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22 CORE VALUES IN FAMILY MEDICINE
Score
0
0 Nothing recorded / available
1Mission / vision of organization only
2comprehensive
3Full mission / vision / FM description / values
No member organization in that country
Some mission / vision / or description but not
3
.dlroe whf ts onogieA rCNOW 3.E2RUGIF
PROCESSES OF EXPLORATION INTO THE CORE VALUES 23
EMR
CIMF
EUR
APR
SAR
AFR
NAR
EMR = East Mediterranean region
Latin American region
EUR = Europe region
APR = Asia Pacific region
SAR = South Asia region
AFR = Africa region
NAR = North America region
No member organization in that country
.enicidey mlmiaf fn ooitpircsed dn, aseulae vron, coisin, voissf mid orocen roitazinagrr oebmeM 4.E2RUGIF
24 CORE VALUES IN FAMILY MEDICINE
Regular global group meetings conducted on the Zoom platform then
commenced. roughout the project, these were run twice at 12 hours apart
at times to suit either participants in Asia or the Americas but also at sociable-
enough times (morning and evening) for steering committee members in
Europe and New Zealand to attend both meetings. Recordings were made
and disseminated for those who could not make either meeting to review.
Leaders and their teams were all invited, and if a lead was unavailable for
either time slot, they were asked to delegate a team member to provide an
update for their region.
e nal establishment and launch of the global project took place at the
WONCA World Conference in Sydney, Australia, in October 2024. In her
keynote presentation, President Anna Stavdal called for a shared vocabulary
needed in uncertain times. She argued that a broadening of the core values
in family medicine and a values-based action plan are needed to respond to
the many challenges facing family doctors: geopolitical stress, environmental
disasters, healthcare workforce shortages, commercialisation of medical care,
and the digitisation and dehumanising of person-centred care. Following this
address, an augural face-to-face workshop was held with the steering com-
mittee, regional leads, and team members. e background, purpose, and
timeline were outlined, along the proposed process for the next two years,
culminating with a nal session of the group and their outcomes at the
WONCA World Conference in Lisbon, Portugal, in September 2025.
ONGOING PROCESSES OF THE GLOBAL CORE
VALUES PROJECT IN 2024 AND 2025
A proposal was prepared for the project to form the basis of a book in the
WONCA Family Medicine Series published by Taylor& Francis, and follow-
ing its submission and peer review, the proposal was accepted and this book
contract was secured in June 2024.
Core value workshops by the teams have been conducted at WONCA
regional meetings. Each region developed their own approach to the task,
including communication with member organizations, data extraction from
documentations, and surveys of member organizations or family doctors.
Details of the regional workshops and processes are outlined in the succeed-
ing chapters.
Regular online meetings took place, with comprehensive regional updates.
Along with the current WONCA president, Karen Flegg, the president
elect, Viviana Martinez-Bianchi, and Nina Monteiro, liaison person for the
WONCA Lisbon Conference 2025, joined the group as ex ocio members.
Each region had their own approach to the task, which included running
workshops at the WONCA regional conferences. eir processes are outlined
in the following regional chapters. To help promote further discussion and
PROCESSES OF EXPLORATION INTO THE CORE VALUES 25
deeper exploration, the steering committee invited selected experts as guest
speakers to talk about professional values by providing an external indepen-
dent view to broaden thinking.
REFERENCES
1. Loudon I. Medical Care and the General Practitioner 1750–1850. Oxford: Clarendon
Press 1986:354.
2. omson A. Westminster medical society. Lancet 1828;11(271):176–7.
3. Goodyear-Smith F. History of primary care research. In: Goodyear-Smith F, Mash B,
eds. International Perspectives on Primary Care Research. London, England: Routledge
2016.
4. Tait I. History of the College. London: Royal College of General Practitioners, 2002.
5. World Health Organization, World Organization of Family Doctors. Making medical
practice and education more relevant to people’s needs: e contribution of the family
doctor. Ontario, Canada: Joint WHO-WONCA Conference, 1994:103.
6. Straand J, Wit N. e transition of general practice into an academic discipline:
Tracing the origins through the rst four professors in general practice/family
medicine. Scand J Prim Health Care 2024;42(3):483–92. https://doi.org/10.1080/0281
3432.2024.2335537
7. Sigurdsson JA, Beich A, Stavdal A. A saga-in-progress: Challenges and milestones
on our way toward the Nordic core values and principles of family medicine/general
practice. Front Med 2021;8:681612. https://doi.org/10.3389/fmed.2021.681612
8. Meyer R. From SIMG to WONCA Europe – ESGP/FM. Prim Care 2009;9(15):268.
9. Royal College of General Practitioners. e Future General Practitioner – Learning and
Teaching. London: BMJ 1972.
10. Richardson IM. e value of a university department of general practice. BMJ
1975;4(5999):740–2. https://doi.org/10.1136/bmj.4.5999.740
11. Horder J. e RCGP a nd other countries: A be ginning . Br J Gen Pract 199 0;40 (334):20 6–9.
12. McWhinney I. A Textbook of Family Medicine. Oxford, UK: Oxford University Press
1989.
13. What Sort of Doctor? Working Party. What Sort of Doctor? Report from General
Practice. London: RCGP 1985:23.
14. Pendleton D, King J. Values and leadership. Br Med J 2002;325(7376):1352–5. https://
doi.org/10.1136/bmj.325.7376.1352
15. Sigurdsson JA, Beich A, Stavdal A. Our core values will endure. Scand J Prim Health
Care 2020;38(4):363–6. https://doi.org/10.1080/02813432.2020.1842676
16. Stavdal A. e Nordic federation of general practice. Scand J Prim Health Care
2005;23(3):129. https://doi.org/10.1080/02813430500217106
17. Nordic Federation of General Practice (NFGP). Core values and principles of Nordic
general practice/family medicine. Scand J Prim Health Care 2020;38(4):367–8. https://
doi.org/10.1080/02813432.2020.1842674
18. Kolesnyk P, Bayen S, Shushman I, et al. Identication and ranking of core values in
family medicine: Amixed methods study from Ukraine. Front Med 2021;8. https://doi.
org/10.3389/fmed.2021.646276
19. Lawson HJO, Nortey DNN. Core values of family physicians and general practitioners
in the African context. Front Med 2021;8. https://doi.org/10.3389/fmed.2021.667144
20. van der Horst HE, de Wit N. Redening the core values and tasks of GPs in the
Netherlands. Br J Gen Pract 2020;70(690):38–9. https://doi.org/10.3399/bjgp20X707681
21. WONCA Europe. e European Denition of General Practice/Family Medicine,
2002:35.
DOI: 10.1201/9781003542353-3 27
CHAPTER3
Family medicine core
values in Africa
Innocent K. Besigye,
Keneilwe Motlhatlhedi,
Catherine Gathu,
and Nana Kwame Ayisi-Boateng
REGIONAL DESCRIPTION
e WONCA Africa region (WAR) covers sub-Saharan Africa (SSA) and
consists of three major regions of the continent: Western Africa, Eastern
Africa, and Southern Africa. SSA is composed of 48 countries (Figure3.1):
23 low-income countries, 18 lower-middle-income countries, 6 upper-middle-
income countries, and 1 high-income country (the island state of Seychelles)
per the 2024 World Bank classication. Among these countries, there are only
15 WONCA member organizations in 12 countries, with Nigeria having 3
member organizations and all others having 1.
Geographically, Sudan, Djibouti, Eritrea, and Somalia are located in SSA.
Dierent organizations include dierent countries in the regions of Africa
and the East Mediterranean – there is no standardized denition. Historically
the World Health Organization (WHO) has classied Sudan, Djibouti, and
Somalia in their East Mediterranean Regional Oce (EMRO), but Eritrea in
their African region. In 2011, following a civil war, Sudan was divided into
the Republic of Sudan (Sudan) and South Sudan. Initially, both countries
remained classied in the EMRO, but South Sudan requested to be reassigned
to the African region. is request was accepted, and South Sudan is now part
of the WHO African region.
28 CORE VALUES IN FAMILY MEDICINE
Because geographically the Republic of Sudan (Sudan), South Sudan,
Djibouti, Eritrea, and Somalia are located in SSA, we include them as coun-
tries in our African region. None of these countries have member organiza-
tions in WONCA. However, WONCA EMR has always been aligned with the
WHO EMRO, so note that Sudan, South Sudan, Djibouti, and Somalia are
also included in their chapter.
Apart from Ethiopia, all other countries in SSA are former colonies of
European countries. Despite the end of colonialism more than 50 years ago,
its eects still exist, with signicant inuence on culture, geopolitical, and
socioeconomic situations. As a result, there are several ocial languages
spoken among the countries, mainly English, French, and Portuguese. e
colonial history contributes to dierences in lifestyle, norms, and beliefs. Such
dierences make it dicult to create cohesion among countries. For example,
there is disproportionate lower inclusion of Francophone- and Portuguese-
speaking countries within the WONCA Africa family.
Family medicine is relatively new in most SSA countries. Family medicine
training started in the 1960s in South Africa and in the 1970s in Nigeria.
1,2
WESTERN
SAHARA
ALGERIA
LIBYA
NIGER
CHAD
NIGERIA
SUDAN
ERITREA
SOMALIA
KENYA
TANZANIA
ANGOLA
ZAMBIA
NAMIBIA
ZIMBABWE
BOTSWANA
MALAWI
MOZAMBIQUE
MADAGASCAR
ESWATINI
LESOTHO
SOUTH AFRICA
BURUNDI
UGANDA
EGYPT
MAURITANIA
MALI
GUINEA
BURKINA
FASO
COTE D’
IVOIRE
GHANA
EQ. GUINEA
GABON
RWANDA
CENTRAL AFRICAN
REPUBLIC
SOUTH
SUDAN
YEMEN
DJIBOUTI
KUWAIT
BAHRAIN
SAUDI ARABIA
QATAR
OMAN
UNITED A
RAB
EMIRATES
CAMEROON
DR CONGO
ETHIOPIA
CONGO
TOGO
BENIN
THE GAMBIA
JINEA-BISSA
U
LIBERIA
SENEGAL
SIERRA
LEONE
FIGURE3.1 Map of Africa showing sub-Saharan African countries.
Source: mapchart.net
FAMILY MEDICINE CORE VALUES IN AFRICA 29
In other countries, family medicine training started in the 1990s, albeit
slowly, with the training in some countries and some institutions stopping
altogether.
3
Currently, there is rapid growth of the discipline, evidenced by
many countries commencing the training and inclusion of family medicine
within their undergraduate curricula.
3,4
is rapid growth is likely to acceler-
ate exponentially with the establishment of the Eastern Central and Southern
Africa College of Family Physicians.
5
As the discipline evolves, there is need for a clear denition for better
understanding among dierent stakeholders. is is because family medi-
cine is highly contextual with no one model working across dierent set-
tings. However, the values and principles are likely to be the same. Denition
of family medicine, its values, and principles in Africa has been part of the
conversation since the early 2000s.
6,7
ACCESS TO FAMILY PHYSICIANS
Access to family physicians in SSA is limited due to low numbers. In most
countries, the total number of family physicians on the specialist register is
fewer than 100. Table3.1 shows the number of registered family physicians
per member country and other related access parameters.
In most cases, family physicians in SSA are not rst-contact clinicians.
ey are mainly working in district hospitals providing general medical care,
including obstetrics and surgical emergencies. First-contact primary care is
mainly provided by nurses, mid-level clinicians (clinical ocers/associates),
and non-postgraduate trained generalists known as medical ocers. e pri-
mary healthcare (PHC) teams are poorly developed, and primary care lacks
ecient gatekeeping. is makes primary care fragmented and uncoordi-
nated, lacking comprehensiveness, continuity, and person-centredness. e
family physicians working in such circumstances have to exhibit exibility
and adaptation to the circumstances but still keep the values and principles
of the discipline.
PROCESSES
e Africa region team was composed of representatives from Western,
Eastern, and Southern Africa. e team members regularly met online to
discuss the methods and strategies of data collection. Online information
by member organizations was collected where available. e data collected
focused on the vision, mission, and goals of family medicine in a country.
Member organizations where no such information was found online were
contacted directly to provide relevant information that might inform under-
standing of family medicine core values. Aworkshop was held at the eighth
WAR conference in Nairobi, Kenya, to ascertain the views of the participants
30 CORE VALUES IN FAMILY MEDICINE
TABLE3.1 Country Population Characteristic and Number of Registered Family Physicians
Country Income Range Population
(millions)
Population
Density (per km
2
)
Urbanization (%) Number of
Registered FPs
Angola Lower middle income 37 30 68 14
Botswana Upper middle income 2.4 4.4 72 40
Cameroon Lower middle income 28.4 60.9 59 16
DRC Low income 106 46.6 47 60
Eswatini Lower middle income 1. 2 70.9 25 6
Ethiopia Low income 126 132 23 55
Gambia Low income 2.7 273 64 6
Ghana Lower middle income 33 148.9 59 365
Kenya Lower middle income 55 99.2 29 59
Lesotho Lower middle income 2.3 77 30.4 14
Liberia Low income 5.4 58 53.6 23
Malawi Low income 21 230 18.3 40
Mozambique Low income 34 44 39 15
Namibia Upper middle income 3.03 4 53.7 4
Nigeria Lower middle income 227 250 54 1,200
Sierra Leone Low income 8.5 117 44 7
Somaliland Low income 6.2 29 - 29
South Africa Upper middle income 68 53 68.8 1,064
Tanzania Lower middle income 66.6 75 37 10
Uganda Low income 46 243 26 50
Zambia Lower middle income 20 27 46 15
Zimbabwe Lower middle income 16.3 43 32 3
Key: FP= family physician.
Source: Online sources as of 2024, with some country verbal communication for number of registered family physicians.
FAMILY MEDICINE CORE VALUES IN AFRICA 31
on the subject, as well as their understanding of family medicine from their
respective contexts. e collected information was collated and analyzed the-
matically to discern the contemporary core values of family medicine within
the African context. Aliterature review was also conducted to explore what
has already been described for the region.
FINDINGS
Family medicine core values have been part of the conversation in Africa for
decades now. e founding fathers of family medicine in Africa were equally
concerned at that time and argued that there was a need to dene family
medicine in the African context.
6–8
Initial family medicine models in Africa
were Eurocentric, based on American and European approaches to primary
care. Current trends show that there have been progressive eorts to reorient
family medicine training and practice towards the African context. Following
are the family medicine core values described for the African region.
Principle of continuity of care
In most African countries, primary care is not well developed, with most
health systems fragmented, focused on vertical programmes in secondary
and tertiary care, and lacking gatekeeping. Family physicians working in
these health systems drawing on global evidence on the contribution of conti-
nuity of care to better health outcomes strive to promote it. ey put emphasis
on establishing a trusted relationship with their patients as a key ingredient
to continuity of care. In some settings, they share their telephone contacts
with their patients for easy personal reach when necessary. Relational conti-
nuity is dicult in the public health sector, as practitioners are occasionally
transferred or rotate from one facility to another. Informational continuity is
mostly through health facility or patient-held handwritten records, with little
or no access to an electronic health record system.
Principle of coordination of care
African family physicians acknowledge that they cannot address and man-
age all the health needs of every individual. Some people in populations they
serve will need to be referred for diagnostic and/or therapeutic purposes. In
some cases, the family physician arranges with the specialist or the facility
where the person is being referred to ensure an easy reception. However, the
family physicians retain the responsibility of coordinating the care team
and follow-up. In some cases, the family doctor remains available to the
patient for guidance where necessary. is strengthens the doctor–patient
relationship.
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