Making Pakistani Primary Care More Resilient
Authors: Hina Jawaid , Abdul Jalil Khan
Corresponding Auhtor: Hina Jawaid (firstname.lastname@example.org)
All articles are published under the Creative Commons Attribution License
Primary Care Physicians (PCPs) or Family Physicians (FPs) also called General Physicians (GPs) are the first port of call or entry point in the healthcare system. It is established through evidence that regions with functioning and well-organised primary care systems have better health outcomes. One of the components of primary care is disease prevention which is associated with reduced mortality, morbidity, and overall betterimproved health. Countries with a higher proportion of PCPs in the population have reduced all-cause mortality ratios across various age groups .
To have a better understanding of the existing primary healthcare system let’s answer these questions. Why is primary care important? Why is it underutilized in our country? Why the imbalance exists? Is the discipline of family medicine or general practice recognised? Are we producing trained primary care physicians to strengthen our country’s primary care system?
In Pakistan, Primary Healthcare (PHC) facilities are either not accessible or have limited resources. Catchment areas or populations for primary healthcare facilities are not well defined either. Hand-held notes or files exist but are not well maintained. Electronic records are found in only a limited number of health facilities in the public and private sectors. Disease registry including the cancer registry at the national level is also lacking. People prefer attending secondary or tertiary healthcare facilities as they have lost trust in the primary healthcare system. This has led to increased disease burden on secondary and tertiary hospitals, late identification and detection of several conditions including non-communicable diseases (NCDs), and eventually poor disease prognosis. With no integration of health services, coordination between primary care physicians and referring specialties, or a framework of referral system existing between primary, secondary, and tertiary healthcare facilities the continuity of care cannot be accomplished. Furthermore, inequity in access to health care services due to the paucity of essential health service packages particularly among rural & suburban populations results in higher mortality and morbidity rates in deprived populations. More funding and investments are diverted towards secondary and tertiary care as the center of focus is mainly curative services. Considering the huge burden of diseases, emphasis on preventive services integration into the existing healthcare system is the need of time. Noncommunicable diseases, mental health care, and care of elderly patients at home or nursing homes must be included in the essential healthcare service package. Primary care physicians must be trained in line with the health needs of local communities and local resources. PHC doctors are mainly non-specialists, with limited or no training as primary care physicians. The concept of trained PCPs/family physicians and recognition of Family Medicine as a specialty must happen. Currently, undergraduate medical students are only exposed to tertiary hospitals. Both undergraduate and postgraduate training in this specialty must be promoted alongside creating posts/ job opportunities to encourage new graduates to take up family medicine as a career .
It would be imprudent not to consider investing in primary care as significant savings can be achieved. Regions where the primary care system is resilient management of non-communicable diseases like cardiovascular conditions, high blood pressure diabetes etc. and prevention and early identification of communicable diseases like hepatitis, tuberculosis, and human immunodeficiency virus (HIV) etc. can be cost-effective. In addition to early recognition of diseases including cancers, and prevention of communicable and noncommunicable diseases (CDs, NCDs) a comprehensive primary care system offers a wide range of services like family planning, immunizations, initial management of acute conditions, cancer screening, antenatal care, new-born examination, 6 weeks check, and screening. It is clear that such measures help reduce health inequality and the outcome is an overall improvement in quality of care. Pakistan is a low-middle-income country with limited resources, and PCPs must act as the gatekeepers of the healthcare system. The concept of the family practice approach has also been supported by the World Health Organisation (WHO). In addition to providing care PCPs also act as health advocates and form the integral component of a country’s health care system.
A study conducted in a peri-urban area of Karachi with over 4000 eligible women concluded that a communitybased family planning counselling program can have a short-term impact on the use of contraceptive methods . Contraception counselling by primary care physicians can help promote the long-term and sustainable use of contraceptive methods. This in turn can have an impact on managing overpopulation issues.
As per WHO’s recommendations, 3 trained PCPs/family physicians are required for the 10,000 population . With the current paucity of trained family physicians, the implementation of a family practice approach cannot be achieved. In a country of 220 million population, approximately 70,000 trained primary care physicians are required. One way to achieve this is through a bridging programme. Such courses ensure the capacity building of PCPs based in both the public and private sectors. Several institutions (universities and degree awarding bodies) across Pakistan are currently offering such capacity-building programmes, some of them are conducting these courses in collaboration with WHO. Revamping of primary care through PCP’s education and training has started recently and efforts to build on is taking place.
There is a huge hiatus in health facilities currently offered in urban and rural parts of Pakistan. All cadres of healthcare workers like doctors, dentists, and paramedics are massively deficient in rural areas. This has resulted in higher maternal mortality in the antenatal and postnatal period, neonatal and infant mortality rates, poor screening of congenital conditions, etc.
We must learn from other countries in South Asia like SriLanka, Iran, and Nepal where family medicine is considered a specialty. Evidence from these countries suggests that primary care services provided by their trained PCPs have supported their existing healthcare system and led to improvement in the quality of healthcare.
A well-organised primary care health system integration into the existing health system is crucial. Supporting the privileged population through Sehat Sahulat programmes and establishing posts/ cadre for trained family physicians in PHC will certainly give the primary care system a boost. Awareness and education of the masses regarding risk factors for various communicable and non-communicable diseases can be effectively achieved through primary care. Another important thing to recognise when offering an essential package of health services is that a team of trained family physicians is required. In the family practice approach, it is the physician’s responsibility to prescribe medications including antibiotics appropriately. Such measures are important to address emerging current antimicrobial resistance and promote guidelines-based prescribing.
Strengthening primary care through multi-pronged and evidence-based strategies must be considered.
Incentives must be provided for family medicine training for PHC physicians. Such training must be made mandatory for practicing as PCP in public-sector and private-sector healthcare facilities. Keeping in mind the shortage of trained PCPs planning to re-designing and reforming of primary care is urgently required. One option could be a public-private partnership; however, the service should be family physicians’ lead, either by capitation model or fee for service.
Both federal and provincial health departments must be on board, and a clear vision and implementation strategies to overcome barriers to accomplish a wellorganised primary care system must be set in motion.
List of Abbreviations
- PCP – Primary Care Physician
- FP – Family Physician
- GP – General Practitioner
- CD – Communicable Disease
- NCD – Non-communicable Disease
- WHO – World Health Organisation
- PHC – Primary Health Care
- HIV – Human Immunodeficiency Virus
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