Primary health care
reforms in Pakistan: A mandatory requirement
for successful healthcare delivery
Sajad Ahmad
(1)
Waris Qidwai (2)
(1) Dr Sajad
Ahmad MRCGP, General Practitioner, Cardiff and
Vale University Health Board, UK
(2) Dr. Waris
Qidwai, MBBS, MCPS (FM), FCPS (FM), FRCGP (INT),
FCGP(SL), MFPH(UK)
The Tajuddin Chatoor, Professor and Chairman,
Department of Family Medicine,
Service Line Chief, Family Health, Aga Khan
University, Karachi
Correspondence:
Dr Sajad Ahmad
33 Hind close, Pengam Green, Cardiff, CF24 2EF,
United Kingdom
Phone: +44 7725361582
Email: drsajadahmad@hotmail.com
Abstract
All
over the world, family physicians take
pride in their work of providing care
at the first point of contact; the concept
is very well established and refined in
the United Kingdom and amongst many other
developed countries.
General practitioners in the UK are often
known as the gatekeepers to the National
Health Service (NHS). This is because
of family physicians being the first point
of contact for the patients. The majority
of patients are managed in primary care,
while a few who require further treatment
are referred to secondary care for further
management. It is known that the access
to family physicians has a positive effect
on the overall health of the patient.
In this paper, we discuss disease burden,
with a brief introduction to current healthcare
provision and conclude with suggestions
for implementation of family medicine
as a speciality in rescuing the ailing
healthcare delivery system of Pakistan.
Key Words:
Family medicine, Family physicians, FCPS
Family Medicine, NHS, United Kingdom,
General Practitioners. Healthcare in Pakistan
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DISEASE BURDEN IN A PAKISTANI CONTEXT |
It is known that access to family physicians
has a positive effect on the overall health
of the patient (1). Pakistan is a country of
more than 184 million people, with a male and
female life expectancy of 66 and 68 years of
age, respectively. It is a country with a high
disease burden, resulting in low quality of
life. With rising costs, the provision of health
care is becoming more challenging in a society
facing many challenges in providing healthcare.
This scenario is against the background that
in 2014, Pakistan spent 2.6% of its GDP on health
(2). In the same year, under-five mortality
rate was recorded at 81 / 1000 (8.1%) of deaths
per live births, a shocking statistic that needs
to trigger a major policy reform in health care
(3).
The majority of disease burden comes from tuberculosis,
HIV and Malaria as well as non-communicable
diseases. Diabetes and cardiovascular disease
are becoming one of the fastest growing disease
burdens in the country. Currently, 38% of its
adult population above the age of 11 years smoke,
while 11.7% above 25 years of age have high
blood sugars and 28.6% suffer with high blood
pressure. In 2012 the three major causes of
death were Ischemic heart disease 111.4 per
thousand (8.4%), Lower respiratory infections
104.5 per thousand (7.8%) and stroke 84.6 per
thousand (6.3%). There has been a gradual increase
in the number deaths between 2000 and 2012 caused
from Ischemic heart disease, stroke, pre-term
birth complications and chronic obstructive
pulmonary disease. (4)
With current statistics for growth, stunting
and malnutrition being comparable to Afghanistan,
the government needs to rethink its overall
health care delivery in general and primary
health care strategy in particular.
A BRIEF COMPARISON OF PRIMARY HEALTHCARE
AND PAKISTAN |
Many countries across the world have started
taking steps towards improving their primary
healthcare by increasing investment and re-structuring
of the healthcare provisions.
According to WHO, Pakistan currently has 2.0
Primary health Care Centres / Units per 10,000
of the population (4). Although an improvement
on previous numbers, the data should provide
evidence that access to a doctor per patient
population is ensured. According to a recent
survey the United Kingdom, for example with
an average sized General Practice, functions
at a doctor to patient ratio of between 1:1400
to 1:2200 (5). This is to say that health centres
are usually managed as partnerships between
general practitioners supported by a team of
highly qualified district nurses, practice nurses,
ancillary staff and healthcare assistants. Denmark
has a far better figure in access to a general
practitioner with numbers ranging at 1:1600
(6). Lacking comparison, we can only equate
the availability of a doctor to a number of
populations. Unfortunately in Pakistan, we not
only lack the number of qualified general practitioners
but also the supporting staff that helps in
the provision of healthcare to the masses.
The provision of primary healthcare services
in the western countries is a good example of
how Pakistan as a nation can tackle the top
three deadliest disease burdens on its list.
Looking towards our close neighbours, we notice
a shift towards improvement of primary healthcare
system. Countries such as Oman, Qatar and Saudi
Arabia are good examples.
Ischemic heart disease and stroke are preventable
and early diagnosis through effective screening
can ensure timely treatment with better outcomes.
A system of patient registrations with a local
health centre is the key for continuity of care
and provision of health promotion. Full use
of electronic medical records have shown to
have a positive impact on patient care (7, 8).
This in turn will reduce the cost of healthcare
by promoting prevention and diagnosing conditions
much earlier thus reducing the disease burden
at a later stage. It is by these means when
the centres are managed by qualified family
physicians that the health of the nation can
change. Patient's contact with a family physician
can have a positive effect on the health of
the patient. Patients who have regular contact
with their family physician tend to do better
(9).
Healthcare in Pakistan is provided through a
mixed healthcare system. The majority of healthcare
provision is through private hospitals with
the remaining being provided by government hospitals,
armed forces through its social security system
and the rest through the employee social security
system. At primary healthcare level, care is
provided through Basic health units (BHUs),
Rural health units (RHUs), and Mother and child
Units (MCHUs). Although the level of care at
secondary level e.g. in private and many government
run hospitals is generally good with doctors
taking up specialisations in different specialities,
primary care is generally ignored. For the Primary
care services, the workforce is generally drawn
from the newly graduated doctors, without adequate
training. These include career grade medical
officers who have opted to settle in the rural
areas, usually close to their place of origin.
Some healthcare is provided by doctors in training,
these are in the process of completing their
specialist training, which is commonly not related
to Family Medicine.
In summary 90% of care is provided by doctors
who have had no training in Family Medicine.
This has a negative impact on the already strained
healthcare; the lack of training in a speciality
gives rise to poor disease outcome. It is widely
known that Pakistan is lagging behind in the
provision of healthcare and has failed to meet
the WHO targets on providing healthcare in key
areas. In 2006 WHO classed it as one of the
57 countries with critical workforce deficiency
(11). The lack of appropriate services, poor
availability of care, and poor funding are all
various reasons for the burden on secondary
care hospitals. Around 21% of the population
visit secondary care services (11). This increases
the financial constraints on the already under
funded government hospitals.
EXAMPLE OF FAMILY PHYSICIAN CONSULTATION
IN THE UK |
Joe Bloggs is a
45 year old overweight male. He lives
in an area classed as four on the Townsend
quintile. He has recently lost his job
and as a result, he has started smoking
heavily due to stress. He attends his
general practitioners with a history of
cough and recurrent chest infections.
His GP examines him, treats his acute
infection with some antibiotics and a
short course of steroids. His GP notices
his frequent attendance for chest infections
and orders a chest x-ray and a spirometry.
Mr Bloggs returns after the investigations
to discuss his results with the GP. He
is diagnosed with a mild COPD, his GP
discusses this with him, offers him smoking
cessation advice and puts him on the practice
COPD register, this way he can have regular
recalls for the review of his chest symptoms.
It is during attendance to one of the
COPD clinics in the practice that Mr Bloggs
quits smoking with the help of Nicotine
patches. His GP who was trained in communication
skills while completing his MRCGP also
notices the nonverbal cues during the
consultation and notices that Mr Bloggs
has been overly stressed. He discusses
this with Mr Bloggs and on further inquiring,
it becomes evident that Mr Bloggs is suffering
with moderate depression. He offers a
sick note to Mr Bloggs, and discusses
the likely treatment options. After shared
decision-making, the GP starts Mr Bloggs
on an antidepressant and also refers him
to the local mental health team for counselling.
After attending 6 sessions of CBT, Mr
Bloggs returns to see his GP, he is now
feeling much better, his COPD is under
control and his depression managed he
decides to come off the sick leave and
look for work.
|
The above scenario is a typical example of
doctor patient relationship in UK general practice.
General Practitioners take great pride in knowing
their patients and patients report an increased
level of satisfaction from the continuity of
care (9, 12). The entire consultation is funded
through the universal tax system. GPs are the
gate keepers to keeping the costs of unnecessary
investigations and treatments under check and
work in line with the guidelines from National
Institute of Care and health Excellence (NICE).
GENERAL PRACTICE TRAINING IN THE UNITED
KINGDOM |
Family Physicians known as general practitioners
in the United Kingdom undergo a training programme
lasting 3-4 years after the completion of house
jobs. This has to be approved by the Royal College
of General Practitioners (RCGP) for doctors
to be able to practice as general practitioners.
The training programme known as speciality training
is based on the RCGP Curriculum (13). The general
practice-training curriculum defines the skills,
knowledge and qualities required to become an
experienced GP. Trainees rotate through a recognised
training post in the first two years consisting
of hospital rotations in different specialities,
including medicine, mental health, accident
and emergency, trauma and orthopaedics, psychiatry,
paediatrics, obstetrics and gynaecology. The
last year of the training programme is generally
spent in Family medicine known in the UK as
general practice rotation or a GP surgery. The
Royal College of General Practitioners have
recently recommended that the training programme
be extended to a four year rotation with minimum
24 months spent in general practice setting
(14). RCGP described it as a "spiral curriculum"
which will work by taking a general practitioner
from a novice stage to being an expert in the
speciality. The candidates after completing
their core competencies during their training
programme sit a written and clinical skills
assessment to gain certificate completion of
training in general practice. They are also
granted Membership of the Royal College of General
Practitioners on completion.
General
practitioners
have
long
been
the
primary
care
providers.
The
turn
of
the
century
saw
a
gradual
shift
towards
more
specialised
care.
This
led
to
care
being
shifted
from
the
primary
care
to
the
secondary
hospitals.
In
Britain,
for
example,
the
concept
of
cottage
hospitals
where
general
practitioners
used
to
treat
patients
was
gradually
abandoned
and
care
was
shifted
towards
more
centralised
major
hospitals.
The
1950s
saw
a
resurgence
in
the
importance
of
family
doctors.
The
college
of
general
practitioners
was
awarded
the
royal
charter
by
HRH
the
duke
of
Edinburgh
in
1972
(15).
General
practitioners
have
contributed
to
the
vast
majority
of
health
of
the
country.
Most
of
the
western
countries
have
a
family
medicine
programme
which
effectively
runs
a
modern
primary
healthcare
system.
The
benefits
of
such
a
system
are
widely
known.
The
current
shift
towards
the
same
system
as
is
seen
in
the
west
by
many
Middle
Eastern
countries
is
evident
by
the
effectiveness
of
it
achieving
better
health
targets
for
its
population.
Regionally
Pakistan
lacks
a
move
towards
such
a
system.
With
currently
a
handful
of
training
programmes,
being
offered
by
a
few
universities
there
has
been
no
effort
towards
the
promotion
of
this
speciality.
In
2014,
the
Pakistan
medical
and
dental
council
released
a
statement
directing
all
medical
colleges
in
the
countries
to
initiate
family
medicine
as
a
speciality
in
the
final
year
exam
for
its
medical
students.
The
college
of
Physicians
and
surgeons
in
Pakistan
awards
Fellowship
in
family
medicine,
but
unfortunately
due
to
the
lack
of
training
facilities
the
uptake
and
future
prospects
for
trainees
haven't
changed
much
since
its
inception.
There
also
hasn't
been
any
change
of
curriculum
at
any
of
the
remaining
medical
colleges
in
Pakistan
towards
the
implementation
of
the
speciality.
Pakistan
needs
to
reform
its
healthcare
policies
from
many
aspects.
The
mass
training
of
family
physicians
as
part
of
many
other
changes
that
are
required
for
healthcare
targets
would
improve
the
outcome
of
service
delivery.
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