Impact success story: Primary healthcare
Ghent University professor Jan De Maeseneer (who retired in 2017) experienced, changed and lived as a general practitioner. His entire career was characterised by accessible, appropriate and responsible healthcare. The impact of his research group is therefore large.
A health insurance system with a surplus every year: in the 1960s this was a reality thanks to unprecedented economic growth. But the oil crisis struck in 1973 and the balance was negative for the first time the following year. “From then on people started to focus on savings. There was a high use of healthcare among people who enjoyed a preferential rate (a higher reimbursement for people with a low income) and immediately there was a call from conservative doctors to abolish the system. But their point of view was ideological,” says De Maeseneer, who was just starting out as a young researcher at Ghent University at the time. “Their position was: ‘Free care is not good; if we have people pay more, this will solve the problem.’ But a scientific study investigated why those people were using more healthcare. Did it have to do with their health status or were there other reasons and could the increased reimbursement be an explanation for that?”
“The way in which science formulates questions brings to it to look at the social impact. Because the conclusion was of course of great importance for the people for whom the care was to become much more expensive. The result of the study? To make a long story short: the people with the preferential rate simply turned out to be more ill and, more importantly, to suffer more from chronic diseases. So there was no reason at all to end the preferential rate.”
A foot in the door with policymakers
“The university must prepare and encourage people to ask these types of questions. It must also provide channels for actively setting the research agenda,” says Jan. His mentor, professor of social medicine Karel Vuylsteek, immediately took him to all kinds of consultation meetings where social actors debated the state of healthcare. “He said: ‘You have to be there, because you’ll learn.’ and that’s what I did it with all of my PhD students.”
Let’s jump back to the 1990s. Professor De Maeseneer was then scientific advisor to the Minister of Public Health Philippe Busquin and was instructed to draw up the policy on primary healthcare. “In that plan, I suggested giving the doctor a more central position, for example by having him/her keep the patient’s Global Medical File (GMD). Through preliminary research, we were able to show that people with a regular general practitioner cause fewer costs overall, with a comparable disease state. It took twelve years, from 1990 to 2002, for the GMD was implemented, but today more than 70% of all Flemish people are registered with a general practitioner and all general practitioners are happy to be able to improve continuity, coordination of care and prevention in this way.”
Development cooperation
Jan De Maeseneer mainly wanted to do projects that were of social importance. When the EU published a call for capacity building projects in healthcare in Africa, his research group was the only one to sign up for it. Their research eventually resulted in more than 20 publications. “In one of those publications we were able to demonstrate that South-South cooperation works. This is still a foundational publication in the field. We were forced to work there with countries such as Sudan that are not actually constitutional states, but where you can make a difference.
Primary care in Africa, that’s Ghent University.
“We’ve been working in Africa for twenty years now. And that’s another nice story, because everything starts with personal relationships: formational networks focusing on issues that matter. In 2005 we were confronted with the fact that everywhere in Africa donor money went mainly to disease-oriented vertical programs: AIDS, tuberculosis, malaria. There was nothing left for primary care. Moreover, there was also a ‘brain drain’ and not just to the West. We found that more Congolese doctors were working outside of Congo than in Congo. But there was also ‘brain drain’ within a country itself. Of the doctors who were trained at the medical faculty of Mbarara, 88% were still active in the country after ten years. And yet, it turned out that 51% were working on one disease: HIV-AIDS. This is dramatic: most of these doctors were mainly doing administrative jobs, and were ‘lost’ to general healthcare. Of all the statistics we’ve compiled, I still think this is the most tragic. Because you know the amount of effort that went into training these people, and that, because of the system (where donors pay much more to doctors than the local government), they cannot give back to their people what they have learned. At the time, we said: we have to do something about this. We’ll set up a consortium with a number of international organisations on the issue: ‘15 in 2015’ or, in other words, the goal was to get all of those disease-oriented donors to invest 15% of their funds in strengthening local primary care by 2015. Our call to integrate vertical disease-oriented programmes into primary care even influenced the debate up to the level of the World Health Organization in 2009 (WHO Resolution 62.12).”
Societal impact is also impact through education and the training of new generations of general practitioners
“In my career I’ve had many opportunities to position the discipline of general practitioner - both at the university, in practice and in policy - within the broader context of primary care and interprofessional cooperation and, above all, to look at the patient with a wide lens: from an ecological, biological, psychological and social perspective. Moreover, we’ve always drawn attention to care for the most vulnerable people in society. Finally, we try to orient care towards the realisation of the patient’s life goals: the question is not merely: ‘What’s wrong with Mrs Jansens?’, but: ‘What matters to Mrs Jansens?’."