Raising awareness about family medicine as a speciality with solutions for health care in Pakistan

APHCP Talks at Peshawar February 2016

An article reviewing our recent awareness talks by Dr. Sajad Ahmad MRCGP

On the 11th and 12th of February a group of us from the association visited Peshawar in Pakistan to deliver talks at two Medical Universities, the talks were culmination of a planned meeting held in January 2016 when it was decided between the members executive committee to do more in raising awareness about Family Medicine.Below is the account of the two days in February 2016.

11th – 12th of February 2016 
We arrived at Gandhara University, the venue of our first talk, this was the first time many of us were coming to the city as guests of an institution, of course, the entire project had been self-funded by the members, but simply being present among our teachers, delivering a talk about a subject that many in the country have little understanding about was a daunting task, we had managed to review each other presentations and made appropriate changes to slides after suggestions and group discussion, I had just landed in Peshawar the day before my first talk. we had a second talk planned at Khyber Medical College, this was going to be an exciting prospect, nerve-wracking at the same time.

Aims 
A variant of Family Medicine is practiced in Pakistan, but due to no compulsory  higher qualifications  in the subject the standards can vary, (1) It was only  in 2006 when United Kingdom took the path of compulsory MRCGP for all General Practitioners (GPs) (2)
We as an association believe that the family medicine should be promoted in Pakistan as it has the capacity as a specialty to be part of the solution to the ailing health care in Pakistan, as has already been proven by certain Middle Eastern countries recently.

We decided on delivering talks in medical universities to help raise the profile of family medicine and to create awareness among the students, this also allowed us to collect some basic information about their understanding after the talks through an online survey which was sent to more than 140 students.
Simple questions were asked about their awareness about the specialty and their likelihood of choosing family medicine as a specialty

Our talk was divided into three parts, 

First, “The Story” was meant to concentrate on three aspects, it began as an ice breaker for the students, sharing our own experiences and time when we were students in the same place more than a decade ago, I then concentrated on telling them what a life of a GP is like in the U.K, the variety, the challenges and the way we split our days, in the third part I concentrated on the history of NHS (3) and RCGP (4)

The second presentation “Why Primary Care” was delivered by Dr. A Jalil Khan, one of our Fellows, he concentrated on the background of WHO statement and understanding the need for primary care, the Hippocratic oath which has been beautifully adapted by Family Physicians the world over. The current model of Primary care in Pakistan was discussed in some detail, together with is the implementation of a western model possible in our country, we only have to look at countries in the Middle East to take an example, these are the ones which have embraced the speciality with open arms and are actively recruiting Family Medicine Consultants from the western hemisphere to improve the delivery of care for themselves

The third presentation “The Future of Family Medicine” was delivered by Dr. Moeen Ashraf, who’s aim was to review the current model of training that is offered across the developed world. Countries such as U.S.A, U.K, and Australian models of training in Family Medicine were discussed. Dr. Ashraf also discussed what is currently available in Pakistan in regards to the availability of training. The sparsity of training available in family medicine is indeed a cause for concern. Currently, only four universities are offering training and FCPS exam on the subject. None offer training in Khyber Pakhtunkhwa and Baluchistan.

Observations
Pakistan has a lot of potential for improvement, this is evident from the enthusiasm of the students and the warm welcome that we received from Mr. Ghulam Noorani Sethi, Dr. Abdus Salam (VC) of Gandhara University, Dr. Ejaz Hassan Khan (Principal / Dean), Dr. Mohsin Shafi and the Social Welfare Society of Khyber Medical College.

Both the students and the staff were keen to welcome the idea of delivering talks to raise awareness of family medicine. we firmly believe that Pakistan as a country can greatly benefit from an organized family medicine specialty which will deliver health care to millions of its citizens through adequate health promotion and continuity of care, this will eventually trickle down to secondary and tertiary level hospitals where the overwhelming crowds can be better managed.

The specialty requires trained clinicians, appropriately trained in the specialty through rotations and gaining Membership or Fellowship examinations, in the end, only then we will benefit from such a model, it is with these trained clinicians that we as leaders will be able to provide high-quality care and improve the livelihood of our citizens.

Many articles reviews have been written in support of family medicine being the torch bearer of health care, it is the only specialty that can cope with the changing demographics and the population boom, it is the only specialty that can keep the costs controlled (5)

Conclusion
Pakistani medical universities could benefit immensely from promoting a department of family medicine in their curriculum. A circular already exists in support of this from PMDC(6)

We had a very positive response from the students with 10% admitting to having had some knowledge about the specialty before the talk. to the question; How likely were you to choose Family Medicine as a Specialty before? 50% answered extremely unlikely before the talk.

We believe the creating of a family medicine department would ensure an interest from the students, and an approved training program would provide highly trained clinicians to rescue an ailing health system that is totally reliant on the secondary care at present.
The government needs to revitalize the Basic Health Units and Rural Health Units on a British model of primary health care.

The doctors need to be given incentives to specialise and to be part of the primary healthcare as is the case in the developed countries (7-8), this will ensure the provision of health care to all while at the same time bring in competitions between health centers to improve their quality of care. We are well aware of the differences in quality of care in different demographics, financial incentives for doctors are also a factor in the deficiency of provision health care (9). This can be only be addressed at a government level with some suggestions that have been mentioned above.

References
1.
Sabzwari SR. The case for family medicine in Pakistan. JPMA The Journal of the Pakistan Medical Association. 2015;65(6):660-4.
2. Riley B. The New MRCGP—What’s it All about? InnovAiT: The RCGP Journal for Associates in Training. 2008;1(1):49-52.
3. Webster C. The national health service: A political history: Oxford University Press, USA; 2002.
4. Fry J, Pinsent RJFH. A history of the Royal College of General Practitioners: the first 25 years: Springer Science & Business Media; 2012.
5. Committee FoFMPL. The future of family medicine: a collaborative project of the family medicine community. The Annals of Family Medicine. 2004;2(suppl 1):S3-S32.
6. Qidwai W. Family Medicine Made Compulsory Subject in MBBS Program: Implications for Health Care in Pakistan and the Region. Annals of Abbasi Shaheed Hospital & Karachi Medical & Dental College. 2015;20(1).
7. Benson T. Why general practitioners use computers and hospital doctors do not—Part 1: incentives. Bmj. 2002;325(7372):1086-9.
8. Shekelle P. New contract for general practitioners. British Medical Journal. 2003;326(7387):457.
9. Farooq U, Ghaffar A, Narru IA, Khan D, Irshad R. Doctors’ perception about staying in or leaving rural health facilities in district Abbottabad. J Ayub Med Coll. 2004;16:64-9.

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The case for family Medicine

An article by : Saniya Raghib Sabzwari

Abstract

The specialty of Family Medicine enjoys a special position in the medical practice of the West, serving as one of the key primary care specialties. Family physicians act as providers of first contact catering to the medical needs of the entire family in all aspects of preventive, curative and rehabilitative stages of illness and to health maintenance. The growth of this specialty, however, has lagged behind in Pakistan for various reasons. Having both a high burden of communicable and non-communicable diseases in Pakistan; family physicians should form the frontline force in dealing with these health issues.
Several success stories of Family Medicine forming the base of medical services have been noted, validating its presence and propagation. The World Health Organisation also supported this in its 2008 report that discusses primary care for all. Growth of family practice needs to be encouraged at both undergraduate and postgraduate levels to ensure adequate training and provision of quality of medical care to our society. The need of the hour is that both medical institutions and the government develop policies to strengthen Family Medicine and incentivise family practice in rural and urban settings to cater to the needs of society at large.

Read the full article here

Family Medicine Made Compulsory Subject in MBBS Program: Implications for Health Care in Pakistan and the Region

By Waris Qidwai
Abstract
Family Medicine is an emerging specialty that offers cost effective, frontline, and comprehensive health care services. It is considered mandatory for the success of any health care delivery system.
Pakistan Medical and Dental Council has taken the courageous step, mandating all medical colleges in Pakistan to have department of Family Medicine and an examination paper on Family Medicine in Final year MBBS program. Repercussions of this PMDC directive will have far reaching and favorable impact on health care delivery and services in Pakistan. PMDC has placed Pakistan in the forefront in healthcare reform in the region and now it is up to all stakeholders to enforce PMDC directive in true letter and spirit.
Keywords: Family practice, General practice, Family physicians, undergraduate medical education.
(ASH & KMDC 20(1):85;2015).

Read the full paper here

The Barefoot Doctors of China

Primary health care may feel like a luxury and domain of the western society, but in fact the concept was seen in early china when an attempt was made to provide care to millions of people in the Chinese people’s republic,

The initial plans were laid out in 1930s as part of the rural construction movement which in it self was born in the 1920s

China had suffered from lack of a uniform infrastructure for years, and with the lack of a uniform provision of health care the rural villages were not the ideal places for a doctor to settle, a situation we still see in many developing nations today, with Pakistan not being an exception.

The barefoot doctors were village farmers who in most cases after finishing school would receive a 6 months of less training in local hospitals and would then settle in the rural areas to provide basic health care, the system took hold due to the lack of availability of doctors from the urban areas who were willing enough to settle in rural China

In 1965 after a speech by chairman Mao the system was developed and institutionalized.

Barefoot doctors acted as a primary health-care provider at the grass-roots level. They were given a set of medicines, both Western and Chinese, that they would dispense. Often they grew their own herbs in the backyard. As Mao had called for, they tried to integrate both Western and Chinese medicine, like acupuncture and moxibustion. An important feature was that they were still involved in farm work, often spending as much as 50% of their time on this – this meant that the rural farmers perceived them as peers and respected their advice more. They were integrated into a system where they could refer seriously ill people to township and county hospitals.

Two-thirds of the village doctors currently practicing in rural China began their training as barefoot doctors.[1] This includes Chen Zhu, China’s former Minister of Health, who practiced as a barefoot doctor for five years before going on to receive additional training.[1]

The barefoot doctor system was abolished in 1981 with the end of the commune system of agricultural cooperatives. By 1984, village RCMS coverage had dropped from 90% to 4.8%.[2] In 1989 the Chinese government tried to restore a cooperative health care system in the rural provinces by launching a nationwide primary health care program.[2] This effort increased coverage up to 10% by 1993.[2] In 1994 the government established “The Program”, which was an effort to reestablish primary health care coverage for the rural population.[2]

[1] Watts, Jonathan (2008). “Chen Zhu: From Barefoot Doctor to China’s Minister of Health”. The Lancet 372 (9648): 1455. doi:10.1016/S0140-6736(08)61561-5. PMID 18930519

[2] Carrin, Guy; et al. (1999). “The Reform of the Rural Cooperative Medical System in the People’s Republic of China: Interim Experience in 14 Pilot Countries”. Social Science & Medicine 48 (7): 961–967. doi:10.1016/S0277-9536(98)00396-7. PMID 10192562

Prescription Patterns of General Practitioners in Peshawar, Pakistan

Abstract

Objectives: To find out prescription patterns of general practitioners in Peshawar.

Methods: Cross-sectional survey of drug prescriptions was done at six major hospitals and pharmacies of Peshawar between April and May 2011. A total of 1097 prescriptions that included 3640 drugs, were analyzed to assess completeness, average number of drugs, prescription frequency of various drug classes, and number of brands prescribed.

Results: No prescription contained all essential components of a prescription. Legibility was poor in 58.5% prescriptions. Physician’s name and registration number were not mentioned in 89% and 98.2% prescriptions respectively. Over 78% prescriptions did not have diagnosis or indication mentioned. Dosage, duration of use, signature of physician and directions for taking drugs were not written in 63.8%, 55.4%, 18.5% and 10.9% of prescriptions respectively. On average each prescription included 3.32 drugs. Most frequently prescribed drug classes included analgesics (61.7%), anti-infective agents (57.2%), multi-vitamins (37.8%) and gastrointestinal drugs (34.4%). We found 206, 130, 105 and 101 different brands of anti-infective agents, gastrointestinal drugs, analgesics and multivitamins being prescribed.

Conclusion: We observed a high number of average drugs per prescription mostly using brand names, and over-prescription of analgesics, antimicrobials, multivitamins and anti-ulcer drugs. Quality of written prescriptions was poor in terms of completeness.

Key Words: General practitioner, Prescription, Polypharmacy

Click the link below to read the full paper

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4048486/

KPK Govt National Programme for Family Planning and Primary Health Care

 All data taken from KPK Health Dept Website

NATIONAL PROGRAMME FOR FP AND PHC

 

 

The National Programme for FP and PHC was launched in NWFP in mid 1994 with the aim to provide PHC and FP services to the community at their door steps by training and deploying 100,000 LHWs in the country and 15909 LHWs in NWFP in phased manner.

 

AIMS AND OBJECTIVES

 

  • To develop the necessary health manpower in support of the Programme by selection, training and deployment of 100,000 LHWs throughout the country
  • To address the primary health care problems in the community, providing promotive, preventive, curative and appropriate rehabilitative services to which the entire population has effective access.
  • To bring about community participation through creation of awareness, changing of attitudes, organization and mobilization of support.
  • To expand the family planning services availability in urban slums and rural areas of Pakistan.

 

TOTAL COST OF THE PROGRAMME

 

  • ADP (It is federally Funded and not on provincial ADP)                             Nil
  • Cost of the programme                                                                                        21533.5 M
  • Cost of programme including (RHP)                                                 22460.6 M
  • Year wise breakdown of cost of NWFP chapter of NP for FP&PHC

(Excluding purchase of Medicine, Vehicle, Printing, Media Campaign)

 

03-04 (M) 04-05 (M) 05-06 (M) 06-07 (M) 07-08 (M) Total
208.892 320.197 423.426 449.457 463.019 1864.99 million

 


DURATION

 

Period of the Programme                                     2003-2008

(Program has been extended till Jun. 2009)

 

THE STATUS OF THE PROGRAMME IN NWFP

 

The detailed breakup of the present status of the programme in NWFP as on 31st October 2008 is as below:

 

S.#   Status
1 Number of Districts 24
2 Districts involved in Programme 24
3 Population Covered by LHWs (Target) 63%
4 No. of Health Facilities involved 729
5 Presently Working LHWs 12953
6 Under Training LHWs 0
7 No. of LHWs Supervisors 529
8 Drivers 443

 

LHWs Selected during year 2007-2008             =              636

LHSs Selected during year 2007-2008               =              61

 

ACHIEVEMENT OF THE PROGRAMME SO FAR

 

  • Starting of National Program in district Kohistan.
  • Women empowerment by creating 15909 job opportunities in NWFP.
  • Financial Management trainings carried out for EDOs (Health), DCNPs and Account Supervisors.
  • Organizing one month course for DCNPs on Primary Health Care and Health System Development at Aga Khan University Karachi.
  • 63% of the population of NWFP is covered by LHWs.
  • Training of LHWs to give routine EPI vaccination in seven Phase-I districts.
  • LHWs have been actively involved in EPI activities, DOTs, nutrition activities such as promotion of breast feeding and iodized salt.
  • LHWs carry out AFP surveillance for detection of polio cases and provision of vitamin A to approx. 16 million children during NIDs.
  • Training of LHWs in Community IMCI (Child Health).
  • Successful conduction of Maternal Mortality Conference (MMC) at the provincial level.
  • Successful conduction of Child Health and Sanitation Week at District Mardan.
  • Safe Motherhood activities including promotion of antenatal care, clean delivery practices and post natal care.
  • As assessment done by FPIU of all the Provincial PIUs, RPIUs and ICT, the PPIU NWFP was ranked on the Top which was also appreciated by Secretary to Govt. of NWFP vide letter No. 6-165/ECO/PC/H/ Vol-IV/2005-06 Dated 07-11-2006.
  • PPIU NWFP is ranked 1st on the basis of performance among 4 provinces and 4 regions of the country in the last annual review meeting of Provincial Coordinators held in 2007 at Federal PIU, Islamabad.
  • In the recently conducted FPOs survey, NWFP is considered on Top among other provinces and regions.
  • Active involvement of National Program staff in the relief activities during natural calamities.
  • FUTURE VISION
  • To achieve the target allocation of 15909 LHWs in NWFP, recruitment of 2956 LHWs during 2008-2009 is under process.

PhD a must for principal, dean of medical colleges

ISLAMABAD: Although faculty members who do not have PhDs or equivalent degrees have previously been appointed professors, the Pakistan Medical and Dental Council (PMDC) has now decided that a PhD degree is a must for faculty members to be promoted to professors.

Following this decision, only faculty members possessing PhDs or Fellowship of the College of Physicians and Surgeons (FCPS) will be appointed vice chancellor, principal or dean of a medical college. Associate professors who do not possess PhDs or equivalent degrees will retire as associate professors.

Content-play

The decision was taken by the council’s management committee to ensure high quality education and meet international standards.

The current management committee was formed after President Mamnoon Hussain promulgated the Pakistan Medical and Dental Council (Amendment) Ordinance 2015 on Aug 26, dissolving the PMDC executive council.

‘Decision will ensure education of international standards’
The committee consists of retired Maj Gen Azhar Kiyani, Prof Abid Farooqi, Prof Nadeem Rizvi, and others. The committee was advised to hold executive council elections within 120 days.

On Dec 11, the national health services (NHS) minister tabled the draft of the bill on the floor of the National Assembly, and the ordinance was extended for another 120 days through a resolution. The management committee has been taking measures to ensure quality education and that Pakistani doctors are able to compete with doctors at the international level.

A PMDC official who is not authorised to speak on record said in the past a special qualification was not required to promote an associate professor to professor.

“There are a few hundred faculty members with just MPhil degrees teaching at different medical colleges who were promoted to professors in the past. The majority of them are teaching social sciences,” the official said.

“It has been decided that, in the future, no faculty members will be promoted to professor without having a PhD or equivalent degree. However, the status of those professors who do not have PhD degrees but have already been promoted to professor will not be changed,” he said.

The official said that the committee had also decided to promote the family medicine faculty in colleges.

“Family medicine is introduced in developed countries like UK, US, Austrial – so a department of family medicine will be established in every university,” he said.

PMDC registrar retired Brig Dr Hafizuddin Ahmed Siddiqui confirmed that the management committee had decided that only PhD-holding faculty would be promoted to professor.

“Moreover, we have decided to encourage family physicians… So universities are being advised to establish departments of family medicine,” he said.

Published in Dawn, December 25th, 2015