General practitioners (GPs) or family physicians (FPs) are an integral part of primary care, they serve as the first point of contact for patients in a health care system. They play a crucial role in managing health issues of the community particularly in initiating diagnosis and treatment of various conditions. It would not be wrong to say that through medical consultations, they have an impact on the health care choices of the patients. Let’s discuss shortly what primary health care (PHC) encompasses. PHC refers to a broad range of health services provided by a multidisciplinary team of health care professionals. These services include diagnosis and treatment of health conditions, prevention, rehabilitation, and palliative care. The team includes GPs/FPs, nurses, pharmacists, dentists, dieticians, physiotherapists, cancer support teams, psychologists or mental health practitioners, etc. FPs play a central role in providing comprehensive management of common acute and chronic health conditions including diagnosis and treatment of communicable diseases (CDs) and non-communicable diseases (NCDs). A 360-degree patient care and continuum of patient care is what forms the core of the family medicine (FM) discipline.

Despite the fact that primary care is the bedrock of the health care system, the specialty of FM is not fully established in the health system of Pakistan. Let’s glance at some of the challenges encountered: medical, both undergraduate or post-graduate, and non-medical professionals are barely familiar with or have an adequate understanding of the subject. In 2014, a notification by Pakistan Medical & Dental Council (PM&DC) recommended FM as a compulsory subject in the fifth year MBBS,¹ however, due to the paucity of faculty and recognized training sites or many other reasons, this could not be implemented in true letter and spirit. The inadequate exposure to the subject has resulted in a lack of awareness about FM among undergraduates, as evident from a recent survey of five medical colleges across Pakistan. This survey aimed to assess the level of knowledge and awareness of fifth-year medical students about the FM specialty. Results revealed that only 14.3% of final-year medical students had heard of FM as a specialty.² Advocacy at local and national levels along with networking with relevant stakeholders has borne fruit. A document called accreditation standards for medical institutions (undergraduate medical education) published in 2022 by PM&DC (formerly PMC) has now included FM as an essential department in teaching hospitals.³

What happens to a health system when there is no functioning or efficient primary care facility available to the community? A high proportion of the population presents to secondary or tertiary care hospitals with undiagnosed or uncontrolled NCDs like diabetes, hypertension, cardiovascular diseases, cancers, and malnutrition in children and adults. In addition, cases of CDs like multi-drug resistant tuberculosis, extensively and multi-drug resistant salmonella typhoid infections, dengue, hepatitis-B and -C, and human immunodeficiency virus-induced co-infections in both adults and children are also brought to the tertiary care hospitals due to poorly performing primary care facilities, particularly in rural settings.

According to the latest (2022) World Health Organization statistics, NCDs kill an average of 41 million people each year, equivalent to 74% of all deaths globally. Of all NCD deaths, over two-thirds (77%) are reported in low- and middle-income countries.⁴ Pakistan has the highest reported prevalence of diabetes in the world. There is one in four adults living with diabetes in Pakistan. According to the International Diabetes Federation, diabetes was responsible for 400,000 deaths in Pakistan in the year 2021.⁵ In the absence of health insurance, patients have to bear the cost of treatment for these NCDs, which is called “out-of-pocket expenditure.” For those living below the poverty line, affordability becomes a major barrier. This further leads to late presentation and advanced stage of illness at the time they report to the hospitals. These challenges can be managed through the establishment of a well-organized PHC system in the country. Having an organized PHC system with trained (qualified) FPs, geared to meet the demands of health care can reduce the cost through early disease identification, disease prevention, and avoidance of ordering unnecessary laboratory tests. Disease prevention, early disease/cancer identification, appropriate guideline-based management, and referral to higher centers can not only reduce the overall cost of treatment but will also help in reducing the burden and advanced stage of disease and mortality thereof. This strategy of holistic care by primary care teams will directly shed the burden of secondary and tertiary care systems with subsequently improved facilities and outcomes of patients in the latter. It is not the mere presence of these physicians but their formal/structured training with the incorporation of community perspective into their clinical practice that can lead to better outcomes through effective health care provision opportunities.

One of the key factors identified as a major barrier in revamping and scaling up health care services is the lack of leadership among physicians. In the existing training systems, at both undergraduate and postgraduate levels, there is little to no focus on the development of leadership skills among the early career as well as the mid-stage physicians.⁶ Compared to other professions, the medical profession has not made significant progress in leadership development and execution. The majority of GPs consider clinical work as a priority, this along with the lack of training opportunities for them creates a gap in this domain. Encouraging leadership development skills among primary care physicians must be given priority as they form the primary contact or the starting point with the patient in the health care system.

In order to improve service delivery, a multi-faceted strategy is required, for instance, existing primary care facilities to be upgraded, opening FM/general practice out-patient (OP) clinics within secondary or tertiary care hospitals, and establishing robust referral systems to optimize health care services. Such reforms will reduce unnecessary burdens on hospital-based specialists and improve current triage systems at our hospitals.

In conclusion, strengthening the PHC system is essential and capacity building of primary care teams must be treated as a priority. Early primary care physician contact with the population will improve the local community’s awareness and knowledge about NCDs’ risk factors and preventive and early reporting practices. It is imperative that the foundations of a health care system may be laid that focuses on patient-centered practices rather than the continuation of traditional substandard health service delivery practices.

List of Abbreviations

Conflict of interest

None to declare.

Grant support and financial disclosure

None to disclose.

Ethical approval

Not required.

Authors’ contributions

HJ, AJK: Conception and drafting of the manuscript, critical intellectual input, and revisions, approval of the final version of the manuscript to be published.

Authors’ Details

Hina Jawaid¹, Abdul Jalil Khan²

1. Assistant Professor, Department of Family Medicine, University of Health Sciences Lahore, Lahore Pakistan
2. Assistant Professor, Department of Family Medicine, Khyber Medical University, Peshawar, Pakistan

References

1. College of Family Medicine, Pakistan. Notification–PMDC declared family medicine as a compulsory subject in final year MBBS exam. [cited 2022 July]. Available from: https://cfmp.org.pk/notification-pmdc-declared-family-medicine-as-a-compulsory-subject-in-final-year-mbbs-exam/
2. Nishat D, Usman G, Shah N, Abbas K, Ahmed M, Khan M. Perception of final year medical students about family medicine. PJMD. 2020;9(1):121-25. https://doi.10.36283/PJMD9-1/023
3. Pakistan Medical & Dental Council. Accreditation standards for medical institutes undergraduate medical education (UGME), 2022. [cited 2022 July]. Available from: https://www.pmc.gov.pk/Documents/Others/2022%20Accreditation%20Standards%20for%20Medical%20Institutes.pdf
4. World Health Organization. Noncommunicable diseases. [cited 2022 Aug 16]. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
5. International Diabetes Federation. With 1 in 4 adults living with diabetes, Pakistan has highest diabetes prevalence in the world. [cited 2022 Aug 20]. Available from: file:///C:/Users/Pathology/Downloads/WDD2021_PAKISTAN_PR_Final.pdf
6. Edmonstone J. Leadership development in health care in low and middle-income countries: is there another way? Int J Health Plann Manage. 2020;33(2):e1193–9. https://doi.10.1002/hpm.2606

About the Author

Dr. Hina Jawaid is a Member of the Royal College of General Practitioners (MRCGP), UK. She works as an Assistant Professor in the Department of Family Medicine at the University of Health Sciences Lahore, Pakistan. She is actively engaged in clinical, academic, and research activities in primary care not only nationally but also in the South Asian region. In addition, she regularly writes newspaper columns on health & medical topics with special emphasis on primary care reforms.