Primary care Physicians job should be made so interesting and fascinating that medical graduates willingly opt for it-Nausherwan Burki


 Panel discussion on Improvement of Healthcare Delivery system
Primary care Physicians job should be made so
interesting and fascinating that medical graduates
willingly opt for it-Nausherwan Burki
Modules for primary care should be included in revised
curriculum-Rakhshanda Rehman The system developed
should satisfy local needs & meet international standards-
Shaukat Ashai

LAHORE: Interesting panel discussion on “Improvement in Healthcare Delivery System in Pakistan” was yet another salient feature of the International Medical Conference on Updates in General Medicine organized by Fatima Memorial Hospital & Nur International University held here last month. Advisor to the Prime Minister on Health Dr. Nausherwan Burki who is also Chairman of Board of Governors of Lady Reading Hospital Peshawar chaired the session which was moderated by Prof. Rakhshanda Rehman, Dean Fatima Memorial System Lahore. Other panelists were Dr. Shaukat Ashai from United States, Dr. Ghulam Rasool Mufti Consultant Urologist and Fitness to Practice Tribunal Member of General Medical Council from UK besides Dr. Tariq Mian who represented the Family Physicians of Pakistan.

In her introductory remarks Prof. Rakhshanda Rehman first shared the highlights from the first panel discussion held on Day-One of the conference on “Health Challenges in South Asia” wherein the two areas which were identified that need intervention to introduce health reforms were Education and Healthcare Delivery System.

Both undergraduate and post graduate education, from entry to exit, she further stated, are of prime importance. Entry refers to selection of students for a program and exit means that the graduates should be competent in the Pakistani context as well as be at par with international standards. They should be able to compete for international licensing examinations like USMLE, PLAB etc. and should also be able to deliver appropriate healthcare to patients. We desperately need curriculum reforms and Modules for primary care should be incorporated into the curriculum.

Dr. Nausherwan Burki (second from left) speaking at the panel discussion held at Fatima
Memorial Hospital recently. Sitting on the dais with him from (L to R) are Dr. Tariq Mian,
Dr. Shaukat Ashai and Dr. Ghulam Rasool Mufti.

Continuing Prof. Rakhshanda Rehman said that PMDC regulations are the next major concern for the medical community, there is an unrest and confusion about the suitability of these regulations in the Pakistani context. We expect that the new Council and management will have a rational review of these regulations. Unfortunately, stakeholders’ involvement in policy making is neglected. Public, private and charitable trust organizations are different sectors. Hence, it is essential that all these sectors get adequate representation in the regulatory bodies. Charitable Trusts function in support of the government without any profit interests, she added.

She suggested that House job in primary healthcare should be a must to ensure community orientation and community service delivery. Post graduate medical education should also focus on producing specialists in general practice and due respect and incentives should be given to them in order to promote primary healthcare service delivery. Streamlining of specialties is important. Some specialties are overcrowded while other specialties like anesthesia, general medicine, intensive care and critical care face dearth of trainees. Involvement of RHC and BHU in postgraduate training should be made mandatory to improve primary healthcare delivery in remote areas and to give flavor of community-based learning to trainees. Hospitals should be safe, caring, responsive, effective and well led. So the problem is that how to ensure that hospitals are keeping up with the healthcare delivery standards? Should there be a regular internal audit, quality assurance department in hospitals, periodic external audit? Should the yardsticks for inspection be same for public Sector, private sector and the third sector i.e. charitable Trusts? These are all the concerns which need to be addressed on priority basis, she concluded.

Participating in the discussion, Dr. Shaukat Ashai pointed out the challenges specifically in South Asia as compared to the rest of the world, especially, with reference to the quality of education. Currently, the education system is at a very critical point. It is at the crossroads where the aim is to develop a system, which satisfies local needs as well as meets international standards. He was of the view that in some places we are doing a great job while some areas need improvement. We have a very wide representation of students from Pakistan in the hospitals abroad. There is a massive difference in the way they fit in the healthcare system there. We have graduates from Agha Khan University who come and fit-in very well with the system. However, this is only 5% of total population of doctors moving abroad. The rest 95% of the graduates don’t fit in and work well in the western system. The aim is to bring these 95% up to the mark and make them ready to join the international medical fraternity. It depicts that we have a potential in our country and we have good role models as well. So it’s time that we take the right jump into the digital age. It’s time that we connect with the world through digital means that are available. He mentioned that PMDC though has a website but it isn’t fulfilling the purpose it should. It doesn’t address the needs and doesn’t promote exposure and collaboration that it should.

Mrs. Shahima Rehman Chairperson of Fatima Memorial System presenting a
memento to Dr. Nusherwan Burki at the end of the panel discussion which was
part of scientific programme of International Medical Conference organized by
FMS and Nur International University recently.

Dr. Ghulam Rasool Mufti expressed his views about the regulations needed for hospitals in order to play effective role in healthcare delivery system. Currently, the debate going on in Pakistan is very healthy and is the first step towards reforms and improvements. UK, he said, also experienced this phase in late 90’s. Clinicians were not involved in this system at that time. Patient’s understanding and expectations about healthcare delivery have changed enormously. Patients now use digital age technology in order to search for the best. And this makes them more aware and more conscious of their rights. He suggested that REGULATE YOURSELF OR THOU SHALL BE REGULATED. It’s very important that we in Pakistan undertake self-regulation. Indian Medical Council doesn’t have any regulations, while Pakistani council has regulations to follow. However, general perception about these regulations among medical community is that these regulations are only to see the DEGREE of the graduate and nothing else. The regulations are neither aligned with the purpose nor do they serve the purpose. The debate is between Govt., Professionals & Providers. Good high quality care for patients can only be ensured if all three stakeholders sit together, talk, describe their views and then come up with a collaborative plan to act on.

We need to incorporate versatile opinions in order to come up with the appropriate model. In Pakistan, a modified UK model is expected to be followed but the ground realities are different. Once a hospital is inspected it should be determined that whether the hospital has effective leadership or not and how Good is the leadership? Is the care being provided safe? Is the treatment to patients effective? Is the health care training safe? Is the hospital responsive? Does hospital address the needs of the community? The UK model can’t completely be adopted in the Pakistani context, because here primary healthcare delivery is the basic issue which needs to be solved. The UK model can’t completely fill this vacuum in Pakistan. We need to come up with an improvised model through discussion on platforms like these, he added.

Dr. Tariq Mian said that family physicians could play a major role in improvement of healthcare delivery in Pakistan as they were the ones working in the community at the grass root level. There are around one lakh forty two thousand General Practitioners in Pakistan. According to WHO 75% of healthcare is being provided by private sector and only 25% by the public sector. Until now, the previous governments, haven’t incorporated GPs of private setup in their policy making. They only include views of GPs from public sector working in BHU and RHC who actually constitute only a small percentage of GP community. WHO states that the countries who invested more in their primary healthcare delivery setup as compared to tertiary setups are much more successful? Therefore, it’s important that we incorporate majority of our GPs in improvement of primary healthcare system. This will not only decrease burden on specialties but will also improve healthcare in the region. In UK, the GP works with the hospitals, with a strong referral system in place, which improves healthcare delivery, saves resources and improves patient health status. Prevention of diseases is far more important than treatment of diseases. If we are able to prevent disease development or if the disease exists and we are able to prevent complication development, our disease burden will decrease automatically. So communicable diseases can be controlled early and non-communicable diseases can be screened regularly in order to improve general health of the society. This will improve the morbidity and mortality indices of our society. Hence, filtration of patients from primary to secondary to tertiary setup with a proper referral system is crucial. A structured training program for general practitioners should be in place for training of family physicians. FMH is the first hospital who took the initiative of training family physicians. A similar effort is needed at the national level. This qualification should be formalized and accredited. This is the only way in which the healthcare problems can be solved.

Dr. Nausherwan Burki participating in the discussion said that he had faced enormous challenges and resistance when he became Chairman Board of Governors of the Lady Reading Hospital. KPK Initially, it was like a nightmare. Pakistan was left with a broken British System of healthcare delivery. Nursing and Medicine both had a shattered system. The condition of hospitals is even worst. The working hours for hospital are from 9.00 am to 2.00 pm, whereas, the challenges of 21st century are too big to deal with. The situation is indeed quite alarming. Change is inevitable. However, this change needs to be owned by the doctors. The authority has to be given back to the doctors and experts. Pakistan has 120 thousand nurses including Midwifes and LHW. Even for the minimum standards to be met (comparing our society to British system), we need 1.7 million nurses. So this vacuum is enormous and needs to be filled up on urgent basis. The human resource in nursing needs to be increased five times and then we will be able to control the system in the next 10 years. There is a massive difference in quality of graduates being produced. So we need to upgrade our education and healthcare care system on the whole in order to achieve better healthcare status.

For improving primary healthcare system, Dr. Nausherwan Burki suggested that job of primary care physician should be made so interesting and fascinating so that medical graduates should be able to willingly opt for it. It can be done by introducing a similar degree like MRCGP of UK in Pakistan and by improving their pay scales. He added that government was working on increasing the health budget which would help in providing job satisfaction and better pays to doctors and nurses. The plan has already been implemented in the KPK and it will be extended soon to other provinces as well.

Dr. Tariq Mian said that media should stop demoralizing the medical profession and should not broadcast, publish any news until it is confirmed properly. The existing practice by media has a damaging impact on doctors and patients. PEMRA should take action in this regard.

Chairperson of Fatima Memorial System Mrs. Shahima Rehman in her concluding remarks highlighted that we had scarcity of resources in our country to fulfill the needs of patients and to provide them with quality health care. Fatima Memorial Hospital had an established role as a charity hospital. It started as a non-profit trust hospital for women and children and then it quickly developed into a tertiary care hospital. She further added that FMH would always sustain and retain the resources it had. She shared it with great pride that many of the post-graduate programs including family medicine and training sites including primary health care center were all recognized by the College of Physicians of Alberta, Canada. Therefore, high quality primary care is being offered in these centers, which is a gift of FMH to the marginalized population of the country.

Some of the important points and recommendations which were finalized after these deliberations were as under:

  1. Regulations need to be facilitative rather than being restrictive. Public, Private and 3rd Sector should all be represented in regulatory bodies.
  2. Government, healthcare provider and professionals should work together.
  3. Formal primary care training should be introduced.
  4. Primary care jobs should be made interesting with added incentives.
  5. Undergraduate Curriculum should include primary care.
  6. House job should have a rotation in primary health care setting.
  7. There should be a referral system; Patients should be screened at the Primary care level and then referred to Secondary or Tertiary centers.
  8. We need to increase at least 5 times the number of nurses to improve the provision of health services.
  9. Job satisfaction and increase in pay of nurses should be looked into so that to ensure their retention in Pakistan.
  10. Five hundred MScN tutor nurses need to be brought in to train BSc nurses.
  11. Health budget should be spent wisely and GDP allocation to health should be increased.
  12. Government should regulate media about the news on health care providers.
  13. Professional specialty organizations should provide local guidelines relevant to their field.
  14. Strong oversight body is needed to govern the hospitals, supervise education and training in medical colleges.
  15. PMDC should not be involved in postgraduate medical education.
  16. Council for Allied Health Sciences should be established.
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