Transcript Family Medicine And Primary Care Teaching Programs As A Priority

Family Medicine And Primary Care
Teaching Programs As A Priority
Discipline In Pakistan
Dr. Sunita Dodani
The Aga Khan University Hospital
Karachi, Pakistan
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
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
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
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.
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 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
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
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
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
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
Pakistan: A developing Country (cont’d)
Socioeconomic Indicators
INDICATOR
Value
1,560
41 %
Adult literacy rate
35 %
Percent urban
Access to improved water(%)[Urban] 85 %
Access to improved
56 %
water(%)[Rural]
Access
to improved sanitation (%)[Urban] 75 %
Access to improved sanitation
24 %
(%)[Rural]
Population per doctor
1,829
Population per hospital bed
1,455
Public health expenditures as % of GDP
1%
Private health expenditures as % of GDP 3 %
Real GDP per capita (PPP)
Year
Source
1997
1997
1997
1996
WDI9901
1996
1996
1996
1993
1993
1995
1991
WDI9901
WDI9901
WDI9901
WDI9901
WDI9901
WDI9901
WDI9901
WDI9901
WDI9901
WDI9901
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
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 %
Medical Education in Pakistan (cont’d)
General practice/ family practice… 4050% ( 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??????
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 groups
Regulation of the private sector is virtually nonexistent, 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
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
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 universal
Pakistan'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.
Reflection of Health Care Policy on Poor
Community Demographic Indicators
(cont’d)
INDICATOR
Total population (000s)
Year
1999
1999
Source
BUC9808
BUC9808
59
1999
BUC9808
Crude Birth Rate
34
1999
BUC9808
Crude Death Rate
10
1999
BUC9808
Women, ages 15-49
Life expectancy at birth (years)
Value
138,197
31,745,592
Number of live births
4,622,789
1999
BUC9808
Annual infant deaths
425,065
1999
BUC9808
2%
1999
BUC9808
Average annual growth rate (%)
Source: Pakistan’s federal bureau statistics
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.
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.
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.
Resources for Change in Policy
Question & Answers