Implementation of a family practice-based model of primary healthcare requires not just well-trained family physicians but also other healthcare staff
on-communicable diseases (NCDs), such as cardiovascular diseases, mental illnesses, diabetes, chronic obstructive pulmonary diseases and cancers, account for 80 percent of global burden of disease and 70 percent of deaths. Just over two-third (77 percent) of the NCD deaths occur in low- and middle-income countries.
This raises questions about NCD related health services in these countries. Let’s have a look at diabetes, a common NCD. With one in four adults living with diabetes, Pakistan has the highest diabetes prevalence in the world. According to the International Diabetes Federation, diabetes was responsible for 400,000 deaths in Pakistan in 2021.
Was a strengthening of capacity-building efforts for the primary healthcare team considered? Was a lack of provider and community awareness and knowledge about risk factors like obesity, unhealthy diets, smoking, physical inactivity leading to higher mortality due to NCDs identified? Was early primary care physician contact ensured?
Primary care physicians (general practitioners or family physicians) serve as an entry point for patient’s healthcare needs. They have considerable influence on patient’s healthcare choices. It is not the mere presence of these physicians but their formal/ structured training with incorporation of community perspective into their clinical practice that can lead to better outcomes through effective care provision.
Looking at the current practices of these physicians, new ways have to be developed to deal with the increasing burden of diseases effectively. Broad as well as specific approaches have to be identified for primary care physicians. Considering the wide range of responsibilities, a primary care physician undertakes, perhaps it is time for a reprioritisation in the health sector.
Currently there are huge variations in the clinical services provided by primary care physicians in low- and middle- income countries. The physicians have to deal predominantly with rural populations where literacy levels are low. Disease management is mainly pharmacological.
Given minimal to zero non-pharmacological management and no screening or prevention, lack of medication availability makes the working conditions in primary care very challenging. Another stumbling block is the unavailability of posts for family medicine consultants in the public sector. Imagine promoting this discipline and providing training to post graduates under such circumstances.
A number of questions arise here. What are the factors that compromise the ability of physicians to deliver services? How can primary care be streamlined and standardised? How is the training of general physicians different from other specialties? What does family medicine teach in addition to what is being taught by other specialities?
Education and Training needs of the family practice team, including the lady health worker (LHW), the family practice nurses, and family physicians need to be identified and incorporated in the curriculum. It is important that all job descriptions are carefully developed.
How do we define standards in general practice? How does a practicing physician maintain standards? What are the ways to develop professional post training i.e., be adequately skilled and competent? Is any regulatory body ensuring that the standards are maintained? Are there mechanisms to escalate concerns relating to learner or patient safety?
In order to answer these questions, we need to go back to the essential principles, i.e., access to basic minimum health services for the population, the availability of which is only possible through trained primary care physicians.
Attention must be given to family medicine at both undergraduate (medical students) and post graduate (residents) levels. Trainings must be appropriate. In terms of medical education, the “does” domain of Miller’s triangle needs considerably focusing on. Clinical observation tools must be included in workplace-based assessments for primary care physicians.
A curriculum specifically designed for primary care physicians has been developed and implemented in nine universities across Pakistan. Grants should be given to medical colleges and universities to promote primary care. The World Health Organisation Regional Office of Eastern Mediterranean (WHO-EMRO) has developed a regional professional diploma programme that has already been endorsed by family medicine experts in Pakistan.
The programme has a blended learning approach to respond to busy clinicians’ needs and provides them maximum opportunity to learn in their home environment with some face to face, on-site training sessions. Nine universities across the country have already signed a memorandum of understanding (MoU) to start this programme. It has been started in Khyber Medical University, Peshawar; University of Health Sciences, Lahore; Health Services Academy, Islamabad; Rawalpindi Medical University, Rawalpindi; and Jinnah Sindh Medical University, Karachi.
The Ministry of National Health Services Regulations & Coordination (MoNHSR&C) needs to facilitate the process and encourage other universities to start the programme soon to ensure that all doctors working in primary care, including private general physicians, are trained.
Implementation of family practice-based model of comprehensive primary healthcare requires not just well-trained family physicians but also other healthcare staff. The Essential Package of Health Services for Islamabad Capital Territory has identified a list of family practice team to deliver health services at the community, basic health unit, community health centre and rural health centre levels.
Education and training needs of the family practice team, including the lady health worker, family practice nurses and family physicians need to be identified and incorporated in the curriculum. It is important that all job descriptions are carefully developed and they are provided adequate education and training to function effectively.
In short, for a successful health insurance model, there is a need for developing a referral system with integration of all levels of healthcare. This requires trained family physicians who not only provide gatekeeping role but also continuity of care by following up in community and provide ongoing care.
Dr Hina Jawaid is an assistant professor in family medicine at the University of Health Sciences, Lahore
Dr Abdul Jalil Khan is an assistant professor in family medicine at Khyber Medical University, Peshawar