The goal of WHO’s universal health coverage (UHC) is to provide people access to health services without financial hardship or in simple terms “health for all”. The aim is to provide and maintain good standard of healthcare services, health promotion, diseases prevention, treatment, rehabilitation and palliative care. In order to provide universal health coverage a strong, well-established and functioning primary care system is needed.
Primary care is defined as the day to day care given to the community by primary care physician (general practitioner, family physician). It is the health system’s bedrock and patients’ first point of contact. A gate-keeping system to filter access to specialised care. Family physicians work alongside specialist, nurses, pharmacist and in certain localities with the traditional medicine professionals. Evidence suggest that countries with more robust and primary–care centered health care delivery system have better health outcomes.
According to the article published in BMC Health services research one of the key features of Iran and Turkey’s successful health transformation plan to attain UHC was creation of family medicine system and integration of health services. It also encompassed designing of new training courses and review of existing programmes for family physicians. Pakistan is a low middle-income country, which has a high burden of both communicable (also called infectious or transmissible) diseases and non-communicable diseases (NCDs, like heart disease, diabetes, cancers etc). In absence of health insurance, patients have to bear the cost of treatment, which is called ‘out of pocket expenditure’. Having an organised primary health care system with trained (qualified) family physicians, geared to meet the demands for healthcare can reduce cost through early disease identification, diseases prevention and avoidance of use of unnecessary tests. Effective functioning of secondary and tertiary care system depends on an efficient and comprehensive primary care, which focuses on providing cost effective and holistic care.
Effective functioning of secondary and tertiary care system depends on an efficient and comprehensive primary care, which focuses on providing cost effective and holistic care
What are the issues? Why family medicine as a specialty is still the missing link in our health system? Some of the challenges include: unfamiliarity and inadequate understanding of the subject among medical and non-medical professionals. An initiative by PMC’s (formerly PMDC) taken 6 years ago, recommending department of family medicine in all medical colleges with inclusion of family medicine in MBBS curriculum, failed to gain attention of relevant stakeholders. This has further contributed to poor understanding of the subject particularly among undergraduates. Only 38% of final year medical students had heard of family medicine specialty as per a recent survey conducted in five medical colleges in Lahore assessing knowledge of final year medical students about family medicine (PJMD, 2020)
Likewise, unavailability of structured post-graduation opportunities in this specialty have had an impact on its noteworthiness. With the exclusion of south-eastern part of Pakistan, where good number of institutions are offering 1, 2 and 4 -year training programmes, the situation of rest of the country including Islamabad capital territory is discouraging. Besides scarcity of trained GPs, shortage of faculty has been created as a result. The situation has been contained to some extent by influx of foreign qualified /trained GPs in recent years, which has led to sharing the responsibility with existing local faculty. MRCGP (UK) qualified GPs based in public sector institutions in Punjab, ICT and KP alongside their peers are playing key role in pushing the case of family medicine specialty recognition forward, build better training programmes and strengthen the foundations. Moreover, the national family medicine committee members, have been pursuing the matter with the administrative leads at provincial and federal levels in both public and private sector. Progress has been made in addressing lack of structured training of GPs.
By making family medicine training mandatory for all medical officers serving in primary health care facilities can help meet minimum service delivery standards as laid out by government. Supervision by qualified family medicine specialist at dispensaries, basic health units (BHU), rural health centres (RHC) can help trainee doctors perform their assigned duties more efficiently. Develop a separate family medicine specialist cadre. These specialists should then be posted in all DHQ Hospitals and RHC. The neighbouring BHUs can then be clustered together with the RHC and DHQs and develop a referral system. The family medicine specialist should also offer clinical supervision to the doctors, medical technician posted in the neighbouring BHUs and also the community teams including lady health visitors (LHVs) Immunization (EP)I technician etc for clinical advice.
With new policies emerging regarding health insurance, health sector reforms including human resources management & ‘contracting out’ of primary health care services, concrete steps have to be taken sooner rather than later to streamline the training of post graduates employed in our health system. Family physician led models to ensure safe and equitable delivery of essential health services.
In summary, the steps needed for progression of family medicine include availability of bridging programmes to catch up with the training of practicing physicians, longer degree programmes (2 and 4 year) to help develop faculty and support training of successors. It must be made essential for all medical colleges and universities to have family medicine department. With regards to the clinical aspect of general practice, effective advocacy is needed to convince decision-makers, measures like government guided health sector reforms focusing on fundamental changes in policies relating to specific healthcare goals for diseases like diabetes, cancer etc, use of interventions to address multiple health issues at the same time by making primary care services a strategic priority and institutional arrangements particularly those through which policies are implemented.
Dr Hina Jawaid (Assistant Professor in Family Medicine, University of Health Sciences Lahore & Dr Abdul Jalil Khan, Assistant Professor in Family Medicine, Khyber Medical University)