BRIDGING ACADEMIC MEDICINE AND POPULATION HEALTH: THE POTENTIAL ROLE OF FAMILY MEDICINE IN AFRICA AZIM H. JIWANI, MD, FCFP Associate Professor & Chair Family Medicine & Postgraduate Medical Education Aga Khan University – East Africa

“HEALTH IS DEFINED AS A STATE OF COMPLETE PHYSICAL, MENTAL AND SOCIAL WELL BEING” - WHO

ISSUES IN EDUCATION & TRAINING - Education not optimally oriented or relevant to the health needs of communities -hence knowledge, attitudes and skills not adequately developed -many training institutions have isolated themselves from decision-making in health care delivery

CROSSING THE QUALITY CHASM: CAN FAMILY MEDICINE LEAD THE WAY? Critical Questions 1.How can medical education be redesigned to influence and reorient public health care? 2.Are access and quality mutually exclusive goals in health and medical care in Africa?

3.How can medicine be made more humane, patient- centered, effective at low-cost and widely available? 4.Is the ideal of family medicine an elitist concept in the context of Sub-Saharan Africa? 5.Can the science, concepts and essential values of family medicine - safe, timely, effective, efficient, equitable and patient-centered care – be applied on a wider scale in a resource-poor and fragmented health delivery system.

THE WORLD HEALTH REPORT OF 2003 “SHAPING THE FUTURE” MAKES THE FOLLOWING STATEMENTS: A baby born in Afghanistan is 75 times more likely to die before age 5 than a baby born in Iceland or Singapore Life Expectancy at birth is Sierra Leone is less than half that in Japan. 4.1 million people in Sub-Saharan Africa are in need of ART, but fewer than 2% have access to them

THE HEALTH STATUS OF LARGE SEGMENTS OF POPULATIONS IN MANY COUNTRIES IS NOT IMPROVING, AND INDEED PAST GAINS ARE REVERSING IN SOME INSTANCES

-1.5 million deaths per year from RTA (50 times more injured) – 90% in developing countries, mostly people between ages 15 – 40 -(U.K. 4,500 deaths / year; Tanzania 18,000) -57 million deaths in 2002; 10.5 million in children under 5 (98% in developing countries) -In 14 African countries rates of child mortality higher now than in % of children in Africa have higher risk of death today than 10 years ago.

ADULT HEALTH IN DEVELOPING COUNTRIES SHOWS THE FOLLOWING TRENDS: -SLOWING OF GAINS AND WIDENING HEALTH GAPS -INCREASING COMPLEXITY OF THE BURDEN OF DISEASE - HIV PANDEMIC

MANY DEVELOPING COUNTRIES ARE EXPERIENCING A DOUBLE-BURDEN OF DISEASE, AS NON-COMMUNICABLE CHRONIC DISEASES INCREASE IN PREVELANCE. 50% OF ADULT DISEASE BURDEN IS NON- COMMUNICABLE DISEASE; PREVENTABLE ON THE BASIS OF EXISTING KNOWLEDGE GLOBALISATION AND CHANGES IN LIFESTYLE HAVE PROFOUND EFFECTS ON HEALTH STATUS OF POPULATIONS

MANY NATIONAL HEALTH SYSTEMS ARE TRAILING BEHIND THESE DEVELOPMENTS NEVER HAVE SO MANY HAD SUCH BROAD AND ADVANCED ACCESS TO SOPHISTICATED HEALTH CARE……………. BUT NEVER HAD SO MANY BEEN DENIED ACCESS TO EVEN BASIC HEALTH

DEARTH OF PROPERLY TRAINED HUMAN RESOURCES IS A MAJOR FACTOR IN THE FAILURE TO PROVIDE APPROPRIATE LEVEL OF CARE

WHO’S MOST URGENT OBJECTIVES INCLUDE THE HEALTH-RELATED MILLENNIUM DEVELOPMENT GOALS 3 by 5 target in HIV treatment Malaria and other Diseases Reduce Child mortality Improve Maternal Health

CHALLENGES OF HEALTH SERVICES DELIVERY : -FRAGMENTATION OF SERVICES -INADEQUATE ACCESS TO CARE – ESPECIALLY IN INNER CITIES AND RURAL AREAS -ESCALATING COSTS -LACK OF PERSONAL RELATIONSHIP WITH A PHYSICIAN -DIFFICULTY IN KNOWING WHICH PHYSICIAN TO CONTACT -HAVING TO CONSULT SEVERAL PHYSICIANS FOR COMMON PROBLEMS - INSUFFICIENT CO-ORDINATION OF CARE

OPTIMAL HEALTH CARE : - COST-EFFECTIVE PUBLIC HEALTH AND PERSONAL SERVICES -FINANCING POLICIES THAT PROMOTE HEALTH - PRIMARY HEALTH AND MEDICAL CARE EMPHASIZED -APPROPRIATE UTILIZATION OF SECONDARY AND TERTIARY CARE SERVICES - HEALTH WORKFORCE PROPERLY EDUCATED AND DISTRIBUTED - FUNDS FOR TRAINING MORE FAMILY DOCTORS

IT SHOULD BE -ACCESSIBLE -EASILY AVAILABLE -CONTINUOUS AND COMPREHENSIVE -AFFORDABLE - ACCEPTABLE TO INDIVIDUALS AND SOCIETY

NUMEROUS STUDIES OVER THE LAST 30 YEARS HAVE SHOWN LARGE VARIATIONS IN HEALTH OUTCOMES EVEN AMONGST COUNTRIES WITH SIMILAR SPENDING / INCOME, EDUCATION AND SOCIO-ECONOMIC FACTORS

THE MAIN FUNCTIONS OF PRIMARY HEALTH CARE / MEDICAL CARE ARE: Health Maintenance Illness prevention Diagnostic and curative care Rehabilitation

FUNDAMENTAL CHANGES ARE NEEDED: IN THE HEALTH CARE SYSTEM IN THE MEDICAL AND HEALTH-CARE PROFESSIONS MEDICAL SCHOOLS OTHER EDUCATION INSTITUTIONS

EFFECTIVE EDUCATION -REQUIRES ETHICAL POSITIONS AS WELL AS TECHNICAL SKILLS -WE HAVE TO BE CLEAR OUR VALUES AS WELL AS OUR SCIENCE -MASTERING THE REALITIES OF TODAY DOES NOT PREPARE STUDENTS FOR THE CHALLENGES OF TOMORROW

MEDICAL EDUCATION RESPONSIVE TO PEOPLE’S NEEDS -UNDERGRADUATE MEDICAL EDUCATION AND MEDICAL PRACTICE ARE CLOSELY LINKED -ROLE MODELS ARE IMPORTANT - NEED TO REBALANCE RATIO OF SPECIALISTS TO GENERALISTS

TEACHING MEDICINE IN THE 21ST CENTURY PRINCIPLES OF ADULT LEARNING -CRITICAL THINKING SKILLS - PROBLEM-BASED LEARNING

-WORLD CONFERENCES ON MEDICAL EDUCATION -EDINBURGH DECLARATION WORLD SUMMIT ON MEDICAL EDUCATION, WHA 1995

IMPROVING HEALTH SYSTEMS: THE CONTRIBUTIONS OF FAMILY MEDICINE – WHO noted lack of family practice training and recommended training programs – WHO Health Assembly encouraged family medicine development

TEACHING MORE GENERAL COMPETENCIES CAN BE MORE IMPORTANT THAN ISOLATED TECHNICAL SKILLS THE NEW PHYSICIAN SHOULD BE ABLE TO SOLVE PROBLEMS, FIND AND EVALUATE CRITICAL NEW INFORMATION

ATTRIBUTES OF THE FAMILY DOCTOR ADDRESSES THE UNSELECTED HEALTH PROBLEMS OF THE DEFINED POPULATION IS AN EXPERT IN THE MANAGEMENT OF THE MANY COMMON DISEASE SEEN IN ALL FIELDS OF MEDICINE

OBJECTIVES OF FAMILY MEDICINE PRACTICE: EARLY DIAGNOSIS AND TREATMENT OF DISEASE THE RELIEF OF INTERCURRENT SYMPTOMS MAINTENANCE OF HEALTH SCREENING FAMILY PLANNING NUTRITIONAL COUNSELLING GENETIC COUNSELING

- REHABILITAION - LONG-TERM CARE -TERMINAL CARE -LEGAL AND ETHICAL -CONTINUING EDUCATION & PROFESSIONAL DEVELOPMENT -RESEARCH -COMMUNITY MEDICINE AND PUBLIC HEALTH

IDEALS OF FAMILY MEDICINE -BIO - PSYCHO – SOCIAL (SPIRITUAL) DIMENSIONS -PATIENT - PHYSICIAN RELATIONSHIP -PERSONALISED CARE FOR INDIVIDUAL (IN CONTEXT OF FAMILY) -ADVOCATE FOR PATIENT’S WELFARE - LEADER AND TEACHER

THE CHARACTERISTICS OF THE DISCIPLINE -A point of first medical contact within the health care system -Develops a patient-centered approach, oriented to the individual, his/her family and their community - Specific decision making process – determined by incidence and prevalence of disease in the community - Makes efficient use of health care resources

-Co-ordinates care -Longitudinal continuity of care as determined by the needs of the patient -Manages simultaneously both acute and chronic health problems of individuals -Promotes health and well-being by appropriate and effective interventions -Has a specific responsibility for the health of the community

POTENTIAL ROLE OF FAMILY PHYSICIANS: -THE FAMILY PHYSICIAN IS AN EFFECTIVE AND SCIENTIFICALLY SOUND CLINICIAN -ADDRESS UNSELECTED AND UNDIFFERENTIATED PROBLEMS REGARDLESS OF AGE, SEX SOCIAL CLASS, RACE OR RELIGION -REGARDLESS OF BODY SYSTEM AFFECTED -FAMILY MEDICINE IS COMMUNITY BASED -FAMILY PRACTICE IS COORDINATED AND COLLABORATIVE

THE DISCIPLINE AND SPECIALITY OF FAMILY MEDICINE -PERSON CENTERED HOLISTIC AND SCIENTIFIC DISCIPLINE - BALANCING HEALTH NEEDS, SERVICES AND TECHNOLOGY

MEDICAL EDUCATION RESPONSIVE TO PEOPLE’S NEEDS REQUIRES : RESOURCES AND POLICIES THAT ENCOURAGE THE TRAINING OF PRIMARY CARE PRACTITIONERS UNIVERSITIES AND MEDICAL SCHOOLS SHOULD EMPHASIZE TRAINING AND RESEARCH IN POPULATION HEALTH POSTGRADUATE PROGRAMS FOR WELL-TRAINED SPECIALISTS IN FAMILY MEDICINE SHOULD BE A PRIORITY IN MEDICAL EDUCATION FAMILY MEDICINE IS A SCIENTIFIC AND AN ACADEMIC DISCIPLINE WITH A DISTINCT BODY OF KNOWLEDGE AND SKILLS