Family Medicine And Primary Care Teaching Programs As A Priority Discipline In Pakistan

1
Family Medicine And Primary Care Teaching
Programs As A Priority Discipline In Pakistan

• Dr. Sunita Dodani
• The Aga Khan University Hospital
• Karachi, Pakistan

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Presentation outline

• Introduction
• Health care system in developed and developing
  countries
• Pakistan, a developing country
• Medical education in Pakistan
• Health care system health care policy in
  Pakistan
• Reflection of health care policy on poor
  community
• Reasons for poor health care system
• Recommendation for change in health care policy
• Resources for change in policy

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Introduction

• Health Care History
• 500 years ago death before 50th birthday
• Today 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

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Introduction (contd)

• 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 delivery
• Health care needs vary world wide

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Health Care System in Developed Countries

• NORTH AMERICA
• Worlds largest health care system
• Use 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.

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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 worlds poor live in
  the Asian, Pacific Region and Sub-Saharan Africa.
  
• Nearly one in three Asians is poor

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Health Care System in Developing Countries
(contd)

• Achieving major poverty reduction is feasible.
• South Asian nations facing tough policy
  challenges
• Deficiencies in social areas
• Infrastructure bottlenecks,
• Reducing still-excessive trade
• Investment barriers,
• Providing quality health care system to common
  man
• Rapid changes in structure and content of health
  care services
• Primary care concept developing at slower pace
  compare to developed countries.

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Health Care System in Developing Countries
(contd)

• Extensive development of Primary Care Management
  at the State Policy and Organizational level
• Sri Lanka, Bangladesh, India, and Nepal
• Significant Health policy reforms
• Family practice training at post graduate level

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Health Care System in Developing Countries
(contd)

• Cuba
• Tremendous improvement in the last 30 years
• Brand new primary care system
• Training and placement based system
• Team of 20,000 family physicians and nurses for
  entire population (11 million)
• Rise in major health indicators

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Pakistan A developing Country

• Multiethnic and linguistic diversity
• 4 provinces and 2 territories.
• Population 130 million
• Rich cultural heritage
• Abundant natural and human resources
• Large and potentially more productive agriculture
  sector
• Strategic trade location

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Pakistan A developing Country (contd)

• Economic growth 5.5 1985 to 1995
• Per capita income 490
• Up 70 in last two decades
• Poverty to population ratios
• half in mid 1980s
• One-third early 1990s

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Pakistan A developing Country (contd)
Socioeconomic Indicators
Source
Year
Value
INDICATOR
1,560
WDI9901
1997
Real GDP per capita (PPP)
1997
41
WDI9901
Adult literacy rate
WDI9901
1997
35
Percent urban
WDI9901
1996
85
Access to improved water()Urban
Access to improved water()Rural
WDI9901
1996
56
WDI9901
1996
75
Access to improved sanitation ()Urban
WDI9901
1996
24
Access to improved sanitation ()Rural
WDI9901
1993
1,829
Population per doctor
WDI9901
1993
1,455 
Population per hospital bed
WDI9901
1995
1
Public health expenditures as of GDP
WDI9901
1991
3
Private health expenditures as of GDP
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Medical Education in Pakistan

• Traditional British system
• Undergraduate medical curriculum comprises
• 3 years of teaching in pre-clinical subjects
• 2 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

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Medical Education in Pakistan (contd)

• No mandatory clinical exposure in family practice
• Further education is entirely optional and
  consists of a range of postgraduate degrees and
  diplomas
• Fellowship degrees in accordance with the
  College of Physicians and surgeons of Pakistan
  (CPSP)
• Total medical colleges and universities69
• Approx graduates qualifying each year 3000
• Higher qualification abroad 30-40 (urban)
• Specialty training.. 20

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Medical Education in Pakistan (contd)

• General practice/ family practice 40-50 (
  without proper trainingmajority)
• Postgraduate training in Family Medicine
• One university - AKU
• 3 year training program
• 4-6 fellows every year. Usually absorbed as
  faculty
• Started 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??????

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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
  PUBLICS 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
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Health Care System Health Care Policy in
Pakistan (contd)

• 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 groups
• Regulation 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

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Health Care System Health Care Policy in
Pakistan
(contd)

• Black markets induce malfunctioning health
  systems
• Health ministries fails to enforce regulations
• Governments 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 large
• No concept of health insurance from the
  government
• Extensive imbalance in service distribution
• Failures in health systems impacts poor the most
• Inequality and denial of an individual's basic
  rights to health

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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

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Reflection of Health Care Policy on Poor
Community (contd)

• Knowledge of family planning has increased
  remarkably and is almost universal
• Pakistan's per capita income is much higher than
  the average for low-income countries

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Reflection of Health Care Policy on Poor
Community (contd)

• 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.

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Reflection of Health Care Policy on Poor
Community
(contd)
Demographic Indicators
INDICATOR
Source
Year
Value
Total population (000s)
BUC9808
1999
138,197
BUC9808
1999
31,745,592
Women, ages 15-49
BUC9808
1999
Life expectancy at birth (years)
59
BUC9808
1999
34
Crude Birth Rate
BUC9808
1999
10 
Crude Death Rate
BUC9808
4,622,789 
Number of live births
1999
BUC9808
1999
425,065
Annual infant deaths
Average annual growth rate ()
BUC9808
1999
2
Source Pakistans federal bureau statistics
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Current and Projected Population by Age and Sex
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Reasons for Poor Health Care System

• Very 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 schooling
• Poor 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.

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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
  doctor
• Balanced medical representation
• Appropriate use of specialists
• Prompt licensing and practice standards
• Disciplined approach towards whole health care
  management system.

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Recommendation for Change in Health Care Policy

• Introduction of referral system
• Sustain 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.

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Resources for Change in Policy
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Question Answers