FUTURE OF THE ARAB FAMILY PHYSICIAN
Arab Islamic civilization is historically considered one of the first to develop scientific concepts of comprehensive health care or medical practice. This was provided over hundreds of years by Arab doctors known as ‘Al-Tabib’ or ‘Al-Hakeem’ meaning 'one who provides care and wise advice'. These individuals used to provide comprehensive health care to all members of the family and community.
This development occurred during the golden age of Islamic and Arab civilization i.e. between the 3rd and 9th century of Hijrah (equivalent to the years 902 – 1600 Gregorian). At the end of this period, came a gradual decline in the educational development of the Arab and Muslim world which was a direct result of the divisions caused by weak rulers, the colonization of Arab countries by other countries as well as social unrest throughout the world. Consequently, in the mid 18th Century (Gregorian) and early 19th century, the Arab world was influenced by Western methods and practices in medicine, mainly those espoused by the British and the French. However, in the mid 19th century, many Arab countries adopted the medical practices of Russia and other Eastern Block countries and of course, those of the USA. All Arab countries during this period developed specialization in clinical practice with no clear recognition for general practice or family medicine. Until the end of 1970s, primary care was poor. Instead of comprehensive or family medicine, there simply existed dispensaries in which patients were seen and given some basic drugs.
Two years after the Alma-Ata declaration in 1978, the Arab world responded to the global call advocating health for all by the year 2000. Primary Health Care was seen as the best strategy to achieve this. However, there are many limitations to the work of family doctors. This as well as the future vision for the role of the family physician will be discussed in this paper. The development of a well-structured postgraduate family medicine program resulted in the production of highly qualified family physicians who had studied the same curriculum as students in Western European and North American programs. These programs were launched in the Arab world in 1979 by the American University of Beirut, and in the same year, a similar program was developed in Bahrain. In 1981, Saudi Arabia established the Fellowship of King Faisal University in Family and Community Medicine, the first fellowship program in Family and Community Medicine. In 1985, the Arab Board developed the Fellowship in Family Medicine which is now conferred in several Arab countries: Saudi Arabia, Bahrain, Lebanon, Qatar, UAE and Oman. Some of the major problems that have arisen in the development of Family Medicine in the Arab World are: (1) A lack of awareness of the importance of Family Medicine not only by the public but also by people in authority in the Arab World as well as by the health care professionals themselves. (2) A shortage of qualified family doctors and PHC teams. (3) The absence of adequate training centers as well as unified standards in family medicine. (4) The inability of the family doctor to practice family medicine according to international standards because of certain constraints. (5) The absence of or inadequately equipped family medicine or PHC centers, most of which are old houses converted into clinics to provide the mainly general curative service and a few preventative programs. At the same time we see the most expensive secondary and tertiary care hospitals being built. (6) Inadequate financial support to the primary care and family doctors has undermined their morale in their general performance and productivity. (7) Medical undergraduates prefer other clinical specialties to family medicine. Many medical schools do not emphasize Family and Community Medicine in the curriculum as a core subject. Medical students rarely go out to study health care in the community. Because of this, family medicine is little understood. Although the term is now familiar to many people and health professionals in the Arab World their ideas are still obsolete.
As a result of these problems, trained family doctors have little job satisfaction as compared to family physicians in the West or other Arab doctors working in secondary and tertiary care hospitals. If not addressed, this inequity may lead to the deterioration in the overall quality of Family Medicine and PHC. Several questions must be posed here: (1) What is the role of the Ministries of Health in solving the problems of health care providers? (2) What kind of solutions have been provided? (3) Have any of the recommendations made by the health care professionals been implemented?
I would like to emphasize here that the real success in health care provision in the Arab World would come when family doctors provide health care to families. To provide good Family Medicine, there must be a careful appraisal of all elements of PHC- the structure, the process (the function) and the outcome. As prevails in many countries, an evaluation of PHC should be followed by measures to correct deficiencies.
How can the role of family physicians be improved? What can be considered an appropriate contract between family doctors and health care teams with the Ministries of Health? To answer these questions a careful study must be done of the experiences of other countries with the family doctor and the entire health care team including pharmacists, nurses, health educators, psychologists, counselors, social workers, dieticians, administrators, secretaries, technicians and volunteers.
In Britain, 99% of the population have their own GP who provides care round the clock. GPs are always accessible. This comprehensive care at the PHC level is preventative, curative and promotional. Ninety-nine percent of GPs have a direct contract with the National Health Service (NHS) and so 90% of the patients they see are NHS patients. Patients have the freedom to choose their own GPs in their neighborhood but they rarely change GPs. When secondary, tertiary care or other health care services are required, the GP is responsible for coordinating the treatment and referral to the other specialty. No patient is accepted to secondary or tertiary care without a referral. About 10% of the GP surgeries (clinics) are run by single GPs (single handed practice) but the majority- 65% are run by 4 or more GPs (group practice). According to the NHS 1998 statistics, the average number of patients seen per year by a physician is 1866. The average number of consultations is 10 000 per year, per doctor. The NHS covers the patients’ bills. GPs are paid according to the number of patients registered on their list- capitation plus additional fees together with the cost of education in health promotion for chronic patient care. The GP is paid for achieving the target of immunization coverage. Additional fees are paid for birth control, and family planning clinics, etc. The GP signs a separate contract with nurses and pharmacists. Only 3% of GPs in the UK mainly in big cities like London are in private practice. In Belgium, 99% of GPs have a direct contract with the health care authority. In Denmark, the GP society arranges the terms of payment in the agreement between family doctors and health insurance organizations. One third of the GP's income comes from patient registrations, but the remainder comes from additional services as in the UK. Every contact between the patient and the GP is considered an additional income whether this contact is to provide consultation in the clinic, at home or over the telephone. In Hungary, 20% of GPs have a contractual agreement with the government based on a monthly salary provided by the health insurance organization, while 76% with their own practice under contract with the health care authority, paid according to the number of patients registered on their list. In addition to fixed fees for additional services as an incentive for those GPs, the local governments provide them with clinics, premises, for which they pay a nominal rental fee or sometimes have free. The GP is responsible for all patients registered in his list in his area, his staff, equipment and all consumables required in his clinic. Only 3% in Hungary have private medical practice and they can see patients from any area. Switzerland, considered the highest in health care consumption, had the highest number of visits per patient per year. Most of its citizens are covered by the health maintenance organization or a health insurance.
In conclusion, the experience of the Arab countries in PHC practice is relatively successful but incomplete. The infrastructure of Family Medicine needs improvement. There has been some success in the fields of immunization and childcare but more efforts is required in maternal health, health education and promotion, patient education, public health, health maintenance, chronic disease management, medical screening and early detection of diseases as well as a better control for endemic health problems. In the curative services, more authority and independence should be given to family doctors to enable them develop improve family practice.
PHC and family practice in the Arab World would benefit a great deal if their secondary and tertiary medical services were modeled and developed on the European and North American services but tailored to suit the Arab communities. It is strongly recommended that the direct contract with the family doctors be adopted giving them full authority to practice independently according to international standards. The government may provide family doctors the clinical facilities and venues to achieve their mission without charge. Let us confidently encourage and support our family doctors and health care teams to develop the best model for family medicine throughout the Arab World.
Dr. Nabil Y. Al-Kurashi, FFCM (KFU)
Associate Professor of Family & Community Medicine
Collegeof Medicine, King Faisal University, Dammam