Family Medicine in Kurdistan:
Now more than ever
A joint Kurdish/Dutch initiative to further the introduction of family medicine in Kurdistan Dr. Johannes Mulder, MD, PhD, FD Dr. Rajab Sanaan, MD, FD
Family Medicine in Kurdistan:
Now more than ever
A joint Kurdish/Dutch initiative to further the introduction of family medicine in Kurdistan 2014
Dr. Johannes Mulder, MD, PhD, FD Dr. Rajab Sanaan, MD, FD
Family Medicine in Kurdistan: Now more than ever
Preface These are challenging times in which to develop family medicine with rapidly changing political, economic, social and medical climates affecting general practice and primary care around the world. There are currently around 40 physicians in the Kurdistan Region of Iraq working under the title of ‘family doctor’. Despite its relatively late arrival into a medical system traditionally dominated by subspecialists, the recent introduction of family medicine is beginning to lead to a restructuring of primary care. However, the public as well as most doctors and health staff currently know little about the concept of family medicine and a network of family practices has not yet been properly established. Creating a supportive environment will give family medicine a sound basis to develop further. This feasibility report presents a historic opportunity to engage the positive force of family medicine for the benefit of Kurdish society and transform the healthcare service delivery system in Kurdistan. Family medicine, recognised as a specialty in its own right, is the cornerstone for developing a community-based health care system and has a greater role to play now than ever before. Translating this vision into reality is within our grasp, but it will require coordinated action at international, national, regional and local levels, utilising the expertise and energy of all the key stakeholders. April 2014, Dohuk, Kurdistan region of Iraq
Family Medicine in Kurdistan: Now more than ever
Table of contents
Family Medicine in Kurdistan: Now more than ever Preface Table of contents 1
Problem and opportunity: the scope of the study
6
Creating a supportive environment for family medicine
1.1
The problem and opportunity to be addressed
8
1.2
The affected stakeholders
8
1.3
Methodology
8
1.4
The project sponsor
9
2
Family medicine: what is the problem?
10
2.1
Family medicine: now more than ever
12
Rationale for adapting health systems to be more responsive to people’s needs
2.1.1
Distinctive features of family medicine
14
2.1.2
Distinction between conventional hospital care and family medicine care
16
2.1.3
Evidence for effectiveness of family medicine in improving health outcomes
18
2.1.4
Strong primary health care, now more than ever.
20
2.1.5
Preconditions and monitoring of family medicine implementation
22
2.2
The medical system in Kurdistan focusing on family medicine
Family medicine is in the initial stages
2.2.1
The situation in Iraq in general
26
2.2.2
Organisation of healthcare in Kurdistan
28
2.2.3
Family medicine in Kurdistan as part of the Middle East
30
2.2.4
Family medicine training in Kurdistan
32
24
1
PROBLEM AND OPPORTUNITY: THE SCOPE OF THE STUDY
Creating a supportive environment for family medicine
7
Family Medicine is currently in the initial stages in the Kurdistan Region of Iraq. The Directorate General of Health in Duhok has committed to further development of this area of healthcare, which has been shown to be of significant benefit.  The introduction of family medicine (FM) is progressing slowly in Kurdistan and the Directorate General wants to understand the reasons for this and create a more supportive environment to allow FM to flourish. In order to analyse the causes, the current level and quality of implementation of FM must be established. It is then necessary to define the problems hindering development, formulate the requirements to overcome them and identify the opportunities for progress. The Directorate General has commissioned the consultants of FMC to perform these analyses.
Family Medicine in Kurdistan: Now more than ever
1.1 Problem and opportunity to be addressed The problem: ´´ The introduction of family medicine in Kurdistan is encountering difficulties Current situation analysis for Kurdistan and the need for family medicine Current approach and level of implementation of family medicine Current impediments to development of family medicine 8
The opportunity: ´´ Creating a supportive environment for family medicine to develop Requirements to overcome the problem Recommended solutions and course of action: the projects
1.3 Methodology This report will explain the situation in which family doctors operate in Kurdistan, their training and how their work can be compared to that of Western family physicians. There is a general lack of documentary information about the needs of the primary care system in Kurdistan and the challenges it faces. To obtain this information, in addition to extensive literature and desk research, assessments were therefore carried out with several family doctors, primary healthcare centre doctors, subspecialist doctors, patients, academic staff and Ministry of Health/Directorate of Health staff. Separate stakeholder dialogue group meetings were also held with subspecialist doctors (7 individuals), patients (5 individuals), family doctors (10 individuals), and Directorate of Health staff (5 persons). The assessments were conducted in English. The trustworthiness of qualitative assessments, like this project, can be assessed in terms of credibility, transferability, dependability and confirmability.With regards to credibility, we are confident that the project was conducted accurately and under adequate scrutiny. The project had a clear focus and the same issues were considered repeatedly from different angles and perspectives by different individuals and groups. Triangulation was achieved by the use of observation, focus groups and individual interviews/ assessments. The selection of participants involved random sampling. The involvement of a native to the local area as co-researcher ensured familiarity with the culture.
Evaluation of the projects (separate booklet)
1.2 The affected stakeholders › Specialist family doctors in Kurdistan › General practitioners/Primary health care centre doctors in Kurdistan › Ministry of Health › Ministry of Planning › Ministry of Higher Education › Medical subspecialists › Primary health care system › Citizens › Kurdistan board of medical specialists
The issue of transferability was addressed by ensuring that sufficient detail of the context of the fieldwork was provided, enabling application of the findings to other settings in Kurdistan to be justified. To ensure dependability the study was conducted over a limited period of time with three stakeholder dialogue groups and several relevant assessments with key individuals. These proved very effective in achieving an understanding of the problems. Finally, the triangulation approach and the consultants’ clear acknowledgment of their own views on family medicine contribute to the confirmability of the project. The main limiting factor was financial, resulting in a relatively short period of research and by this limitation of assessment. For readability, it has been decided to place references together in a separate chapter. The project evaluations are in a separate booklet.
2
FAMILY MEDICINE: WHAT IS THE PROBLEM?
11
2.1
FAMILY MEDICINE: NOW MORE THAN EVER
13
Rationale for adapting health systems to be more responsive to people’s needs
Family Medicine in Kurdistan: Now more than ever
2.1.1 Distinctive features of family medicine
14
Primary care refers to the work of health care professionals who act as the entry point to the healthcare system for all patients. FM is a component of primary care and defined as a specialty of medicine concerned with providing personal, comprehensive and continuing care for individuals and groups in the context of the family and the community. The service delivery reforms advocated by the FD and primary healthcare (PHC) movement aim to put people at the centre of health care, so as to make services more effective, efficient and equitable. Although family doctors (FD) around the world have much in common, the scope of family practice (FP) services can vary significantly between different countries and communities. The actual scope of FP services is determined by the prevalence of disease and health problems, the availability of resources, the training of individual FDs and the organisation and funding of health services. For example, a world survey by Wonca showed that 98% of FDs performs preventive procedures, 94% diagnostic office procedures, 90% office surgical procedures, 73% laboratory testing and 63% supervision of healthcare personnel. FDs are medical specialists in their own right with an extensive vocational training program leading to certification. This distinguishes them from general doctors who may work in the community without any further specialist training following medical school. However, in many low and middle income countries family medicine is mistakenly regarded as synonymous with primary health care and aspects of this discipline are therefore practised by a variety of health professionals. Family medicine centres (FMC) are also known as family practices or general practices depending on the country. Similarly, the family medicine specialist is known by different names in different parts of the world: family physician, family doctor, family practitioner or general practitioner. Confusingly, this last term is often used in middle and low-income countries to refer to untrained basic doctors. In Kurdistan, the non-specialised primary health care centre doctor is known as a general practitioner while the specialised, board-certified family medicine specialist is known as an FD.
What are the distinctive features of good PHC/FM according to the World Health Organisation (WHO) and the World Organization of Family Doctors (Wonca)
´´ Person-centredness Person-oriented rather than disease-oriented, building enduring relationships ´´ General care Providing a comprehensive and integrated care package as the first point of contact for the unselected health problems of the whole population ´´ Continuous care Long-term personal relationship between doctor and patient, continuity of information ´´ Comprehensive care Health promotion, curative care, palliative care ´´ Coordinated care Care manager, gatekeeper, navigator, timely informed referral ´´ Collaborative care Works together with other medical, health and social care providers ´´ Family/community-oriented care Sees patients in context, including social, working and community aspects of life ´´ Regular and trusted entry point Has a stable, long-term, personal relationship and is the entry point to the health system ´´ Responsibility for a well-identified population
2.1 - Family medicine: now more than ever
Unfortunately, national healthcare systems in low and middle income countries tend to be characterised by a trend towards conventional hospital-oriented healthcare systems, including a disproportionate focus on specialist, tertiary care, often referred to as “hospital-centrism�. Fragmentation, resulting from uncoordinated programmes and projects combined with pervasive commercialisation of health care often leads to hospital-centrism as well.
17
The world health report 2008 : primary health care now more than ever. World Health Organization 2008
2.1 - Family medicine: now more than ever
Macinko et al, Health Serv Res 2003; 38:831-65.
19
Comprehensive careMore comprehensive health centres have better vaccination coverage, The world health report 2008 : primary health care now more than ever. World Health Organization 2008
2.1 - Family medicine: now more than ever
The World Health Report 2008
Primary Health Care
SERVICE DELIVERY REFORMS
Now More Than Ever
PUBLIC POLICY REFORMS
UNIVERSAL COVERAGE REFORMS LEADERSHIP REFORMS
21 The World Health Report 2008: Primary Health Care: Now More Than Ever. WHO 2008
The World Health Report 2008: Primary care now more than ever. WHO 2008
EM/ARD/022/E/R Distribution: restricted
Country Cooperation Strategy for WHO and Iraq 2005–2010
Iraq Pongsupap Y, Van Lerberghe W. Choosing between public and private or betweenhospital and primary care? Responsiveness, patient-centredness and prescribingpatterns in outpatient consultations in Bangkok. Tropical Medicine and InternationalHealth, 2006, 11:81−89.
World Health Organization Regional Office for the Eastern Mediterranean Cairo, 2006
CCS for WHO and Iraq, WHO 2011
Family medicine is in the initial stages
25
2.2 - The medical system in Kurdistan focusing on family medicine
ratification of key policies and strategies, the promotion of evidence-based policy formulation and decision- making and a review and upgrade of health legislation. When asked for their perspective on this stakeholder, the FDs stated that it is essential to increase this stakeholder’s understanding of the value of high quality FM and of family practice as the vehicle through which this is accessed and delivered in the community. Their perception is that the government is reluctant to give them empowerment in terms of funding and authority and they believe that the government needs to actively influence patients by conducting campaigns to educate the public on this subject. The general public tends to favour direct access to subspecialists in the belief that they provide the best service. The government needs to use appropriate legislation, public education and professional incentives to reverse this trend.
Finally Cooperation between the stakeholders is the most likely means of improving the overall functioning of health systems. Fragmentation can be overcome through shared goals that incorporate the values of quality, equity, relevance and cost-effectiveness. FDs are a critical link in the infrastructure of a well-functioning, coordinated, costeffective health system. However, to fill this role they require a system that encourages and supports the efforts of all stakeholders.
39 173. Adapted from Wollast E, Mercenier P. Pour une régionalisation des soins. In: Grouped’Etude pour une Réforme de la Médecine. Pour une politique de la santé. Bruxelles,Editions Vie Ouvrière/La Revue Nouvelle, 1971.174. Criel B, De Brouwere V, Dugas S. Integration of vertical programmes in multifunctionhealth services. Antwerp, ITGPress, 1997 (Studies in Health Services Organizationand Policy 3). Towards unity for health : challenges and opportunities for partnership in health development : a working paper / Charles Boelen Geneva : World Health Organization 2000
Towards unity for health : challenges and opportunities for partnership in health development : a working paper / Charles Boelen Geneva : World Health Organization 2000
2.2 - The medical system in Kurdistan focusing on family medicine
41
2.3
WHAT FACTORS ARE INHIBITING THE DEVELOPMENT OF FAMILY MEDICINE?
3
REQUIREMENTS FOR SUCCESSFUL DEVELOPMENT OF FAMILY MEDICINE
References
References 1 Problem and opportunity: the scope of the study Shenton AK: Strategies for ensuring trustworthiness in qualitative research projects. Educ Info 2004, 22(2):63–75 2.1 Family medicine: what is the problem? Rationale for adapting health systems to be more responsive to people’s needs Abyad A, Homsi R. A comparison of pregnancy care delivered by family physicians versus obstetricians in Lebanon. Family Medicine, 1993 25:465−470. Alwan A: Health in Iraq: the current situation, our vision for the future and areas of work. 2nd edition. Baghdad: Ministry of Health; 2004. Ammar W. Health system and reform in Lebanon. Beirut, World Health Organization Regional Office for the Eastern Mediterranean, 2003. Beach MC. Are physicians’ attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Education and Counselling, 2006, 62:347−354 Bergeson D. A systems approach to patientcentred care. JAMA, 2006, 296:23. Bindman AB et al. Primary care and receipt of preventive services. Journal of General Internal Medicine, 1996, 11:269−276. Chande VT, Kinane JM. Role of the primary care provider in expediting children with acute appendicitis. Achives of Pediatrics and Adolescent Medicine, 1996, 150:703−706. Country Cooperation Strategy for WHO and Iraq, 2005–2010, World Health Organization Regional Office for the Eastern Mediterranean, 2006 WHO De Maeseneer JM et al. Provider continuity in family medicine: does it make a difference for total health care costs? Annals of Family Medicine, 2003, 1:131−133. Elder NC, Vonder Meulen MB, Cassedy A. The identification of medical errors by family physicians during outpatient visits. Annals of Family Medicine, 2004, 2:125−129. Elwyn G. Safety from numbers: identifying drug related morbidity using electronic records in primary care. Quality and Safety in Health Care, 2004, 13:170−171. Fiscella K et al. Patient trust: is it related to patient-centred behavior of primary care physicians? Medical Care, 2004, 42:1049−1055. Forrest CB, Starfi eld B. Entry into primary care and continuity: the effects of access. American Journal of Public Health, 1998,
88:1330–1336. Gadomski A, Jenkins P, Nichols M. Impact of a Medicaid Primary Care Provider and Preventive Care on pediatric hospitalization. Pediatrics, 1998, 101:E1 Gill JM, Mainous AGI, Nsereko M. The effect of continuity of care on emergency department use. Archives of Family Medicine, 2000, 9:333−338. Gill JM. The structure of primary care: framing a big picture. Family Medicine, 2004, 36:65−68. Greenfield S et al. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. Journal of the American Medical Association, 1995, 274:1436−1444. Grunfeld E et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. Journal of Clinical Oncology, 2006, 24:848−855. Hjortdahl P, Borchgrevink CF. Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. British Medical Journal, 1991, 303:1181–1184. Hurley RE, Freund DA, Taylor DE. Emergency room use and primary care case management: evidence from four medicaid demonstration programs. American Journal of Public Health, 1989, 79: 834−836. James Pfeiffer International. NGOs and primary health care in Mozambique: the need for a new model of collaboration. Social Science and Medicine, 2003, 56:725–738. Krikke EH, Bell NR. Relation of family physician or specialist care to obstetric interventions and outcomes in patients at low risk: a western Canadian cohort study. Canadian Medical Association Journal, 1989, 140:637−643. Lasker R. Medicine and public health: the power of collaboration. New York, New York Academy of Medicine, 1997. Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: historical perspective. Journal of the American Board of Family Practice, 2001,14:54−563 MacDonald SE, Voaklander K, Birtwhistle RV. A comparison of family physicians’ and obstetricians’ intrapartum management of low-risk pregnancies. Journal of Family Practice, 1993, 37:457462.
51
Family Medicine in Kurdistan: Now more than ever
Abbreviations CCS CME EC FAO FD FM FMC FMPR FP GDP HIV/AIDS
54
IFHS IFRC IHSES IMF IOM KRG MCH MDG NCD NGO NHA PHC PHCC UN UNAMI UNDAF UNDG UNDP UNEP UNFPA UNICEF UNIDO UNIFEM USAID WB WFP WHO WONCA
Country Cooperation Strategy continuing medical education European Commission Food and Agriculture Organization of the United Nations family doctors Family Medicine Family medicine center The Kurdistan Family Medicine Residency Programme Family practice Gross domestic product Human immunodeficiency virus/acquired immune deficiency syndrome Iraq Family Health Survey International Federation of Red Cross and Red Crescent Societies Iraq Household Socio-Economic Survey 2008 International Monetary Fund International Organization for Migration Kurdistan Regional Government Maternal and child health Millennium Development Goals Noncommunicable disease Nongovernmental organization National health accounts primary healthcare primary health care centres United Nations United Nations Assistance Mission for Iraq United Nations Development Assistance Framework United Nations Development Group United Nations Development Programme United Nations Environmental Programme United Nations Population Fund United Nations Children’s Fund United Nations Industrial Development Organization United Nations Development Fund for Women United States Agency for International Development World Bank World Food Programme World Health Organization World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. WONCA’s short name is World Organization of Family Doctors.
Abbreviations
55
Family Medicine in Kurdistan: Now more than ever