LET me first clarify that while the title of this article might give the impression that we are educating and training our medical students about quality Primary Health Care (qPHC), we are not.
Recently though, some important policy developments have taken place, which are paving the way for sustainable education and training in qPHC in Pakistan. But before that, let us frame the problem.
In my article ‘Dubious distinctions’, published on these pages on Jan 13, 2023, I provided some startling figures that indicate the depth of the public health crisis in Pakistan. To summarise: 149 countries have a higher life expectancy than us; we have a very high population growth rate; we have the world’s second highest neonatal mortality rate; 40 percent of our children are physically and mentally stunted; 43pc of women have iron deficiency anaemia; we have a high maternal mortality rate; we have failed to eradicate polio (in fact, cases are going up again); 23.5pc of the children are not immunised; we have one of the world’s highest prevalence rates of Hepatitis C, the fifth highest burden of TB, and the second highest rate of increase in the number of HIV cases in Asia; every fourth woman suffers from perinatal depression; every fourth adult above 20 years suffers from Type II diabetes; every third adult above 45 years has elevated blood pressure.
The list of tragedies is long and heartbreaking. Why? Because the state and successive governments have not prioritised the health of the people. The irony is that all of the above and many other issues afflicting Pakistan’s people — especially the poor living away from the big cities — are preventable and can be effectively managed if detected at an early stage.
The PMDC has taken some far-reaching decisions.
This happens at the primary healthcare level — in BHUs, RHCs, and GPs — and not in big hospitals. According to the WHO, up to 90pc of essential healthcare can be provided at the PHC level. Specialists in big hospitals in big cities only treat the failure of PHC at a very high cost, in terms of both money and human suffering.
If this is our context, then we should be prioritising qPHC in our policies, education and training, budgetary allocations, etc. But we don’t. Let us take medical and public health education and the training of medical students.
Currently, there is a very high probability that a young doctor, having finished her/his five-year medical education in a medical college and one-year house job at a tertiary-level hospital has never set foot in a Basic Health Unit or a Rural Health Centre. To expect this young doctor to play a role in dealing with the above-mentioned public health problems at the PHC level is wrong. It is not her/his fault. We have neither educated her nor trained him in a PHC setting. So, why this expectation? In other words, our medical education is not aligned with our public health problems on ground.
I have mentioned medical students. The same is true for nurses, medical technologists of various kinds and other health professionals. None of them are being educated and trained to work at the PHC level.
And now, the good news. The Pakistan Medical and Dental Council, the regulator of medical education and practice in the country, has underscored this problem and has decided to play its role in strengthening qPHC. By following its mandate, the Council has decided to introduce PHC education and training in medical and dental schools.
On Sept 19, 2023, the third meeting of the PMDC discussed ways to strengthen primary healthcare in Pakistan. The subject was introduced by the current president of the Council, Prof Rizwan Taj. The Council unanimously decided that “following its mandate PMDC will play an active role in strengthening PHC in the country through taking appropriate actions to embed PHC education, training and services in medical and dental colleges. To this effect, PMDC will establish a Family Medicine and PHC expert committee to develop the scope and curriculum to be implemented by the medical and dental colleges”. On July 1, 2024, a 16-member expert committee was notified.
Another key decision made by the Council was to move in the direction of “making it mandatory for all the recognised medical and dental colleges to establish/adopt up to five PHC facilities by implementing best practices in their vicinity of 10 kilometres. These PHC centres will be developed as teaching facilities by implementing best practices in PHC in order to deliver integrated preventive, promotive, curative, and rehabilitative health services in accordance with the federal and provincial essential packages of health services”.
The recognised institutions will also introduce the subject of family medicine and PHC, in accordance with the curriculum developed by the PMDC, and by recruiting appropriate faculty. The PMDC is now preparing to invite volunteer medical and dental colleges to start this programme.
These are historical and far-reaching decisions. If effectively implemented this can quietly transform healthcare in Pakistan in the coming years and decades. Bravo PMDC!
Imagine 185 medical and dental colleges in the country, each with five teaching PHC facilities of its own. This can result in 925 teaching PHC facilities. Our future generation of doctors can be potentially educated and trained in qPHC. This will go a very long way.
The Nursing Council and the Allied Health Professionals Council should also follow PMDC in terms of introducing PHC education and training in their member institutions. The AHPC, for example, has 30 disciplines being taught in its 203 member institutions across the country catering to a wide variety of paramedical education and training. All of them need to be oriented towards PHC. It is a team of health professionals at the PHC level, and not just a doctor, that can provide quality healthcare to the catchment population.
I hope this programme is implemented in letter and spirit and, unlike many others, doesn’t fall through the cracks.
The writer is a former health minister and currently a professor of health systems & population health at Shifa Tameer-i-Millat University.
Published in Dawn, July 26th, 2024
