Thursday, March 28, 2024

Jan De Maeseneer | Social Cohesion and Primary Care in Europe, Africa, and the US

by Editor

Primary Care providers and organisations like Community Health Centres contribute to social cohesion and connectedness based on solidarity. JDeM

“Interrelated Connectedness “

by Guy Timmerman.  (Photo: Studio Claerhout)

. In his artwork ‘Interrelated Connectedness’, Guy Timmerman has given birth to a symbiosis between individuality and collectivity, as if it were artistic recipe for happiness. “  Jan-Jakob Delanoye,

 

One of the world’s leading Academics in Primary Care…

“Born in 1952, I was part of the ‘Baby Boomers’. There were six children and we lived in a small house. But, most important, our parents decided that after four years in the local neighbourhood school, we could go to the college to the city, and finally to university.  It’s only thanks to subsidies, financial support for children to go to university, that we six children had the opportunity to study.”

Watch the full interview above, or listen to the podcast below

Jan De Maeseneer As a child of ‘May 68’, I was 16 years old at the time, we were very much inspired by this movement. It was about emancipation, it was about participation, it was about finding new direction, and that included the professions.  In our country, two things that emerged from ‘May 68 ‘were innovation in schools and in healthcare. We had had the traditional model of the doctor as the French say, on the ‘piédestal’, looking down at the patient. It was not a horizontal relationship but a patriarchal relationship.

I started when I was a student. We were involved in social movements, social medical working parties, and already we questioned the way that the healthcare system was organized.  In our third year of undergraduate study we wrote a document proposing a new professional structure that would better suit the needs of society and we came up with the idea of an integrated interprofessional community health center. With students from medicine, pharmacy, social work, and nursing, we had already begun to prepare for this type of interprofessional practice.

Another very important experience was that, in 1977, my wife and I had the opportunity to go to Rwanda.  I worked as a volunteer for three months in a community health center and learned what healthcare means if you have a broad perspective of healthcare across the community.  This experience greatly inspired how we began in practice.

My wife and I started a group practice and, in the beginning, our practice was in the building where we lived, and our first child was born there. We started with two doctors, but as it grew, we had to leave the building as we needed more and more space for the practice.  In time, we created an Interprofessional Community Health Center with family doctors, nurses, assistant nurses, dietitians, health promoters, community health workers, psychologists, dentists and so on so all working together.  And we invest greatly in training young students in all these disciplines.

From the very beginning we lived in that community. Why did we choose to work there? We lived there as students and, living in that community, we saw the problems.  There was such a challenge in dealing with the problems of poverty, violence, addiction, and the social determinants of health such as bad housing conditions and poor income, that we had no competitors. Our community is part of what we call the 19th century belt around Ghent, which meant there was historical poverty and deprivation.  Confronted with these problems we decided this was the place to put our ideas in practice. ‘Let’s do it here’, and that’s why we started.

At the same time in Ghent, there were other initiatives in different community health centers, so we were not alone.  There was a kind of movement – trying to create an alternative to traditional single-handed practices, monodisiplinary practices, in the fee for service system that provided reactive care to the population. So, in 1982 we went to the National Institute for Health and Disability Insurance and asked them to change the financing system because we knew that the fee for service wouldn’t work if we wanted to achieve our aim of addressing the social determinants of health through an integrated ecobiopsychosocial approach to patients. We needed another way of payment. We negotiated and, after a year of negotiation, we had new regulations based on a capitation system. We had created the environment that would enable us to achieve our goals.

Another important factor was that we quickly entered into dialogue with our local authorities in the city of Ghent. That was also very important.  As a family doctor, you can make a lot of difference to individuals in their lives.  If I look back at my career, working 40 years in that same community, there were times when I had the privilege of contributing to give meaning to the lives of many people-  helping them in important moments in their lives.  But, more than that, we also have a responsibility, when we look at the social determinants and upstream causes of ill health, to engage in an advocacy role in our community.

A further inspiration was that, from 1986 to 2016, I had the privilege of chairing a community meeting where, every three months, all providers of primary care, community representatives, the local policemen, the local schools, about 40 people in all, joined together to identify issues in the community to act accordingly.  For me that was an incredible inspiration. By that time I had started to work part-time as an academic at the University, and that local community meeting was especially important because I did not want to lose contact with patient care and with what was happening in the community.

DMacA: Your own personal research career is fascinating because your PhD was pivotal in the development of primary care in Belgium.

JanDeM In 1989 I completed the first PhD in Family Medicine in Belgium. There were other Belgian family doctors with a PhD but these were undertaken outside Belgium. It was a purely a description, an analysis of the patient encounters of 110 GPs, and I analysed some 5 000 encounters using the International Classification of Primary Care.  I looked at what problems doctors were facing, how they behaved, their interventions, and tried to find explanations of inter doctor variation.

A week after the defence of my PhD, I received a letter from our Minister of Health asking if I would be interested in helping him strengthen primary care. So I went and we had a very open discussion and he said- I don’t want you to become a member of a political party, I need your expertise and your independence”. I started to develop a system where every citizen in Belgium could be linked to his GP who was responsible for the “Global Medical Record” It took a long time, from 1990 until 2002, before the whole population had access to the system because there were financial implications- the doctor was paid to keep that record and there was a high cost to pay the increased reimbursements for patients-  so, finally in 2002, it was generalized to the whole population. Nowadays in Flanders, over 85 percent of the population has a global medical record with a GP in a primary care practice.

 DMacA: Your time in Rwanda was clearly very influential because you have since invested a lot of time and effort in developing primary care in Africa.

JanDeM. In 1995, which was one year after the end of Apartheid, I was in contact with a professor at University of Cape Town who said- you have to come here to see the coal face of primary care here in the African environment.  I went there for a study visit and visited the seven Departments of Family Medicine/ Primary Health Care then starting in South Africa and it was very interesting. At the same time we were developing an inter-university collaboration in Flanders, working together with all the departments and one single training program.  I thought,  let’s work together linking our network in the north with these seven departments in the south.  So, it was a north-south-south collaboration of learning from each other from the beginning. That was the starting point. 

From there it expanded. We had some funding from the Belgian Development Corporation, and later on from European Union, which we invested into broadening the network. East Africa joined, Central Africa joined with DRC, Rwanda joined, and so on.  And then North and West Africa.  It still continues and we now have a network in 25 countries, with 45 institutions involved in training of health professionals for primary care: family doctors, GPs and also nurses are involved in that network. In 2017 the whole organization was completely Africanized so, while we are still there, we are no longer the lead.  We help a little bit and we give advice, but they are now completely independent and they do wonderful things; they exchange programs, they exchange examiners, they exchange training sites.  They work together and are a factor of change in most of those countries.

I never went to Africa to teach them.  What could I teach that’s relevant for them? They are better in HIV diagnosis and treatment than I can ever be because they know the problem.  What we really emphasized was how to build a community where primary care can develop. There was a lot on advocacy, on strategy, a lot on strengthening international cooperation, but also on research. Many PhDs have already been completed in Primary Care and Family Medicine. There are GP professors in many countries, Colleges are developing, and it’s still a wonderful experience.  It’s something I look back at with a very positive feeling.

DMacA: This must be an enormous contrast to your work in the U.S.

JanDeM: In 2019 I became an international member of the National Academy of Medicine and I came in contact with the American Board of Family Physicians –   very interesting people like Larry Green, Bob Phillips and all the others.  The interesting thing was that we faced common challenges, similar to the challenges that we face in Africa.  Namely, how can we strengthen a primary care system that is responsive to the needs of the population. It was in an economically different environment, of course, but also a divided environment where equity is still a very big challenge and where there are a lot of problems, for instance, in the way they deal with diversity.  Although the context may be different, it requires the same values, the same strategies, and that’s in linking with local communities, looking at the upstream causes of ill health, and trying to find interventions that can make a difference.

And, of course, when it comes to the human interaction I have had the privilege of sitting with a general practitioner in consultation rooms in 25 different countries in the world and,  what I took from these encounters was that there is so much similarity.

DMacA: Finally, let me talk about your book because our colleague Per Kallestrup, from Denmark, described the book as being full of optimism, enthusiasm, and energy.  Are you still an optimist?

JanDeM: Yes, I’m still very much an optimist.  I have a lot of energy but I also have a positive outlook.  Even when things are difficult, I still believe that we will find that step, that strategy, that action, that can make a difference.  And I believe, and of course I’ve had many very positive experiences that increased my belief, that change is possible.

At the same time it is difficult and it requires a commitment that includes engagement with political change processes, with societal change processes.  When it comes to the defence of family medicine/ primary care, and we have to talk to politicians to convince them about the important role of primary care, I don’t only speak about integrated care and the challenges of chronic conditions but, more and more, I try to explain that primary care,  family medicine and general practitioners, fundamentally contribute to social cohesion, to increased connectedness.

What society needs today in order to implement political projects, projects that improve people’s conditions, is that you need connectedness, you need social cohesion. I’m convinced that at local level in the community, what we do as GPs in primary care level, is that we see the needs of the population, we engage with them, and we contribute to building social cohesion- this connectedness that our society needs so badly. That is a strong point of primary care, that makes primary care important, and should be included in political strategy.

DMacA: That is a wonderful note to end this conversation.  Jan De Maeseneer, thank you very much for your enormous contribution to primary care, and for this conversation today. Thank you very much

 

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