July 2017 News Updates

by Dr. Sajad Ahmad

It has been a while since I have written about any progress or new updates, a lot has been going on for the past six to eight months. We had an amazing July this year, more about that later.

At the end of last year, some of us started to engage with Khyber Medical University on how we could be of help in promoting Family Medicine. The interest had been mutual, a discussion of those few months saw the foundation of a separate panel on family medicine flourish at Khyber Medical University’s 8th Annual Health and Research Conference held on the 25th of April 2017. Family Medicine was discussed in detail by the secretary of health and options and discussion surrounding its promotion, trailing health centers, as well as the training of future family physicians, was discussed in detail.

Many insights were discussed in the panel dedicated specifically to Family Medicine by our Dr. Asma Kazmi representing APHCP.

The momentum from this did carry on, slow and steady, but this resulted in the formation of a focus group. Participation was encouraged from all over Pakistan with Ayub Medical College (Abottabad), Shifa (Islamabad), Fatima Memorial, University of Health Sciences (Lahore), Agha Khan University (Karachi) as well as the unflinching support of the World Health Organisation EMRO has been a key to the progress so far. It has been a great honor and privilege for APHCP to be a part of this team and help shape the future of Family Medicine in Pakistan.

The discussions from the initial focus group and after exchanging ideas and discussion in hundreds of emails in countless chains and telephone calls we flew to Pakistan in early July to participate in a two-day consultatory workshop held by Khyber Medical University under the auspices of World Health Organisation. The two-day event was attended by participants from all the four provinces including representatives from Kashmir and Gilgit Baltistan.  The attendance of Health department has been the key in taking the proposals forward. Presented by Family Medicine academics, senior examiners, PMDC, Family Physicians from both within Pakistan and the United Kingdom had the opportunity to suggest a way forward for the future. The two-day consultation concluded with the formulation of a concept note, a list proposals for the health department to carry out.

It has been an enormous privilege to be part of the team to help in laying the foundation of this wonderful speciality in Pakistan. Although some elements of Family Medicine are present in scattered forms in other provinces, Khyber Pakhtunkhwa, Balochistan and Gilgit Baltistan in particular lacks a setup to towards training generalists doctors. This in-spite of the facts that Four Medical Training Institutes of the province are recognised for Membership of the  College of Physicians and Surgeons of Pakistan in Family Medicine.

I believe more can be achieved in Khyber Pakhtunkhwa,  I believe there is a lot of potential for change towards better primary health care while keeping the costs of providing service down, I believe we can train our doctors working in the basic health units and provide them with the skills of family medicine. I believe we, working together can create a structure of primary health care that will complement the subspecialties of medical care already in existence. To do this, we need ownership, for, without it, we would be lost.

 

 

 

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Primary Healthcare reforms in Pakistan.

by Dr. Sajad Ahmad,

Pakistan as a country needs to a lot more  to improve its healthcare. We have been raising the profile of family medicine together with a better system for the implementation of a modern primary healthcare. It is clear that to achieve the WHO millennium goals politicians need to come up with a clear exhaustive policy which needs to be followed through to the end.

You can read one of the articles I recently wrote for MEJFM here. You can also search for the article on google scholar.

Web linkhttp://www.mejfm.com/November%202016/Pakistan.htm

Citation : Ahmad S, Qidwai W. Primary health care reforms in Pakistan: A mandatory requirement for successful healthcare delivery. MIDDLE EAST JOURNAL OF FAMILY MEDICINE.;7(10).

 

APHCP Presents at Ayub Medical College – Abbottabad.

No matter how much we talk about the importance of modern primary health care, a concept of family medicine, it is nothing but a drop in the ocean. Many of us know that Family Medicine as a concept still needs to be nurtured in Pakistan. It was in the middle of the year we started planning our talk at Ayub Medical College at Abbottabad. A city named after Major James Abbott (1), It grew from a small district in January 1853 to the second largest city in Khyber Pukhtunkhwa Province of Pakistan. With a current population of above one million souls (2) many have come to this beautiful site, an existence in the foothills of Himalayas, doctors have often struggled to provide health care.

Primary health care like anywhere else in Pakistan is provided by multiple sources. Ranging from private providers to specialists often treating multiple specialties in their private clinics. However, it was the earthquake of 2005 that saw a major burden on the already over-stretched health care system in Abbottabad. Many volunteered from the west, Orthopedic specialists, General Surgeons, and even Physicians, but of great pride is the involvement of Family Physicians in a disaster situation (3).

Pakistan as a country desperately needs a better system of primary health care, it needs the concept of trained family physicians, generalists specializing in the generality of medicine. That, we believe should be the way forward.

It was natural for us to plan one of our talks in the second largest city in Khyber Pakhtunkhwa province after our talks in Peshawar earlier, this time, the venue was Ayub Medical College at Abbottabad, the city of pines as its lovingly known. The planning for the talk was the culmination of discussions with the Dean and Associate Dean of Ayub Medical College. The Associate Dean, Dr. Umer Farooq arranged and hosted the event.

On 21st September 2016 We arrived at Ayub Medical College, the venue of our talk. Presented by two of our core committee members Dr. Abdul Jalil Khan coming back to his alma mater and Dr. Moeen Ashraf.

We were very warmly welcomed by the team of Community Medicine Department.

“It was very emotional to meet my great teachers Professor Huma Jadoon (head of department), Professor Saleem Wazir, Dr Umer Farooq (Associate Dean, AMC), Professor Dilawar, Professor Nisar Sb and Professor Aziz-un-Nisa (Dean, AMC).” ~ Dr A Jalil Khan

The talk was attended by final year MBBS Students, House officers, Trainee Medical Officers and the faculty Members. It has been a source of great pride, as Dr. Jalil stated, “I was really pleased to see my class fellows and other fellow students now sitting in the faculty seats especially Dr. Aftab Khan, Dr. Owais Khan, Dr. Zeeshan and Dr. Inaam. I am really thankful to Dr. Yousaf Aziz (pediatric Surgeon in Kuwait) who also attended our talk”.

Our aims and objectives of these talks have always been to promote family medicine as a specialty. The discussion we have had so far with the health professionals in Pakistan has concluded that a comprehensive primary care may be one of the better solutions to improve the health care system in Pakistan. For primary health care to be promoted in any capacity would require funding, training of general practitioners is the core foundation of any modern primary health care system and is directly related to the funding it receives. We have seen first hand how the inequality in the health care budget and lack of prioritization have led to the sprawling of specialists hospitals. But the lack of investment in primary health care still burdens the same hospitals (4) which ironically were set up to cope with the disease burden in the first place.

The talk at Ayub.

It all began with a brainstorming session, a scenario we placed to the medical students, asking them to come up with ideas how to improve the health care system. The purpose for this was to let the audience think differently, by challenging the common perceptions , the ideas we already have ingrained in our subconscious. and then began the talk, delivered by Dr. Abdul Jalil Khan and Dr. Moeen Ashraf.

The first part of the talk, “The Story” was meant to share an experience of being transformed from a student at Ayub Medical College into a career GP and Family Physician in U.K. The life of a GP in United Kingdom’s National Health Service (NHS), the variety, the challenges and most importantly the trust of community in this speciality.

The second presentation which was the main theme of the talk “Family Medicine as specialty and it’s Future” was delivered by Dr. Moeen Ashraf. Here came the advice to the students on current models of training that is offered across the developed world especially U.S.A, U.K, and Australia. Dr. Ashraf also discussed what is currently available in Pakistan in regards to the availability of training.

The last part of the talk “Why Family Medicine” was delivered again by Dr. A Jalil Khan. It was concentrated on the importance of a comprehensive primary care and how we might adopt it in Pakistan.

The talk was concluded by the closing remarks from the Dean, Professor Aziz-un-Nisa who acknowledged the importance of a comprehensive primary care. She mentioned how the specialist outpatient clinics are overcrowded by patients presenting with primary care problems. She agreed that developing a family Medicine specialty will not only train future Family physicians but will also run the filter clinics and improve the triage system in tertiary Hospitals.

References: 

1. Wikipedia. James Abbott (Indian Army officer): Wikipedia; 2016 [cited 2016 14th October]. Available from: https://en.wikipedia.org/wiki/James_Abbott_(Indian_Army_officer).

2. Wikipedia. Abbottabad Web: Wikipedia 2016 [cited 2016 17th October]. Available from: https://en.wikipedia.org/wiki/Abbottabad.

3. Newmark J. A month as a GP in the earthquake area of Pakistan. British Journal of General Practice. 2006;56(524):224-5.

4. Ahmad S. Letter to the editor (How to extend GP training and improve urgently and emergency primary care). Br J Gen Pract. 2016.

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.

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