– Dr. Sameen Siddiqi
Universal Health Coverage [UHC] is one of the health targets of the Sustainable Development Goals to which every country committed during the last United Nations General Assembly. UHC can only be achieved if all the population is financially protected and has access to a benefit package of quality health services. This is by no means an easy task and requires at a minimum well trained family practice teams led by the family physicians, adequate health infrastructure, availability of essential technologies, referral and feedback mechanism, effective recording and reporting system, oversight and supportive supervision, and an engaged community that has a trust in services delivery.
The World Health Organization’s Regional Office of the Eastern Mediterranean has been promoting family practice as the principal approach to ensuring access to person-centered and integrated health services. The key interventions include assessing the situation of family practice and production of family physicians in the region; preparing strategic documents on strengthening family practice and scaling up production of family physicians; organizing regional consultations and capacity development workshops; and developing a bridging program for general practitioners. In addition, direct technical support has been offered to several countries to strengthen family practice programs.
The presentation will focus on the key issues, challenges and opportunities, and propose strategic options for action by the different constituencies to establish family practice and scale up production of family physicians in countries of the Eastern Mediterranean.
In the year 2000, the nations of the world signed up to the United Nation’s Millennium Development Goals and agreed to targets for the next fifteen years to eradicate extreme poverty and hunger, reduce maternal and child mortality and tackle serious infectious disease, ensure all children have access to education, empower women and girls, and ensure the sustainability of our natural environment. Fifteen years later, there have been substantial improvements in several of these areas in many parts of the world but there is still a long way to go.
2015 saw the release by the United Nations of the new Sustainable Development Goals (SDGs). While attaining each of the 17 new goals relies on healthy people in healthy communities, there is only one specific health SDG, to “ensure healthy lives and promote well-being for all at all ages”; in other words, to promote universal health coverage in every nation of the world.
This renewed focus on universal health coverage provides an unprecedented opportunity for family medicine, because, unless a nation has a strong system of community-based health care delivery, universal health coverage is not attainable. Family doctors, and other members of our primary care teams, have the capacity to work in partnership to ensure the delivery of universal health coverage in all parts of the world. Yet in many parts of the world only a minority of people has access to effective health care through family medicine.
This presentation will draw on the work that the World Health Organization (WHO), the World Organization of Family Doctors (WONCA) and other global organizations have been engaged in around the world over recent years to strengthen family medicine and primary health care and ensure universal health coverage. This work has highlighted the importance of strengthening primary health care and multidisciplinary team approaches to community-based health care delivery in each country of the world. Participants will receive a global perspective on why strengthening family medicine and primary health care is the most viable way to close the treatment gap and ensure that all people in all communities get access to the health care they need.
As the momentum builds to achieve universal health coverage and address the challenge of noncommunicable diseases, most governments are struggling to find a viable resourcing plan for their health reforms. Even governments such as the U.K., with a longstanding commitment to taxation funding of health services which are then ‘free at point of use’, are using more private contracts, and family doctors are often working in a ‘mixed model’ of salaried and owned services. This keynote will discuss how to identify and advocate for models that can underpin – rather than weaken- services that are comprehensive and deliver effective personal community based care.
Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, sexes, each organ system and every disease entity. It is the website approach.
The HMC/GCC States was very keen since the conference held in February 1976 and before alma-ata declaration in 1978 to give more care and support to all subjects included under the framework of PHC/FM especially those related to maternal and child health, environmental problems and nutrition.
With the continuous care and concern of PHC programs on the part of the countries in addition to successive developmental resolutions issued by the HMC/GCC states, a network for PHC centers was established all over the Gulf member states. Moreover, a lot of systems and regulations were issued supporting the work of these centers and helping them to realize their objectives especially as related to easy access to the service by all populations, Changing Public and M.D. Perceptions and giving more care to the most vulnerable groups of the community (children – mothers – elderly – disabled – adolescents – etc.).
Future plan to accelerate the process of QA in all aspects of PHC / FCM Medicine should be emphasized including patient safety.
Universal Health Coverage [UHC] is a strategic goal to which all Member States of the Region have expressed their commitment. Through the WHO Regional Committee for the Eastern Mediterranean, Ministers of Health endorsed a regional framework for action for advancing universal health coverage in the Region. Ensuring access to an essential package of quality health services through a family practice approach is a critical element of the UHC framework.
Raising awareness and developing evidence-based information to Member States on Family Practice is a priority. WHO has recently undertaken a regional assessment, conducted training courses for master trainers, developed short term training of General Practitioners on the principles of family practice, advocacy video, operational guide and assessment tools.
The World Health Organization has collaboration with WONCA over the last couple of years including regional consultations on “strengthening service provision through family practice approach”, assessment of family medicine education and training capacity in the region, and scaling up of family practice in EMR countries.
WHO Symposium will compose of
 Advocacy Video (7 minutes): Role of Family Practice in Universal Health Coverage.
PowerPoint presentation (15m): “Scaling up Family Practice in the Eastern Mediterranean: Progressing towards Universal Health Coverage”, Dr Hassan Salah, Medical Officer, WHO EMRO.
 PowerPoint presentation (10m): “On Line Training Course to Improve Knowledge and Skills of GP”, Prof and Chair of Family Medicine Dept., American University in Biuret.
 PowerPoint presentation (10m): “On–Site Training of Regional Master Trainers on Family Practice”, Dr Huda al-Duwaisan, Director of Yarmouk PHC, Kuwait.
 Panel discussion (50m): Challenges, Lessons Learned and Priorities to Enhance Family Practice program in 3 groups of EMR countries. The panel will include:
- Moderator: Dr Sameen Siddiqi, Director Health System Development, WHO EMRO.
- WHO Representative: Dr Mohamed Assai, Coordinator Integrated Service Delivery, WHO EMRO.
- WONCA Representative: Dr Oraib Al Smadi, Wonca EMR honorary treasurer.
- Academia Representative: Prof Faisal Abdullatif Al Nasir, Prof and Chair of Family Medicine Dept., Arabian Gulf University, Manama, kingdom of Bahrain.
- MoH Representative
Family Medicine as a specialty evolved in response to societal and health system needs. The training content and structure have thus varied from one society to another and changed in time within the same community.
This fact is crucial for institutions designing Family Medicine curricula. Every community will need to identify its health related problems and design the GP/FP curriculum which can best fit its health system and address its needs.
In the presentation, an overview of the evolution of primary care is described, a glimpse on how curricula are designed and a couple of slides show current content of training in the MENA region.
The speaker briefly addresses the educational & training challenges of the Patient Centered Medical Home initiative, the advances in technology and societal economic pressures.
Medical practice is a highly respectable profession in our society. With respect in society comes responsibility to provide ethical and up to date evidenced based clinical care to patients in accordance with good clinical practice.
Rapid scientific progress has resulted in addition of fresh knowledge and information on an ongoing basis. Knowledge today will become obsolete in a few years and will be replaced by fresh information that will require incorporation into clinical practice.
It is the responsibility of every Family Physician to refresh clinical knowledge on an ongoing basis. They need guidance and opportunities to keep their professional knowledge and skills up to date.
Each country needs a CPD policy for Family Physicians that is developed and implemented at the government level. It is the responsibility of regulation and licensing authorities in each country, to develop guidelines, regulations and monitoring system for Family Physician, to ensure their knowledge and skills remain up to date, to provide safe and evidenced based clinical care to their patients.
It is the responsibility of academic institutions as well as national and international organizations, to develop CPD programs that provide opportunities for practicing doctors, to upgrade their knowledge and skills. These institutions and organizations will have to work with regulatory and licensing authorities of their country to ensure uniformity of the CPD program and their relevance and quality.
WONCA is playing a major role in promoting CPD opportunities for Family Physicians around the globe. Its role is central and can be further strengthened and streamlined.
An overview will be presented with regards to importance and role of CPD in the professional life of Family Physicians.
The strategy of the primary health care in Dubai Health Authority based upon providing inclusive and integrated services viz. promotional, protective, therapeutic, and rehabilitative, thus it has been necessary to prepare some of the cadres, particularly the national ones in this field.
Family medicine has been recognized as an essential specialty to improve the quality of Primary Health Care (PHC) physicians worldwide (Ssenyonga & Serenga 2007; WHO 2008). The family practice has expanded dramatically over the past several years and has become competitive to PHC (Stevens 2001).
Dubai Family Medicine Residency Training Program that started on 1993 considered as one of the successful specialized program in the field of Family Medicine in the United Arab Emirates as well as in the system of Dubai Programs of Medical Specialties in Dubai Health Authority, which confirmed competency and eligibility throughout the previous years until it has been locally and externally reputed. The graduates of the program represent the majority of the graduates from all Dubai Programs for the Medical Specialties and also form the majority of the family doctors who annual graduate on the level of the same. The qualified graduated doctors directly join the primary care practice as fully privileged independent Family Physicians.
Dubai Family Medicine Residency Training Program, depends upon training resident doctors to promote their medical culture and practical experience, that enables them to make correct sound diagnosis and successful treatment to the most common health problems in the society as well as to identify the serious conditions, through four years of training program; the teaching in the first year, second year and half of the third year shall be by joining the practical sessions in the hospitals of the authority (DHA), therefore the trainee is given a chance to comprehend the medical knowledge in most of the specialties from those concerned specialized doctors. In addition, trainees’ medical skills are crystallized and developed in the period of last one year and half of the program through joining training in the health centers of the primary health care in Dubai Health Authority.
During the last decade, there has been an increased recognition by the World Health Organization of the importance of primary health care (PHC) in improving the health of populations. The responsibility lies with qualified Family Physicians (FPs) who on a daily basis have several tasks to be carried out. These functions include: Consulting patients and their family, treating acute and chronic illnesses, preventative services, coping with an outsized variety of problems being medical and non-medical, promoting health, counseling and trying to satisfy patients’ expectations, delivering health education, working with health personnel and liaising with other agencies to lift the health standard for the whole family and the community, helping to identify health threatening factors within the community and attempting to answer the unreciprocated queries. On the other FPs have great responsibilities and accountability to the communities in providing quality care to raise the health standard of the state. And to do so, FPs are compelled to have the evidence supporting their decision. Hence, they need to do research. It is believed that any doctor should possess three characteristics; being a physician treating patients; an educator with information delivery skills and a researcher with the abilities to analyze various faced problems looking for an answer. There is a growing belief supporting the need for research in primary health care for the provision of excellent clinical care. The 2002 European WONCA definition of general practice/family medicine highlighted the need for research by stating that “General practice/family medicine is an academic and scientific discipline, with its educational content, research, evidence base, and clinical activity.” There is no doubt about the importance of research where without it science couldn’t have developed and will not be able to survive. Therefore, many health authorities and medical colleges have been highlighting the importance of research in PHC. In Bahrain, for example, and to pass the family medicine residency program the candidates have to complete a research project. FPs would not be entitled to promotion unless they have published few papers. Similarly, within the medical schools, research activity are incorporated into the curriculum, and students are required to engage and finish a research project throughout their medical studies to orient and equip them with information and skills for performing a research work.
The advantages of partaking in research are numerous, the foremost vital are; to increase the clinicians’ professional confidence and self-esteem, to improve the status of primary care as a career choice, provision of higher standard of health to patients, solving queries of issues that influence health, raising the health standard of the nation, decreasing the prevalence of communicable and non-communicable diseases and reducing the mortality and morbidity. However, there are many challenges and limitations for the full implementation of research within the PHC which will be highlighted in this presentation.
Background: A strong primary care system is fundamental to provide effective and efficient health service in every country of the globe. Research in primary care is essential to advance science and inform practice, develop sound policies and eventually better health systems. However, research in general practice faces many challenges from inception to translation. These range from lack of resources, limited research capacity, poor clinicians’ engagements, and absenct translations of research findings.
What are these challenges? How can we address such challenges? What are the roles of service practitioners and academia? What are the primary care research priorities? Are the challenges the same in resource-poor countries? These and many other questions will be addressed in this paper.
Methods: These include:
- Review of the current literature on conducting research in primary care
- Reflect on the best practices available in the developed and developing countries
- Reflect on the findings and how EMRO countries should steer in the directions that improve the research outputs that aim at advancing clinical practice and improve population health.
Conclusion: Research is one of the key pillars of primary care. While resource rich countries have managed to steer the research agenda in the right direction and improve population’s health, this is certainly not the case in many other countries. These countries have to act and build the capacity needed for research in primary care. This paper will suggest some directions to improve the primary care research for the benefit of individual and population health.
Dubai has instituted standards of care for COPD management to deliver high-quality and cost-effective patient care. There are 13 COPD audit tools used and they can be classified into four categories: healthcare site; severity of COPD; and long-term plan of care. These tools were derived from the best available evidence and guidelines and have been produced through the collaborative efforts among healthcare, social care, health ministry and their partners and service users. The presentation will provide a comprehensive explanation on the implementation of these audit tools.
The Chronic Care Model (CCM) uses a systematic and well organized approach for restructuring care of diabetic patients to create strong partnerships between health systems and local communities.
To describe how Family Physicians have applied CCM in primary care settings to provide care for diabetic patients and to describe outcomes of CCM implementation in Family Practice Settings – Jordan.
Implementation and Results
There is a significant gap between evidence-based diabetes care and actual care delivery. Despite evidence-based guidelines for diabetes care goals, the majority of patients do not reach these goals. This is not a shortcoming of Family Physicians or patients, but rather a reflection of our healthcare delivery system. The Chronic Care Model (CCM) was developed to bridge this gap and translate scientific knowledge directly to the care of patients. Implementation of the CCM has been shown to improve outcomes for diabetes by providing a system for productive interactions of a prepared proactive Family Practice Team and an informed patient. The CCM is a primary care based framework that identifies the essential elements of high quality Diabetic care. It includes attention to self-management support, delivery system design, decision support, information technology, community linkages, and the health care organization as a whole. The presentation will describe these elements and provide evidence for their use in improving diabetes care in Family Practice settings , also will illustrate results of implementing CCM for Diabetic patients in Family Practice settings in Jordan .
CCM is being used for diabetes care in Family Practice settings, and positive outcomes have been reported. Integration of CCM into FP settings for diabetes management should measure diabetes process indicators. Increased focus on healthcare professionals implementing this model of care across different practice settings is recommended to improve diabetes outcomes.
Mental disorders affect thousand of people in Kuwait and most of them are under diagnosed and left untreated, which create an enormous toll of suffering and disability. Integrating mental health services into primary care in Kuwait is a new concept with lots of challenges but it is affordable. Integrating this system in primary care for the last four years bring important benefits for the patients and the health system, which was evidenced by statistical date and improvement in the indicator results. There is no single best practice model in the Middle East that can be followed, but Kuwait PHC system succeeded in this Integration because of the support by the health policy, senior leadership, adequate resources and ongoing governance.
The pancreas acts like a thermostat to keep our houses comfortable. When blood sugar (BS) rises, the pancreas secretes more insulin whereas it secretes glucagon when BS drops. For type 2 diabetic patients, the consensus is to start with lifestyle modification and metformin from the time of diagnosis. A suggested hierarchy of medications order will be presented with highlight of the pancreas paradigm and the best available evidence as possible. The decision to which medication(s) to start with depends on many factors; the most important are 1) drug effectiveness, safety and contraindications 2) risk of hypoglycemia, 3) impact on patients’ weight. Other factors include patient motivation, cardiovascular and other end organ complications, age, general wellbeing and cost. Five kilograms of weight gain can cause insulin resistance to double. On the other hand, loss of seven percent of total body weight is associated with a 2% drop in AIC value and reduction in the number and doses of drugs. Doctors and the public alike need to be updated and educated on the new literature on the role of diet. Randomized controlled trials and a systematic review have shown that food rich in trans-fat (industrially hydrogenated) confers harmful CV complications. Similarly, high consumption of refined CHO in food is associated with an increase in insulin resistance and weight gain. Patients’ life long journey with diabetes may include false perceptions that deter them from healthier behavior. Physicians need to learn how to educate their patients; therefore, I will present an example a real life scenario from my practice.
Depression is an important public-health problem and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression, alone or as comorbidity, on overall health status. The objective is to study the prevalence of depression and depressive symptoms among NCD patients attending PHC at Dubai Health authority facilities, Dubai, UAE; and to study the distribution of socio- demographic determinants of the NCD patient presented with depression or depressive symptoms and some associated risk factors. A cross-sectional study has been carried out among randomly selected sample of 306, both males and females (patients with different chronic diseases status attending primary health care facilities at Dubai health authority in Dubai for the year 2014. Sample size estimated using Epi–info software and was 306. Sample type was multistage stratified random sample with proportional allocations from different primary health care centers both in Deirah and Bur Dubai sides.
Interview administered questionnaire has been used for data collection (Depression Anxiety Stress Scales “DASS 21”). Data was analyzed using SPSS 21. The study showed that 18% of presented with mild depressive symptoms as detected by DASS, 15.4% of the study population have moderate depressive symptoms and 6.5% severe depressive symptoms and extremely severe depressive symptoms were among 7.2% the total depressive symptoms among patients with chronic diseases attending PHC clinics was 48.2%. The study reflected that age factor has no significant association with depression, P Value=0.498, the (odds ratio was 1.3270 (95% CI: 0.785-2.243). The (odds ratio of the effect of nationality factor on developing of depression among was 0.641 (95% CI: 0.369-1.114). The effect of marital status factor on developing depression among was not statistically significant P value= 0.42. Frequency rates of depression associated with chronic diseases are significantly high which reflected two direction effects. Some socio-demographic factors were shown to be playing significant role such as gender and nationality. Depression intervention program needs to be developed to prevent two direction negative impacts and improve quality of life and over all life expectancy.