Family Medicine And Primary Care

Teaching Programs As A Priority Discipline In Pakistan

Dr. Sunita DodaniThe Aga Khan University Hospital

Karachi, Pakistan

Presentation outline IntroductionHealth care system in developed and developing countriesPakistan, a developing countryMedical education in PakistanHealth care system & health care policy in PakistanReflection of health care policy on poor community Reasons for poor health care systemRecommendation for change in health care policyResources for change in policy

IntroductionHealth Care History:

500 years ago: death before 50th birthdayToday: Global average 65 years

Health expectancy: average number of years an individual can expect to live in a favorable state.Increased longevity does not come free. 21st century: Still many millions die prematurely or are disabled by diseases.Longer life can be a penalty as well as a prize

Introduction (cont’d)

WHAT IS HEALTH CARE SYSTEM?An investment organization and infrastructure for the deployment of health care providers who work to improve the quantity and quality of life of the individuals that make up the population for whom the system is responsible

Providers with appropriate skills guarantee efficient deliveryHealth care needs vary world wide

Health Care System in Developed Countries

NORTH AMERICA:World’s largest health care systemUse of GATEKEEPERS: Family physicians - first point to provide health care services to a common man.Strong Health Care Policy: Strong accountability and licensing of family physician in USA.Canadian Medicare System: Provides comprehensive, universal, accessible, and portable provincial health care programs.

Health Care System in Developing Countries

Significant health and education improvement in 20th century resulted in:

Infant Mortality, Life Expectancy, Literacy Rates

Asian and Pacific poverty marked by two significant factors: magnitude and diversity. 900 million or 75% of the world’s poor live in the Asian, Pacific Region and Sub-Saharan Africa. Nearly one in three Asians is poor

Health Care System in Developing Countries (cont’d)Achieving major poverty reduction is feasible. South Asian nations facing tough policy challenges:

Deficiencies in social areasInfrastructure bottlenecks, Reducing still-excessive trade Investment barriers, Providing quality health care system to common man

Rapid changes in structure and content of health care servicesPrimary care concept developing at slower pace compare to developed countries.

Health Care System in Developing Countries (cont’d)

Extensive development of Primary Care Management at the State Policy and Organizational levelSri Lanka, Bangladesh, India, and Nepal:

Significant Health policy reformsFamily practice training at post graduate level

Health Care System in Developing Countries (cont’d)

Cuba Tremendous improvement in the last 30 years Brand new primary care system:

Training and placement based systemTeam of 20,000 family physicians and nurses for entire population (11 million)Rise in major health indicators

Pakistan: A developing CountryMultiethnic and linguistic diversity 4 provinces and 2 territories.Population ~ 130 millionRich cultural heritageAbundant natural and human resourcesLarge and potentially more productive agriculture sector Strategic trade location

Economic growth: 5.5% 1985 to 1995Per capita income: $490

Up 70% in last two decades

Poverty to population ratios:

half in mid 1980sOne-third early 1990s

Pakistan: A developing Country (cont’d)

WDI9901 19913 %Private health expenditures as % of GDP

WDI9901 19951 %Public health expenditures as % of GDP

WDI9901 19931,455 Population per hospital bed

WDI9901 19931,829Population per doctor

WDI9901 199624 %Access to improved sanitation (%)[Rural]

WDI9901 199675 %Access to improved sanitation (%)[Urban]

WDI9901 199656 %Access to improved water(%)[Rural]

WDI9901 199685 %Access to improved water(%)[Urban]

WDI9901 199735 %Percent urban

WDI9901 199741 %Adult literacy rate

WDI9901 19971,560Real GDP per capita (PPP)

SourceYearValueINDICATOR

Socioeconomic Indicators

Pakistan: A developing Country (cont’d)

Medical Education in PakistanTraditional British systemUndergraduate medical curriculum comprises:

3 years of teaching in pre-clinical subjects2 years of clinical rotations in accredited hospitals.

The MBBS (Bachelor of Medicine& Bachelor of Surgery) degree is conferred at the end of 5 years. Aga Khan University: offers more then traditional medical degree:

clerkship consist of subspecialty rotations.3 months of primary care rotation.Medical School is followed by an internship year at a accredited Hospital under supervised medical practice

Medical Education in Pakistan (cont’d)

No mandatory clinical exposure in family practiceFurther education is entirely optional and consists of a range of postgraduate degrees and diplomasFellowship degrees in accordance with the “College of Physicians and surgeons of Pakistan” (CPSP)Total medical colleges and universities…69Approx graduates qualifying each year… 3000Higher qualification abroad……… 30-40% (urban)Specialty training……………….. 20 %

Medical Education in Pakistan (cont’d)

General practice/ family practice… 40-50% ( without proper training…majority)Postgraduate training in Family Medicine:

One university - AKU3 year training program

4-6 fellows every year. Usually absorbed as facultyStarted with one trained family physician in 1994.To date trained: 16 family physicians, 7 faculty members, 1 in UK, 3 unemployed, 3 medical officers, 2 gone for MRCGP.Is this enough for whole Pakistan??????

Health Care System & Health Care Policy in Pakistan System allows unrestricted and independent General Practice after completion of MBBS and internship, without the need of proper training in family practice or primary care.No proper law of licensing or accountability exists

Non-existence OF PROPER RULES AND REGULATION, SELECTION OF GPs AND/OR SPECILIST DEPENDS ON PUBLIC’S CHOICE OR ABILITY TO PAY.

No credentialing or recertification after MBBS.Total expenditure on health care services:

Sector % of GDP

Government 2

Private & Public 3

Health Care System & Health Care Policy in Pakistan (cont’d)

Ability to pay in Pakistan is clearly associated with the utilization of services.Most physicians work simultaneously for the public sector and in private practice. Private doctors are the most common type of providers for all groupsRegulation of the private sector is virtually non-existent, especially regarding standards for registration of premises, staffing, infrastructure and fees. Private hospitals are not subject to licensing or certification of needs before instruction or operation. Malpractice including excessive medication and unnecessary procedures is thought to be common

Health Care System & Health Care Policy in Pakistan (cont’d)

Black markets induce malfunctioning health systems Health ministries fails to enforce regulations Government’s money spent on high cost hospital services serving the more affluent Too many hospital beds have been built and too much medical equipment has been purchased, increasing pressures on medical inflation and leaving beds and equipment underutilized. The rising costs of hospital-based medical care leave little for essential clinical and public health services for the public at largeNo concept of health insurance from the governmentExtensive imbalance in service distributionFailures in health systems impacts poor the mostInequality and denial of an individual's basic rights to health

Reflection of Health Care Policy on Poor Community

People in Pakistan have grown healthier over the past three decades.The rates of immunization of most groups of children have more than doubled over the past decade

Reflection of Health Care Policy on Poor Community (cont’d)Knowledge of family planning has increased remarkably and is almost universalPakistan's per capita income is much higher than the average for low-income countries

Reflection of Health Care Policy on Poor Community (cont’d) Health care indicators

Communicable diseases such as diarrhea diseases, respiratory infections, tuberculosis, and immunizable childhood disease still account for the major portion of sickness and death in Pakistan.Maternal health problems are also widespread, complicated in part by frequent births.Pakistan lags far behind most developing countries in women's health and gender equity; of every 38 women who give birth, 1 dies.The infant mortality rate (101 per 1,000) and the mortality rate for children under age five (140 per 1,000 births) exceed the averages for low-income countries by 60 and 36 percent, respectively.Although use of contraceptives has increased, fertility remains high, at 5.3 births per woman.

Source: Pakistan’s federal bureau statistics

BUC9808 19992 %Average annual growth rate (%)

BUC9808 1999425,065Annual infant deaths

BUC9808 19994,622,789 Number of live births

BUC9808 199910 Crude Death Rate

BUC9808 199934Crude Birth Rate

BUC9808 199959Life expectancy at birth (years)

BUC9808 199931,745,592Women, ages 15-49

BUC9808 1999138,197Total population (000s)SourceYearValueINDICATOR

Demographic Indicators

Reflection of Health Care Policy on Poor Community (cont’d)

Reasons for Poor Health Care SystemVery low government expenditure on health services. (not only this ,but also per-capita income, education)some countries achieve far better health outcomes with lower health expenditures such as China, Sri Lanka and Greece have life expectancies five to ten years longer than would have been predicted by their expenditures, income or schoolingPoor value obtained by the public from what the government spends, because of weak management and corrupted practices such as absenteeism.Poor quality of care from many private health care providers.Lack of proper training in primary care/general practice.

Recommendation for Change in Health Care Policy

Government should ensure basic set of health services adequate supply of appropriately trained physicians Quality public health services and primary care available to all as a matter of national policy. Enhance primary care status and role of family doctorBalanced medical representationAppropriate use of specialistsPrompt licensing and practice standards

Disciplined approach towards whole health care management system.

Recommendation for Change in Health Care PolicyIntroduction of referral systemSustain interprofessional consensus, contractual agreements and financial incentives.Every person should know the name of his or her primary care provider. Individual patients should be actively encouraged to nominate one doctor as their principal primary medical care provider. Individual family doctor should be actively encouraged to maintain a register of all the individuals and families for whom they take responsibility as principal primary care providers.Colleges, academies, or other independent self-regulating professional associations of family doctors should be established in ALL cities of Pakistan. or their members.Family doctors should devise standards for all aspects of family practice based where possible on published research evidence including both quantitative and qualitative aspects. Formal recognition of Family Medicine as a special discipline in medicine - already accepted in many countries.

Resources for Change in Policy

Question & Answers