Non-communicable diseases (NCDs), such as cardiovascular diseases, mental illnesses, diabetes, chronic obstructive pulmonary diseases and cancers, account for 80% of the global burden of disease and 70% of deaths. Just over two-thirds (77%) of NCD deaths occur in low- and middle-income countries.
This raises questions about NCD-related health services in these countries. Let’s take a look at diabetes, a common NCD. With one in four adults living with diabetes, Pakistan has the highest prevalence of diabetes in the world. According to the International Diabetes Federation, diabetes was responsible for 400,000 deaths in Pakistan in 2021.
Have enhanced capacity building efforts for the primary health care team been considered? Has a lack of provider and community awareness and knowledge of risk factors such as obesity, unhealthy diets, smoking, physical inactivity resulting in higher mortality from NCDs been identified? Was early contact with a primary care physician ensured?
Primary care physicians (general practitioners or family physicians) serve as the entry point for patient health needs. They have a considerable influence on patients’ health choices. It is not the mere presence of these physicians, but their formal/structured training with the integration of the community perspective into their clinical practice that can lead to better outcomes through effective care delivery.
Looking at the current practices of these physicians, new ways must be developed to effectively deal with the growing disease burden. Broad and specific approaches should be identified for primary care physicians. Given the wide range of responsibilities that a primary care physician undertakes, it may be time to reprioritize the healthcare industry.
Currently, there are huge variations in the clinical services provided by primary care physicians in low- and middle-income countries. Physicians must deal primarily with rural populations where literacy levels are low. The management of the disease is mainly pharmacological.
Given minimal to zero non-pharmacological care and the absence of screening or prevention, the lack of availability of drugs makes working conditions in primary care very difficult. Another stumbling block is the unavailability of family medicine consultant positions in the public sector. Imagine the promotion of this discipline and the training of postgraduate graduates in such circumstances.
A number of questions arise here. What are the factors that compromise the ability of physicians to provide services? How to rationalize and standardize primary care? How does the training of general practitioners differ from other specialties? What does family medicine teach in addition to what is taught by other specialties?
The education and training needs of the family practice team, including the female health worker (LHW), family practice nurses, and family physicians should be identified and incorporated into the program. It is important that all job descriptions are carefully crafted.
How do we define standards in general practice? How does a medical practitioner maintain standards? What are the means of developing professional post-training that’s to say, be sufficiently qualified and competent? Is there a regulatory body that monitors compliance with standards? Are there mechanisms to escalate concerns about learner or patient safety?
To answer these questions, we must return to the essential principles, that’s to say, access to minimum basic health services for the population, the availability of which is only possible through trained primary care physicians.
Attention must be paid to family medicine both at the undergraduate (medical student) and postgraduate (resident) level. Training must be adapted. In terms of medical education, the “fact” area of Miller’s triangle deserves special attention. Clinical observation tools should be included in workplace assessments for primary care physicians.
A curriculum specifically designed for primary care physicians has been developed and implemented in nine universities in Pakistan. Grants should be given to medical schools and universities to promote primary care. The World Health Organization Regional Office for the Eastern Mediterranean (WHO-EMRO) has developed a regional professional degree program which has already been endorsed by family medicine experts in Pakistan.
The program has a blended learning approach to meet the needs of busy clinicians and provides them with maximum opportunities to learn in their home environment with face-to-face on-site training sessions. Nine universities across the country have already signed a Memorandum of Understanding (MoU) to start this program. It was started at Khyber Medical University, Peshawar; University of Health Sciences, Lahore; Academy of Health Services, Islamabad; Rawalpindi Medical University, Rawalpindi; and Jinnah Sindh Medical University, Karachi.
The Ministry of National Health Services Regulation and Coordination (MoNHSR&C) should facilitate the process and encourage other universities to launch the program soon to ensure that all doctors working in primary care, including doctors private generalists, are trained.
Implementing a comprehensive family practice-based primary health care model requires not only well-trained family physicians, but also other health personnel. The essential package of health services for the Islamabad Capital Territory has identified a list of family practice teams responsible for providing health services at the community, basic health unit, community health center and rural health center.
The education and training needs of the family practice team, including the female health worker, family practice nurses, and family physicians, should be identified and incorporated into the curriculum. It is important that all job descriptions are carefully crafted and receive adequate education and training to perform effectively.
In short, for a successful health insurance model, it is necessary to develop a referral system with integration of all levels of health care. This requires trained family physicians who not only provide a gatekeeper role, but also continuity of care by following up in the community and providing ongoing care.
Dr Hina Jawaid is Assistant Professor of Family Medicine at Lahore University of Health Sciences
Dr Abdul Jalil Khan is Assistant Professor of Family Medicine at Khyber Medical University, Peshawar