC network.
Editor Labib Girgis
In 1988 the Arab Board of Family Medicine post-graduate certification was established as a 33 month specialty program. Oman began a 4-year residency programme, achieving recognition by the UK’s Royal College of General Practitioners in 2001, becoming the first country in the world to conduct the MRCGP-Int exam.(Al-Shafaee)
In 2006 Tunisia formed an interfaculty group comprised of the Tunisian Family Medicine Society, local and international academic institutions (among them the faculties of medicine in the University of Montreal and Paris VII) and experts from various countries to begin national level reflection on family medicine and after several workshops developed a 2 year post-graduate diploma training in family medicine in 2011. Efforts were focused on developing a vision for Family Medicine, a framework document to clarify concepts and developing a faculty development program with WHO and the University of Montreal. Twenty two physicians have benefitted from this program which includes seminars and a 3-12 week rotation in family medicine departments in Montreal. Tunisia has recently developed a College of Family Physicians and has participated in networking with other family medicine / general practice societies in the North African region in the Maghreb Network of Family Medicine Societies (Essaafi, 2015).
In Turkey, while a primary health care system was established by law in 1961, it was not based on family physicians and the first 3-year family medicine residency training program affiliated with the Ministry of Health was only later developed in 1985 (as a primarily hospital-based training); university affiliated programs were offered starting in 1993 and graduate around 300 residents annually. (Gunes, Uzuner).
Egypt has a six year basic medical education degree followed by a year’s internship, rotating through specialties to achieve recognition as a general practitioner. After fulfilling an obligation to provide a year’s rural service, candidates can then apply for residency programs in different specialities including family medicine. Family medicine, while not generally appreciated, includes four years of training in any of hospitals, family planning centres or rural areas’ primary health care units, as well as doing an academic Master’s including two exams in different medical disciplines (eg. internal medicine, surgery, pediatrics, and obs & gyn) along with a thesis through one of four Egyptian universities: Cairo, Ain Shams,Alexandria, and Suez Canal. Cairo university also offers a PHD (MD) in family medicine, which is similar to the Master’s degree but more sophisticated. A program similar to North America and Europe is the Egyptian Family Medicine Fellowship Program with four years of practical clinical training, half of which held is in specialties in prestigious hospitals, and the other half in a family medicine centre. This includes a less rigorous research requirement, conducted in groups and related to common family medicine problems.There are two written exams and a final clinical exam accredited by the Royal College in the UK together with the possibility of doing an Arab Board exam. Cairo and Alexandria each have about 10 centres 10+ trainers and more than 100 trainees while 20 other smaller centres each have about 1-4 trainers and 10 to 40 trainees. The residency stream doubled in size from to 2007-2010 with 50 trainers and 500 trainees per year while fellowship increased almost 10 fold over the three years.
Algeria also has an education system similar to Egypt’s with 6 years of undergraduate medical education followed by 1 year of internship. This year consists of 4 rotations, 3 months each, in internal medicine, general surgery, pediatrics, and obstetrics and gynecology. Following this internship, all candidates obtain their licence as general practitioners. In contrast to Egypt, Algeria as yet, has no postgraduate training programs in family medicine.
(courtesy Labib Girgis)
Iran has developed a PHC system with good coverage across the country reducing the urban rural gap and improving health indicators. A joint Ministry of Health & Medical Education established in the mid 1980s specifically tied medical education to meeting community needs. This was accomplished even before the establishment of family medicine, through rural health centers staffed by community health workers and establishing a health information system. Family medicine developed as a specialty in response to the perceived low-quality of GPs and the need to orient provision of primary care by physicians towards prevention, patient-centeredness and longitudinal care and to address the growing burden of NCDs,
Essaafi, S. 2015, Member of the National Authority for Health Accreditation, Tunisian Ministry of Health [personal communication] (January 2015).
Saab B et al. 2003. Postgraduate educational program for primary care physicians in remote areas in Lebanon. Journal of Continuing Education in the Health Professions, vol 23 pp 168-172).
Al-Shafaee Mohamed. Family Medicine Practice in Oman Present and future. Sultan Qaboos Univ Med J. Aug 2009; 9(2): 116–118.
UNRWA, 2013. Health Department Annual Report 2012, UNRWA
Family Medicine training began in Singapore in 1971 with the formation of the College of General Practitioners after which vocational Family Medicine training consisted of self-directed learning, lunchtime talks, and examination preparation courses run by hospital specialists during part-time Diploma studies. After 1988 a formal three-year Masters program developed and now about 10% of GPs have done the examination. A Diploma course still exists, which is distance-learning through workshops and tutorials. (Thomas, Wong) and it houses the Asia Pacific Family Medicine Journal http://www.apfmj.com/
A four year (including research) full time Master of Family Medicine Programme began in 1989 at the University of Malaysia. Since then over 250 Family Medicine Specialists (FMSs) graduates have trained in the three main universities. More than three quarters of the FMS is works with the MOH; the rest in the both public and private practice. Although only 15% of health clinics are currently staffed by family medicine graduates, the MOH has a goal to ensure each has at least one such specialist. Two more Universities have more recently added this specialty post-graduate program. (Ahmad) A two year part time structured course conducted by Academy of Family Physician Malaysia (AFPM) allows a Diploma in Family Medicine (DFM) training after which students may continue with the Vocational Training Scheme (VTS) and sit for the MAFP/FRACGP Malaysian/ Australian General Practice allowing certification in Australia. In 1973 Malaysian Family Practitioner, as of 1989 called Malaysian Family Physician and now with free online access.
General Practice was approved as a specialty by the Thai Medical Council in 1969; the first three year rotating postgraduate residency training program was started in 1973 and by the late 1980s 9 programs were in place (seven in Bangkok and two in the North) including a general practice block in provincial or community hospitals. With lack of a general practice departments, trainers, preceptors, course organizer and with little role of the General Practitioners Association in the postgraduate general practice residency. residency training programs were revised in 1992. By 1999, after a decade when the government chose to renew a focus on primary health care only 216 (1.7%) of the 12,500 Thai board-certified physicians went through specialty general practitioner training.(Williams) So five three year family practice programmes emphasizing outpatient care in family practice sites, regional and provincial hospitals conceptual elements that define the discipline of family medicine, such as continuity of care and the biopsychosocial model began with 9 trainees. The number of residents joining these programs increased yearly, reaching a peak of 60 trainees in 2002 at which time the curriculum was revamped and the College of Family Physicians of Thailand established to take a central role in postgraduate education. (Prueksaritanond)
In 2003, the government of Lao created a family medicine programme to attract and retain graduates in rural district hospitals as part of a national poverty reduction strategy. Medical students and Family Medicine residents are sent to Provincial Hospital training sites, to learn community engagement and skills to allow work in remote communities. Second year residents spend six months living and learning and doing research in rural communities. Since, over 100 students have graduated from the program, most of whom are working in MOH positions in rural areas.
The Vietnam Family Medicine Project worked for over a decade until 2012, developing, implementing and evaluating a national family medicine training program in supporting Hanoi Medical University and other universities in reforming the training of primary health care physicians to scale up the specialty quickly. (Montegut)
The WONCA South Asia region is a comparatively new region in WONCA with a first regional conference at the end of 2010. with member organizations from Bangladesh, India, Nepal, Pakistan, and Sri Lanka.
Tribhuvan University in Nepal began training family medicine residents in 1982 (about 12 per year) partly in Calgary. After the first batches became faculty, around 1991, they repatriated the entire three-year study. (Lewis) Since, they have scaled up family medicine studies successfully at three Universities and multiple rural training hospitals including Pokhara, Surkhet, Palpa. Patan University has now begun their own post-graduate program. (Ackerman) Some issues include a high portion of residents being from India and returning there.
But how about the two largest countries representing almost 40% of the world’s population?
India with 1.2 billion people seems to have seen little movement towards formal residency training till recently. One doctor for every 1700 people Interestingly in India, 387 medical colleges of which 206 are private sector, Of 30000 MBBS grads about 18000 choose specialties. (Anand Kumar) A 2011 study of young interns in south India showed that nearly 95 per cent preferred one of medicine, surgery, obstetrics and gynaecology, and paediatrics. (Niharika and Jain) Regulatory restrictions bar GPs, family physicians, medical officers (MOs), and other primary care physicians from becoming a faculty at universities.
Since the early 1970s there has been Department of Ayurveda, Yoga and Naturopathy, Unani (Muslim), Siddha (Tamil) and Homoeopathy (AYUSH) under the Ministry of Health monitoring higher education, research and supporting such medicine. Practitioners of allopathic medicine are seen by many on equal footing with homeopathy and traditional Ayurvedic 50,078 medical students including other India also has more than 250000 homeopathic practitioners now more than 180 training centers offer degrees in traditional Ayurvedic medicine. http://timesofindia.indiatimes.com/india/Homeopath-doctors-double-in-two-decades/articleshow/16098627.cms http://en.wikipedia.org/wiki/Ayurveda Much care is done by local chemists (pharmacists) and dispensers.
1946, the Bhore Committee pre-Independent India “social physician” three-month course on preventive and social medicine In 1983, the Medical Education Review committee called for “…a cadre of suitably trained manpower” that can deliver “comprehensive and integrated healthcare at the family level.” and family medicine was recognised as a speciality that year. (Niharika and Jain) In 1983 a Diplomate of the National Board (DNB) was established and since the 1990s the Medical Council of India has certified a three year residency integrating inpatient and outpatient learning and field training at community health centres and clinics leading to an MD (post Grad) in Family Medicine, (MBBS being the basic undergrad degree).
The Government Medical College, Kozhikode< Kerala became the first institution to start a family medicine MD in 2012 (Kumar) Raman Kumar young faculty at the All India Institute of Medical Sciences (AIIMS), President of the “Academy of Family Physicians of India” (AFPI) http://www.afpionline.com/Pages/default.aspx and founder of Journal of Family Medicine and Primary Care www.jfmpc.com cites 200 family medicine residency training sites with 700 training posts annually accredited by the National Board of Examinations (NBE) India examining issues such as academic acceptance, curriculum development, uniform training standards, faculty development, research in primary care. (Kumar) Recently the Medical Council of India admitted ‘no definition of family doctors and no curriculum for the specialisation either at the UG or PG level.‘) (Niharika and Jain)
AIIMS is now moving towards 3 year residency MD (specialty as opposed to MBBS, basic) developing 155 DNB family medicine seats under the NBE, beginning with Bhopal in 2012 at six regional AIIMS-like Institutes, each with Departments of Family and Community Medicine which will also train undergrads, (Kumar) Most family medicine training sites are at multi specialty community hospitals where a family medicine trainee is assigned to a guide, who is most often an internist or a consultant physician.
Since 1993 CMC Vellore been running a Family Medicine course In 2007 DNB fellowship changed to Post Grad and now is a two year Master’s course. It appears that 1800 docs will have graduated by 2014 with distance teaching through Christian colleges, mission hospitals and regional study centres recently partnering with the University of Edinburgh on self learning, video and in person teaching focused on understanding primary care management of disease and family units to reduce referrals. gives preference to doctors working in needy sectors or Government setups, Many vacant community spots.
The Indian Medical Association offers a one year distance education programme of the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka for GPs who have been in practice for five years. Garada 2013
BMJ good to check this 2009 Arulrhai commentary Abraham, Sunil. “Practicing and Teaching Family Medicine in India.” Family Medicine 39, no. 9 (October 2007): 671–72.
China pioneered the barefoot doctors programme http://en.wikipedia.org/wiki/Barefoot_doctor training rural farmers in medical and paramedical skills after 1968, with about six months of training at a hospital epidemic disease prevention (sanitation, immunization), curing simple locally relevant ailments, integrating Western medicines and techniques along with Chinese. This was seen as reducing costs an inspiration to Alma Ata but was abolished in 1982. 20% of barefoot doctors later went on to medical training including the last Minister of Health to 2013 Chen Zhu.
The role of the family physician in the Chinese context however remained limited, often relegated to that of triaging patients towards specialists for definitive care. In 2010, when only 5.3% of more than 2,3 million physicians were family physicians or family physician assistants, six ministries of the Chinese government jointly issued a plan for building team-based primary care led by family physicians, prompting the creation of new models of family medicine training across the country, with 50,000 practicing physicians and physician assistants to be selected by provincial governments for one year full-time or 2 years (part-time) in hospital-based family medicine residency training programs affiliated with a medical school or university. new ones before the end of the decade Training programmes in China are partnering with a variety of institutions throughout North America to expand this dramatically to several hundred thousand. (Chen 2007, 2008, Dai 2013)
Ackerman L. Karki P. Family practice training in Nepal. Fam Med 2000 Feb;32(2):126-8.
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Chen, Tian-Hui, Yaping Du, Alex Sohal, and Martin Underwood. “Essay – Family Medicine Education and Training in China: Past, Present and Future.” The British Journal of General Practice: The Journal of the Royal College of General Practitioners 57, no. 541 (August 2007): 674–76.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2099684/
Dai, Honglei, Lizheng Fang, Rebecca A. Malouin, Lijuan Huang, Kenneth E. Yokosawa, and Guozhen Liu. “Family Medicine Training in China.” Family Medicine 45, no. 5 (May 2013): 341–44.
Thomas S. Family medicine specialty in Singapore. Journal of Family Medicine and Primary Care. 2013 Apr-Jun; 2(2): 135–140)
Wong, Teck Yee, Phui Nah Chong, Shih Kiat Chng, and Ee Guan Tay. “Postgraduate Family Medicine Training in Singapore–a New Way Forward.” Annals of the Academy of Medicine, Singapore 41, no. 5 (May 2012): 221–26. )
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Prueksaritanond, S., and P. Tuchinda. “General Practice Residency Training Program in Thailand: Past, Present, and Future.” Journal of the Medical Association of Thailand = Chotmaihet Thangphaet 84, no. 8 (August 2001): 1153–57)
Montegut, Alain J., Julie Schirmer, Cynthia Cartwright, Christina Holt, Nguyen Thi Kim Chuc, Pham Nhat An, and Steve Cummings. “Creation of Postgraduate Training Programs for Family Medicine in Vietnam.” Family Medicine 39, no. 9 (October 2007): 634–38.
Lewis M, Smith S, Paudel R, Bhattarai M. General Practice (Family Medicine): meeting the health care needs of Nepal and enriching the medical education of undergraduates. Kathmandu University Medical Journal. (2005) Vol. 3, No. 2, Issue 10, 194-198)
Kumar R Family Medicine at AIIMS- Like Institutes J Family Med Prim Care. 2012 Jul-Dec; 1(2): 81–83. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3893973/
Kumar U Anand India Has just one doctor for every 1700 people Indian Express Sept 22, 2013 http://www.newindianexpress.com/magazine/India-has-just-one-doctor-for-every-1700-people/2013/09/22/article1792010.ece
Family Medicine at AIIMS- Like Institutes Raman Kumar J Family Med Prim Care. 2012 Jul-Dec; 1(2): 81–83. http://www.jfmpc.com
Niharika M / Mahima A Jain What ails family practice in India November 14, 2014 http://www.thehindubusinessline.com/features/pulse/what-ails-family-practice-in-india/article6600089.ece
Garada 2013 BMJ good to check this 2009 Arulrhai commentary Abraham, Sunil. “Practicing and Teaching Family Medicine in India.” Family Medicine 39, no. 9 (October 2007): 671–72