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

2. 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

3. 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

4. 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 delivery • Health care needs vary world wide

5. Health Care System in Developed Countries NORTH AMERICA: • World’s 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.

6. 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

7. Health Care System in Developing Countries (cont’d) • 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.

8. Health Care System in Developing Countries (cont’d) • 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

9. 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 system • Team of 20,000 family physicians and nurses for entire population (11 million) • Rise in major health indicators

10. 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

11. Pakistan: A developing Country (cont’d) • 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

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

13. 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

14. Medical Education in Pakistan (cont’d) • 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 universities…69 • Approx graduates qualifying each year… 3000 • Higher qualification abroad……… 30-40% (urban) • Specialty training……………….. 20 %

15. Medical Education in Pakistan (cont’d) • General practice/ family practice… 40-50% ( without proper training…majority) • 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??????

16. 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:

17. 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 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

18. 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 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

19. 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

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

21. 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.

22. Reflection of Health Care Policy on Poor Community(cont’d) Demographic Indicators INDICATOR Value Year Source Total population (000s) 138,197 1999 BUC9808 Women, ages 15-49 31,745,592 1999 BUC9808 Life expectancy at birth (years) 1999 BUC9808 59 Crude Birth Rate 34 1999 BUC9808 Crude Death Rate 10  1999 BUC9808 Number of live births 4,622,789  BUC9808 1999 Annual infant deaths 425,065 1999 BUC9808 Average annual growth rate (%) 2 % 1999 BUC9808 Source: Pakistan’s federal bureau statistics

23. Current and Projected Population by Age and Sex

24. Reasons for Poor Health Care System • Very low government expenditure on health services. (not only this ,but alsoper-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.

25. 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.

26. 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.

27. Resources for Change in Policy

28. Question & Answers