Universal Health Coverage Challenges Facing Family Medicine Prof

Universal Health Coverage: Challenges Facing Family Medicine Prof Faisal Abdullatif Alnasir FPC, FRCGP, MICGP, FFPH, Ph. D Chairman; Home Health Care Centre General Secretary & Treasures; International Society for The History of Islamic Medicine Chairman; Home Health Care Center Temp Advisor WHO EMRo Former Chairman; Dept. Of Family & Community Medicine Former President; Scientific Council Family & Com. Medicine Arabian Gulf University Former President Family & Community Medicine Council. Arab Board for Health Specializations Faisal Alnasir 2017 1

Universal Health Coverage: Is the core to reducing health inequalities and eliminating poverty Faisal Alnasir 2017 2

Universal Health Coverage It is not a new concept, but its inclusion in the Sustainable Development Goals (SDG) agenda is a significant acknowledgment by the nations of the world that progressing toward UHC will not only improve the health of millions, but will also contribute to reaching many of the other SDGs. Faisal Alnasir 2017 Marie-Paule Kieny, WHO Assistant Director-General, 2016 3

Universal Health Coverage It has the potential to increase economic growth, improve educational opportunities, reduce impoverishment and inequalities, and foster social cohesion. Tripathy RM, 2014 Faisal Alnasir 2017 4

Expansion of universal health coverage in the EMRo Region is critical : • 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. Faisal Alnasir 2017 WHO and World Bank Group 5

Arab region has dramatically reduced poverty and inequality in the 20 th Century. ” n 65 million adults are illiterate, two-thirds women n 10 million 6 -15 year olds are not in school (if current trends persist, that number will increase by 40% by 2015) n 54 million lack access to safe water n 29 million lack access to health services “The Yet…… Faisal Alnasir 2017 6 UNDP, 2013

NCD epidemic Leading to serious implications on the regional health situation and a negative impact on socioeconomic development. • In 2008, >2. 2 million people died from NCDs, (35% of them before the age of 60). • The anticipated deaths will increase to 3. 8 million in 2030. Ala Alwan, Former Assistant Director General, World Health Organization Faisal Alnasir 2017 7

In EMR • The prevalence hypertension affecting of 26% 125 million individuals. • Each year, there are several million new cases of hypertension and more of pre- hypertension. Report on the regional consultation on hypertension Faisal Alnasir 2017 UAE, 2003 8

Prevalence of overweight and obesity in EMR countries(WHO. 2004) Country Overweight/obesity (%) Males Females Saudi Arabia 64. 0 70. 0 Lebanon 60. 0 53. 0 Islamic Republic of Iran 57. 0 67. 7 Bahrain 56. 4 79. 0 Kuwait 79 56 Egypt 43. 8 41. 0 Libyan Arab Jamahiriya 42. 5 74. 9 Oman 40. 5 43. 5 Morocco 37. 2 21. 7 United Arab Emirates 25. 5 39. 9 Jordan 46. 0 43. 7 Tunisia Faisal Alnasir 2017 13. 1 41. 9 9 9

In EMR: Maternal mortality rate remains unacceptably high. With 350 maternal deaths occurring per 100 000 live births. (Maternal mortality in Somalia and Afghanistan continues to be among the highest in the world). Regional Committee for the EMR September 2008 Faisal Alnasir 2017 10

Ageing population: The prevalence of people above the age of 60 is increasing markedly in the developing countries while it is almost stable in the developed world. Bahrain as an example of EMRo it is anticipated that the percentage will reach to 15% by the year 2025 and 25% by the year 2050. Alnasir, 2011 Faisal Alnasir 2017 11

Insufficient Health Workers: Low and lowermiddle income countries need 18 million more health workers if they are to achieve UHC. Marie-Paule Kieny, WHO Assistant Director-General, 2016 Faisal Alnasir 2017 12

Doctors’ Shortage is an invisible problem CNBC 2015 The USA nation’s shortage of doctors will rise to between 46, 000 and 90, 000 by 2025 Forbes March 2015 The doctor shortage is real Association of American Medical Colleges(AAMC) 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) Faisal Alnasir 2017 13

In UK >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 14 Faisal Alnasir 2017 ,

So What is the Ideal Health System? ØIs the one that: “Secure the Health of the Whole Population” © WHO C Centre, Imperial College London Faisal Alnasir 2017 15

And its Goals: Improve Health Responsiveness to needs Financial Protection Faisal Alnasir 2017 16 WHO C Centre, Imperial College London

Reiter Syndrome Faisal Alnasir 2017 17

Health coverage: Comprehensive and not disintegrated Family Medicine Faisal Alnasir 2017 18

Family Medicine is not new. Since ancient times, doctors have been using the holistic approach while practicing medicine. Avicenna, Alrazi and other ancient doctors were implementing the concepts of family medicine while caring for their patients. They were adopting a holistic approach. However, with the disintegration of medicine into various specialties and subspecialties this concept was lost overtime Faisal Alnasir 2017 Alnasir Faisal , 2010 19

• Family Medicine (FM) Is the fifth medical specialty that provides the individuals and the whole family; primary, personalized and continuous health care. It offers comprehensive care ie. responsible for offering a total health care from the first contact and initial assessment to the management of acute & chronic problems. With emphasis on prevention and early recognition of disease. Faisal Alnasir 2017 20

Primary Health Care n It is the care that (PPCM): -Promote health -Prevent illness -Provision of care for acute & chronic illnesses -Manage ongoing health problems (Psych-social) Faisal Alnasir 2017 21

Principles of Primary Health Care That Leads To UHC Intersectoral/ Interdisciplinary Personal care Accessible Affordable & Sustainable P H C Family & Population Health Continuous Care Appropriate Efficient Faisal Alnasir 2017 22

• Family Medicine Should Shape the Reform of any health system Not Vice Versa. • Family physicians have to be in the forefront of any health care reform. Faisal Alnasir 2017 Barbara Starfield , 2009 23

For UHC Health Care Should be Reformed (With PHC Concept) Medical model Primary Health Care Treatment Health promotion Illness Health Cure Prevention, care 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 Faisal Alnasir 2017 24 Barbara Starfield, Johns Hopkins University, 2009

Provision of health care in many countries THC SHC PHC SHC: Secondary Health care THC: Tertiary Health Care PHC: Primary Health Care Alnasir F, 2014 Faisal Alnasir 2017 25

The optimal health care provision THC SHC PHC Family Medicine is the foundation of any health system PHC: Primary Health Care SHC: Secondary Health care THC: Tertiary Health Care Alnasir F, 2014 Faisal Alnasir 2017 26

Why Is PHC Important? • Better Health Outcomes • Lower Costs • Greater Equity Faisal Alnasir 2017 27

Health systems oriented to primary health care is able to respond continuously to the new challenges in all countries, whether developing or developed, rich or poor and in conflict or in peace. Regional Committee for the EM/RC 55/INF. DOC. 6(a) Eastern Mediterranean September 2008 Faisal Alnasir 2017 28

• Greater equity A well-trained family physician 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 Faisal Alnasir 2017 29

• On average each one additional family physician per 10, 000 people is associated with a 5. 3% reduction in mortality Ian Scott, Goldis Chami CCFP Faisal Alnasir 2017 30

Cost of health services in Bahrain 2009 Heath center visit cost Hospital OPD visit cost Admission per night cost Admission intensive care US$ 14 -20 US$ 130 ( 600%) US$ 530 -660 US$ 1300 Alnasir F, 2009 Faisal Alnasir 2017 31

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 (2 ndary Care) £ 5, 000 • Tertiary Care £ 20, 000 Faisal Alnasir 2017 WHO Collaborating Centre, London PHC 2 Care 32 Source: Rawaf, Dubois, 2007

MIND YOU!!! Although it is very economical, PHC is not an approach for poor countries, for poor people or for diseases of the poor. Regional Committee for the EM/RC 55/INF. DOC. 6(a) Eastern Mediterranean September 2008 Faisal Alnasir 2017 33

50% of the physicians’ work force in any country should be constituted of Family Physicians. Barbra Starfield Faisal Alnasir 2017 34

TRAINING Providing optimal generalist care requires broad and comprehensive training that cannot be gained in brief and uncoordinated educational experiences. (Kimball and Young, 1994) Faisal Alnasir 2017 35

• The Arab Health Ministers in Kuwait in February 1978, decided to establish the Arab Board for Health Specializations It aims to: § improve medical services in the Arab world § raising level of professional skills § develop and institute guidelines for training in different medical disciplines § maintain quality by periodic review. • Only around 1567 (2000) physicians (FD) have graduated since its foundation 28 years ago. Faisal Alnasir 2017 ABHS 2014 36

• World-wide, the optimal Family doctor/patient ratio is 1800 people. • With the realization that its population is over three hundred and seventy million, the Arab World now needs more than 205600 FD specialists. Faisal Alnasir 2017 37

• Continuation at the current production rate of Board qualified FD by the ABHS, (150 to 200 per year); Arab countries would require 1030 -1370 years to have optimum number of immediately required FDs!!! Faisal Alnasir 2017 38

What is the solution Faisal Alnasir 2017 39

Solution: The strategy is to focus on 4 areas: • Policy makers, MPs and the public • The Training Centers/ Programs • The doctors (trainer & trainee) • General Faisal Alnasir 2017 40

1)Policy makers, MPs and the public: Ø Conviction by the policy makers about the importance of FM Ø Admiration that FM is the foundation of all of provided health services Ø Recognition that FM is the fifth specialty in Medicine Ø Political determination to implement FM Ø Increase budget pertained to FM (training, health centers) Ø Increase public awareness about the importance of FM in order that they form political pressure on policy makers to implement strategies favoring FM Ø Faisal Alnasir 2017 41

2)-The Training Programs/Centers: Ø Increase number of training programs Ø Increase the capacity of existing ones Ø Establish ideal training PHC centers Ø Improve the work environment Ø Increase the incentives to FD Ø Opportunities for FD to acquire foreign experience Faisal Alnasir 2017 42

3)-The Doctors Ø Have in-depth knowledge of Family Medicine Ø Have interest in joining the program Ø Realize that FD status is no less or different than other specialty Ø On going, on job continuous medical education programs Ø Self satisfaction (payment, rewards, working environment) Faisal Alnasir 2017 43

4)-General: Ø Increase number of medical schools and its intake Ø Establish departments of Family Medicine in every medical school Ø Adopt Community oriented curriculum. Ø Support Arab Board for Health Specialties Ø The Arab Board Qualification should not be underestimated or downgraded Ø Intensive training programs for the existing PHCs’ doctors Faisal Alnasir 2017 44

The family unit is the backbone of any country. Universal Health Coverage for this unit is of paramount importance. Hence, family practice should be in-built within the national health policy. Prof. Lalitha Mendis, Director, Post-Graduate Institute of Medicine (PGIM), University of Colombo, Faisal Alnasir 2017 45

Primary care everywhere in the world is most of the care, for most of the people, most of the time. Barbara Starfield Faisal Alnasir 2017 © WHO Collaborating Centre, London 46 Source: BMJ, 2008

Representing some 500, 000 family doctors in over 130 countries Faisal Alnasir 2017 47

• Conclusion The concept of Universal Health Coverage will be affected dramatically and may be in danger if no drastic measures are taken to implement Family Medicine and increase the number of FDs. Faisal Alnasir 2017 48

Family Doctor leads the way Thank you Faisal Alnasir 2017 49