Building the foundation for universal healthcare: Academic family medicine’s ability to train family medicine practitioners to meet the needs of their community across the globe

Background The Declaration of Astana marked a revived global interest in investing in primary care as a means to achieve universal healthcare. Family medicine clinicians are uniquely trained to provide high-quality, comprehensive primary care throughout the lifespan. Yet little focus has been placed on understanding the needs of family medicine training programs. Aim This study aims to assess broad patterns of strengths and resource challenges faced by academic programs that train family medicine clinicians. Methods An anonymous online survey was sent to family medicine faculty using World Organization of Family Doctors (WONCA) listservs. Results Twenty-nine representatives of academic family medicine programs from around the globe answered the survey. Respondents cited funding for the program and/or individual trainees as one of either their greatest resources or greatest limitations. Frequently available resources included quality and quantity of faculty and reliable clinical training sites. Frequently noted limitations included recruitment capacity and social capital. Over half of respondents reported their program had at some point faced a disruption or gap in its ability to recruit or train, most often because of loss of government recognition. Reflecting on these patterns, respondents expressed strong interest in partnerships focusing on faculty development and research collaboration. Lessons learnt This study provides a better understanding of the challenges family medicine training programs face and how to contribute to their sustainability and growth, particularly in terms of areas for investment, opportunities for government policy and action and areas of collaboration. Keywords family medicine; primary care; medical education; global health; community medicine.


Introduction
The 40th anniversary of the Alma Ata declaration in 2018 saw a renewed dedication to primary health care as the 'cornerstone of a sustainable health system for universal health coverage (UHC)'. 1,2 The World Health Organization has emphasised that strong primary health care systems must be comprehensive and holistic, caring for people throughout their lifespan in the context of their communities and broader environment. 3 Family medicine is a clinical primary care discipline in which healthcare providers are trained to realise the ideals of comprehensive primary care. 4,5 However, investment and support of family medicine training programs from both institutions and governments have been subpar. 6,7 faculty development, specifically in the African region. 12,13 However, limited attention has been given to understanding the strengths and challenges faced by academic centres that train family physicians globally. This study aims to address this.

Methods
The authors, members of the Family Medicine Global Education Network (FamMedGEN), designed a survey to describe the program structure, training capacity and limitations of academic departments of family medicine around the world, as well as possible opportunities for partnership and collaboration between departments. The survey instrument was created through discussion and literature review by the research team. An initial draft of the survey was pilot tested with five key informants from four countries. Subsequently, the revised survey tool

Ethical considerations
The Human Research Protections Program (HRPP) of the University of Minnesota Institutional Review Board reviewed this proposed study and determined that the proposed activity is not research involving human subjects as defined by DHHS and FDA regulations (ref. no. STUDY00011867).

Training program structure
Twenty-nine individuals responded to the survey, with all geographic regions represented (Appendix 2). The results were analysed by response frequency. Most respondents represented university-based programs, either in large academic health centres (48.3%) or in the community (37.9%). Remaining respondents represented programs at community health centres or regional hospitals. Most respondents (72.4%) were associated with programs in existence for greater than 10 years.
In describing faculty composition, some responses were either left blank or did not sum to 100%; these responses were removed from the survey results (Appendix 2). In a majority (65.5%) of the programs, more than 50% of faculty members were family medicine specialists or general practitioners, as opposed to other speciality clinicians or physicians, with 14 (48.3%) of respondents reporting that above 90% of their training program faculty were family medicine specialists.
The number of respondents reporting that their programs offer family medicine training at the undergraduate level was equivalent to those offering graduate-level training (86.2%).

Training program capacity
Twenty-two respondents (75.9%) provided complete responses to questions related to available resources at their training program (Table 1). Resources frequently cited as top strengths of programs included quality (59.0%) and quantity (31.8%) of faculty, funding for the program as a whole (31.8%) and for individual students or trainees (50.0%), and reliable clinical sites (31.8%).
While some respondents saw these resources as adequate, others noted program funding and individual student or Fifteen respondents (51.7%) reported their program had experienced a disruption in its ability to recruit or train residents at some point during its life cycle (Appendix 3). The most frequent source of the disruption was the loss of government recognition for the program (40.0%).

Opportunities for partnership
Twenty-three (79.3%) respondents provided suggestions of academic partnerships that might be beneficial to address the resource barriers or limitations they had identified ( Figure 1). The most frequently suggested benefits from partnerships included a focus on faculty development and research as well as collaborations to improve government support, demonstrate family medicine's overall value and provide direct funding. Partnerships focusing on learner exchange and/or providing enhancements in the teaching environment (examples provided included simulation training and access to journals and textbooks) were cited less commonly.

Impact
It is important to consider the capacity of academic family medicine to adequately produce the primary care workforce needed to ensure universal healthcare. This survey highlights the most common strengths and resources that family medicine training programs note in abundance, including quality and quantity of faculty, program and trainee funding and reliable clinical sites. Meanwhile, recruitment capacity and social capital were common limitations and barriers. Programs were divided as to whether funding for students or trainees was their most dependable resource or their greatest challenge. These findings provide insight into the existing capacity of training programs and highlight potential areas for investment.
Over half of respondents noted their program had at some point experienced a disruption in their ability to train, with loss of government recognition identified most frequently as the main cause. This suggests that investment in primary care should be valued as a long-term policy goal, as gaps in training can potentially disrupt an academic unit's long-term viability.
Respondents most frequently suggested that partnerships with other academic institutions would be most beneficial if

Partnerships with other academic insƟtuƟons that would be beneficial to address idenƟfied resource barriers or limitaƟons (n = 23)
Faculty development Research funding Engagement to demonstrate family medicine's value '[S]upport capacity building of faculty … funding for faculty remuneraƟon incenƟves to aƩract long-term faculty from the region capacitaƟng sites to improve quality of teaching (e.g. skills labs).' 'More funding focus on primary care research. Most of the funding is opened to different specialƟes and many Ɵmes technology seems more appealing than primary care.' 'Within the medical community family medicine is not known enough, and therefore, medical students do not desire to enter a medical specialty with limitaƟons posed by this constraint.'

Sample responses
http://www.phcfm.org Open Access they were focused on faculty development and research, while learner exchange and direct resource provision were considered less beneficial. As institutions reconsider how to design more equitable, multidirectional global partnerships, these responses highlight key areas in which to consider collaboration.
This study was designed to provide a high-level overview of challenges that academic family medicine departments face. For family medicine to thrive, there is a need for further studies that examine governmental support of academic family medicine departments in various countries, the specific variations of academic department functioning and areas in which academic departments could benefit from robust partnerships with professional organisations like WONCA, among other topics.

Limitations
This study offers a cross-sectional view into the current state of family medicine training globally, with respondents representing a broad distribution of geographic regions. This was achieved through utilising established WONCA listservs for family medicine educators. However, as the survey was forwarded to a regional WONCA-specific listserv for Africa, this may have resulted in oversampling of that region. An added bias may have been introduced by the survey's language, as it was offered only in English. Additionally, as more established training programs may be better connected to WONCA and its working groups, the survey may have oversampled more long-standing training programs (21 of the 29 respondents represented training programs in existence for > 10 years).
The survey intentionally did not ask respondents to provide the name or even the country of their program, to ensure anonymity (recognising that some countries have only one family medicine training program) and facilitate transparency in response. However, it is possible that anonymising respondents in this way may have led to over-sampling of some programs.
Finally, this survey addresses programs' self-perceived resources and barriers to develop family medicine providers capable of meeting the unique needs of their communities. It is important to note that learners in these programs -and perhaps the community itself -might assess that balance differently.

Conclusion
As policymakers and potential global partners continue to pursue a path towards cementing support for primary health care as the basis for universal healthcare, it is critical to consider how best to support family medicine training programs that produce highly skilled clinical leaders at the community level. This survey provides an opportunity to gain a better understanding of what challenges are faced and how best to contribute to the sustainability and growth of these programs.