Challenges facing Family Medicine & UHC

Historically, the ancestor physicians were holistic doctors applying a patient-centred approach and implementing the concepts of family medicine while caring for their patients. However, with the development and the disintegration of medicine into various specialities and sub-specialities, such a concept was disoriented over time.
Although during recent years and since Alm Ata declaration numerous endeavours have been made in many countries to implement family medicine, such did not reach the expected goals. A considerable number of countries around the globe still do not believe in the concept of family medicine while few of the others who began it are still struggling with the rigorous shortage of qualified family doctors.
Realizing that family medicine should be the predicate of any health accommodation substratum and that fifty per cent of the working physicians in any country ought to be constituted from family doctors, we can visually perceive why the health of the nation in numerous developing countries is not reaching to the standard level. Such countries are not only suffering from the re-emergence of a few communicable diseases, but they do experience the ill effects of the outcomes of the high prevalence of non-communicable illnesses as well. Therefore, they are in extreme need of developing and applying family medicine.

1. Universal Health Coverage: Challenges Facing Family Medicine Prof Faisal Abdul l atif Alnas e r FPC , FRCGP, MICGP, FFPH, PhD Imperial College London, UK Chairman ; Home Health Care Centre General Secretary & Treasures; International Society for The History of Islamic Medicine Temp Advisor for WHO EMRo WONCA Direct Member Former Chair; Dept. Of Family & Community Medicine Former P resident; Scientific Council Family & Com. Medicine Arabian Gulf University Former President Family & Community Medicine Council. Arab Board for Health Specializations Faisal Alnasir 2018 1

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4. Faisal Alnasir 2018 4 Famine: Over 17 million of Yemen's population are at risk UN Food relieve agency 2017

5. 5 400 million people do not have access to essential health services. 6% of people in low- and middle-income countries are pushed further into extreme poverty because of health spending. WHO and World Bank Group Faisal Alnasir 2018

6. NCD epidemic Leading to serious implications and a negative impact on socioeconomic development. Kill 41 million people/year (37% of them before the age of 60). (It consist of 70% of all deaths worldwide) The anticipated deaths will increase to 52 million in 2030. World Health Organization, 2018 6 Faisal Alnasir 201 The prevalence is 26 % affecting 125 million individuals.

7. 7 Prevalence of overweight and obesity in EMR countries ( WHO.2004) Overweight + obesity (%) Country Females Males 70.0 64.0 Saudi Arabia 53.0 60.0 Lebanon 67.7 57.0 Islamic Republic of Iran 79.0 56.4 Bahrain 56 79 Kuwait 41.0 43.8 Egypt 74.9 42.5 Libyan Arab Jamahiriya 43.5 40.5 Oman 21.7 37.2 Morocco 39.9 25.5 United Arab Emirates 43.7 46.0 Jordan 41.9 13.1 Tunisia Faisal Alnasir 2018

8. 8 In EMR: Maternal mortality rate remains high . With 350 maternal deaths occurring per 100 000 live births. (Maternal mortality in Somalia and Afghanistan among the highest in the world). Regional Committee for the EMR September 2008 Faisal Alnasir 2018

9. 9 Ageing population: The prevalence of people above the age of 60 is increasing in the developing countries while almost stable in the developed world. In Bahrain the anticipated percentage will reach to 15% by the year 2025 and 25% by the year 2050. Alnasir, 2011 Faisal Alnasir 2018 World Population Prospects – 2017 Revision

10. 10 Insufficient Health Workers: Low and lower-middle income countries need 18 million more health workers if they are to achieve UHC. Marie- Paule Kieny ,  WHO Assistant Director-General, 2016  Faisal Alnasir 2018

11. Faisal Alnasir 2018 11 Doctors’ Shortage is an invisible problem CNBC 2015 The doctor shortage is real Association of American Medical Colleges(AAMC) The USA nation’s shortage of doctors will rise to between 46,000 and 90,000 by 2025 Forbes March 2015 It is estimated that between 12,500 and 31,000 Primary Care Doctors will be needed in the USA Association of American Medical Colleges(AAMC)

12. Faisal Alnasir 2018 12 More than million people are registered with a GP serving more than 3,000 patients (almost twice the average list size of 1,600). Rowena Mason , The telegraph December 2011 England has 25,000 FDs. But there are growing concerns that the NHS faces a retirement crisis. One in eight GPs is planning to retire within two years. Survey by the British Medical Association published in June 2011 , In UK

13. What is the Ideal Health System? Faisal Alnasir 2018 13 Is the one that: “ Secure the Health of the Whole Population ” WHO C Centre, Imperial College London

14. Improve Health Responsiveness to needs Financial Protection And its Goals: WHO C Centre, Imperial College London Faisal Alnasir 2018 14

15. Faisal Alnasir 2018 15 UK: NHS on the 5 th November 2018 to change the health system strategy from curative to preventive And allocated 20 billion sterling pounds for that purpose.

16. Faisal Alnasir 2018 16 Expansion of universal health coverage in the EMRo Region is critical Health cost in the Arab World will rise to 60 Billion within 10 years WHO

17. 17 Comprehensive and not disintegrated Health coverage:   Faisal Alnasir 2018 Family Medicine

18. Universal Health Coverage Will not only improve the health of millions, but will also contribute to reaching many of the other Sustainable Development Goals (SDGs). Marie- Paule Kieny ,  WHO Assistant Director-General,2016 Faisal Alnasir 2018 18 By A Well Trained Family Physician

19. Family Medicine is not new. Ancient doctors used holistic approach while practicing medicine. Avicenna, Alrazi and other implemented family medicine concepts while caring for their patients. However , with the disintegration of medicine into various specialties and sub-specialties this concept was lost overtime Alnasir Faisal ,2010 19 Faisal Alnasir 2018

20. Family Medicine Should Shape the Reform of any Health System Not Vice Versa. 20 Barbara Starfield ,2009 Faisal Alnasir 2018 Family physicians have to be in the forefront of any health care reform.

21. Health Care Reform (With PHC Concept) 21 Medical model Primary Health Care  Illness  Health  Cure  Prevention, care  Treatment  Health promotion  Episodic care  Continuous care  Specific problems  Comprehensive care  Individual practitioners  Teams of practitioners  Health sector alone  Inter- sectoral collaboration  Professional dominance  Community participation  Passive reception  Joint responsibility Barbara Starfield , Johns Hopkins University, 2009 Faisal Alnasir 2018

22. Faisal Alnasir 2018 22   The optimal health care provision SHC: Secondary Health care THC: Tertiary Health Care PHC: Primary Health Care Alnasir F,2014 Family Medicine is the foundation of any health system

23. 23 W ell-trained FD is able to deal with 80% of health problems that affect the human being, whether the person is a child, adult, male or female. AUB Dept of Family Medicine Greater equity Faisal Alnasir 2018

24. Faisal Alnasir 2018 24 E ach one additional FD per 10,000 people is associated with a 5.3% reduction in mortality. Ian Scott, Goldis Chami CCFP

25. Faisal Alnasir 2018 25 Reiter Syndrome

26. 26 Cost of health services in Bahrain 2009 Heath center visit cost US$ 14-20 Hospital OPD visit cost US$ 130 ( 600%) Admission per night cost US$ 530-660 Admission intensive care US$ 1300 Alnasir F, 2009 Faisal Alnasir 2018 Each One US$ spent in preventive care is equal to 7 US$ in curative

27. 27 Cost-Effectiveness (Intervention cost/case) : Telephone Call £16 Family Physician £15 Walk-in-Centre £55 FP with Special Interest £75 Hospital Outpatient £150 Day Care £500 One-Day Admission £1,000 Inpatient (2ndary Care) £5,000 Tertiary Care £20,000 PHC 2 Care 3 Care WHO Collaborating Centre, London Source: Rawaf , Dubois, 2007 Faisal Alnasir 2018

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29. 50% of the physicians’ work force in any country should be constituted of Family Physicians. Barbra Starfield 29 Faisal Alnasir 2018

30. Establish by decision of the Arab Health Ministers in Kuwait in February 1978 Up to 2014 Only 1567 FDs have graduated since its foundation 28 years ago . ABHS 2014 30 Faisal Alnasir 2018 Arab Board for Health Specializations

31. World-wide, the optimal Family doctor/patient ratio is 1800 people. With the realization that its population is over 410 million, the Arab World now needs more than 228000 FD specialists. 31 Faisal Alnasir 2018

32. Continuation at the current production rate of Board qualified FDs by the ABHS, (150 to 200 per year); Arab countries would require years to have optimum number of immediately required FDs!!! 32 Faisal Alnasir 2018 1138

33. Why there is shortage of FDs? 33 Faisal Alnasir 2018 What is the solution?

34. Solution: To focus on 4 areas: Policy makers, MPs and the public The doctors (trainer & trainee ) Training Centers/ Programs General 34 Faisal Alnasir 2018

35. 1)Policy makers, MPs and the public : Importance of FM FM is the foundation of health services FM is the fifth specialty in Medicine Political determination to implement FM Increase budget pertained to FM (training, health centers) Increase public awareness about the importance of FM. 35 Faisal Alnasir 2018

36. 2)- The Doctors knowledge of Family Medicine Interested in joining the program FD status is no less than other specialty Continuous medical education programs Self satisfaction (payment, rewards, working environment) 36 Faisal Alnasir 2018

37. 3)- The Training Programs/Centers: Increase number of training programs Increase the capacity of existing ones Establish ideal training PHC centers Improve the work environment Increase the incentives to FD Opportunities for FD to acquire foreign experience 37 Faisal Alnasir 2018

38. 4)-General: Increase number of medical schools and its intake Establish departments of Family Medicine in every medical school Adopt Community oriented curriculum Support Arab Board for Health Specialties Admire Arab Board Qualification do not downgraded Intensive training programs for the existing PHCs’ doctors 38 Faisal Alnasir 2018

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40. Faisal Alnasir 2018 40 Mariam’s Dx

41. Primary care everywhere in the world is most of the care, for most of the people, mos t of the time. Barbara Starfield 41 Faisal Alnasir 2018 In conclusion

42. 42 Thank you Family Doctor leads the way Faisal Alnasir 2018

43. Cost of a program with the intake capacity of 20 intake: Number of trainer to trainee 1 to 4 (Total 5 Trainers FD) Cost of 5 Trainers salary US$ 10500 x5= 52500 /month = 630000 / year) Cost of trainee (Monthly salary=US$ 2200x 20=44000 per month= 528000 per year) Arab Board fee US$ 250/candidate per year= 300 x20= 6000 Administrative expenses US$ 100000 per year Total= 630000+528000+100000+ 6000= US$ 1264000 Cost per Graduate = 1264000/20= 63200x 4 years= US$252800 Per Year $63200 43 Faisal Alnasir 2018