The way to universal health coverage

A resilient primary care system that offers intensive management of non-communicable diseases can be cost-effective

The way to  universal health coverage

A well-trained health workforce is required to provide quality, people-centred integrated healthcare. At present, there are 252,336 MBBS doctors in Pakistan according to Pakistan Medical Commission (PMC). A number of these doctors work as general practitioners (GP or family physicians) in the community. How can their medical practice be made more efficient and productive?

Considering the number of aforesaid doctors, which has accumulated over the years, how can we attract them towards a better opportunity? We need some arrangement in place for this cohort to be able to provide services more effectively and safely.

Fundamentals first, let’s understand the way a primary care system works. Family practice is a broad specialty. A well-organised system offers a broad range of services, both clinical and non-clinical to the population. The benefits are manifold: disease prevention, early disease recognition, reduced inequality in health and improved quality of care.

A family practice approach is part of health policies in 16 countries in the Eastern Mediterranean region. Due to lack of enough trained family physicians it is not easy to implement, according to the WHO. A family practice approach is linked to family physicians’ role and responsibilities (

The core tasks associated with the role include: providing holistic care, order (appropriately) and interpret diagnostic tests, providing expert advice on disease prevention, following up on patients’ progress and collaborating with other healthcare professionals.

Pakistan can learning from regional countries like Sri Lanka and Nepal, where family medicine is recognised as a specialty. Nepal, which has a predominantly rural population, produces 60-70 trained GPs per year through a three-year training scheme. Evidence suggests that comprehensive clinical and non-clinical services provided by GPs have added value to their existing healthcare facilities through augmentation of clinical services and quality improvement initiatives (BMC, 2018).

With a significant gap between health facilities in urban and rural Pakistan, low doctor-, dentist- and paramedic- to population ratio, high pregnancy-related maternal mortality ratio, high percentage of malnourished children under the age of five, deficient contraception counselling, rapid population growth and limited expansion of healthcare delivery system, make the approach attractive.

A strong and resilient primary care system which offers intensive management of non-communicable diseases (e.g. diabetes, hypertension) and prevention and early identification of communicable disease (i.e. TB, hepatitis, HIV), can be cost-effective.

Investing in primary care would lead to significant savings for our healthcare system.

What do we need to achieve this? Besides physicians, the requirements include primary care facilities offering an essential package of health services in both the public and private sector and rural and urban settings, institutions with family medicine departments and faculty offering capacity building, short-term training programmes and, above all, the willingness of professionals to implement policies.

Bringing major reforms in a fragile and fragmented healthcare system is not going to be an easy task. Nonetheless, we have to start from somewhere and require a multi-pronged approach.

Let us have a look at some of the figures: Pakistan’s population is 220 million. According the WHO we need three family physicians for a 10,000 population. So for the entire population, approximately 66,000 trained primary care physicians are needed. A colossal task indeed.

The PMC, a statutory regulatory authority, has defined the qualifications as:

(i)- post-graduate qualifications (Pakistani/ foreign) acquired after certification of completion of a structured training programme.

(ii)- qualifications acquired in addition to a postgraduate qualification after completion of a structured training programme under direct supervision to develop specific competencies after completion of a post graduate qualification.

(iii)- alternative qualifications (Pakistani/ foreign) alternate to (i), obtained after either a period of training or acquiring minimal competencies (

Reviewing the current availability of family medicine programmes in the country, there is one post-graduate qualification (Pakistani) taken up by a minority whereas an overwhelming majority undertakes alternative qualifications (Pakistani/ foreign) through experience pathway as training options are either non-existent or are unpaid. This is a critical situation and needs urgent attention.

Structured training under direct supervision is a much-needed reform which will certainly contribute to the promotion of training pathways in family medicine. The process of teaching and training has started in some regions across the country, however, a faster pace is required in places where facilities to train are already in place.

Once trained, these physicians will need an environment that promotes health, where the provision of facilities for managing chronic conditions, dealing with acute/emergency problems, essential medications and services for multi-disciplinary approach are within easy reach. Sharing responsibilities with public sector through public-private partnerships in health service delivery can help achieve better coverage.

In conclusion, the time to act is now. Great opportunities don’t come every day; one should recognise and seize them. Integrating family medicine programmes into national health policies and developing a cadre to incorporate general practitioners and trained family physicians in health system will certainly give a head start to the discipline.

The re-designing and reforming of primary care is needed. It is even more important that training is made mandatory in all post-graduate qualifications, particularly the general practice (family medicine).

In the backdrop of a severe deficiency of faculty, the sustainability of discipline heavily relies on training of their post-graduates.

Dr Hina Jawaid is an assistant professor in family medicine at the University of Health Sciences, Lahore and Dr Abdul Jalil Khan is an assistant professor in family medicine at the Khyber Medical University, Peshawar

The way to universal health coverage