This document discusses universal health coverage and challenges facing family medicine. It notes that 400 million people lack access to essential health services and 6% of people in low- and middle-income countries are pushed into poverty due to health spending. It also discusses issues like non-communicable diseases, maternal mortality, aging populations, and shortages of health workers. The document argues that family medicine should be the foundation of health systems as it provides comprehensive, continuous, cost-effective primary care. However, there is a large shortage of family physicians globally and in the Arab world specifically. It proposes strategies to increase training programs and recruitment into family medicine to address this shortage.

1. Universal Health Coverage:
Challenges Facing Family
Medicine
Prof Faisal Abdullatif Alnasir
FPC, FRCGP, MICGP, FFPH, PhD
Chairman; Home Health Care Centre
General Secretary & Treasures; International Society for The History of
Islamic Medicine
Chairman; Home Health Care Center
Temp Advisor WHO EMRo
Former Chairman; Dept. Of Family & Community Medicine
Former President; Scientific Council Family & Com. Medicine Arabian Gulf University
Former President Family & Community Medicine Council. Arab Board for Health
Specializations
Faisal Alnasir 2017 1

2. 2
• 400 million people do not
have access to essential
health services.
• 6% of people in low- and
middle-income countries
are pushed further into
extreme poverty because
of health spending.
WHO and World Bank Group
Expansion of universal health coverage in the
EMRo Region is critical :
Faisal Alnasir 2017

3.  65 million adults are illiterate,
two-thirds women
 10 million 6-15 year olds are
not in school (if current trends
persist, that number will
increase by 40% by 2015)
 54 million lack access to safe
water
 29 million lack access to
health services
UNDP,2013
“The Arab region has
dramatically reduced
poverty and inequality
in the 20th Century.”
Yet……
3Faisal Alnasir 2017

4. NCD epidemic
Leading to serious implications
on the regional health situation
and a negative impact on
socioeconomic development.
•In 2008, >2.2 million people
died from NCDs, (35% of them
before the age of 60).
•The anticipated deaths will
increase to 3.8 million in 2030.
Ala Alwan, Former Assistant Director General, World Health
Organization
4Faisal Alnasir 2017

5. 5
In EMR
• The prevalence of
hypertension 26% affecting
125 million individuals.
• Each year, there are several
million new cases of
hypertension and more of
pre-hypertension.
Report on the regional consultation on
hypertension
UAE, 2003
Faisal Alnasir 2017

6. 6
6
Prevalence of overweight and obesity in EMR countries(WHO.2004)
Overweight/obesity (%)Country
FemalesMales
70.064.0Saudi Arabia
53.060.0Lebanon
67.757.0Islamic Republic of Iran
79.056.4Bahrain
5679Kuwait
41.043.8Egypt
74.942.5Libyan Arab Jamahiriya
43.540.5Oman
21.737.2Morocco
39.925.5United Arab Emirates
43.746.0Jordan
41.913.1Tunisia Faisal Alnasir 2017

7. 7
In EMR:
Maternal mortality rate
remains unacceptably
high.
With 350 maternal deaths
occurring per 100 000 live
births.
(Maternal mortality in Somalia and
Afghanistan continues to be among
the highest in the world).
Regional Committee for the EMR
September 2008
Faisal Alnasir 2017

8. 8
Ageing population:
The prevalence of people
above the age of 60 is
increasing markedly in the
developing countries
while it is almost stable in
the developed world.
Bahrain as an example of
EMRo it is anticipated that
the percentage will reach
to 15% by the year 2025
and 25% by the year
2050.
Alnasir, 2011
Faisal Alnasir 2017

9. 9
Insufficient Health Workers:
Low and lower-middle
income countries need 18
million more health workers
if they are to achieve UHC.
Marie-Paule Kieny,
WHO Assistant Director-General, 2016
Faisal Alnasir 2017

10. Faisal Alnasir 2017 10
Doctors’ Shortage is an invisible problem
CNBC 2015
The USA nation’s shortage of doctors will
rise to between 46,000 and 90,000 by 2025
Forbes March 2015
The doctor shortage is real
Association of American Medical Colleges(AAMC)
It is estimated that between 12,500 and
31,000 Primary Care Doctors will be
needed in the USA
Association of American Medical Colleges(AAMC)

11. Faisal Alnasir 2017 11
>Million people are registered with a GP
serving more than 3,000 patients(almost twice the
average list size of 1,600).
Rowena Mason ,The telegraph December 2011
England has 25,000 FDs
But there are growing concerns that the NHS
faces a retirement crisis.
One in eight GPs is planning to retire within two years.
Survey by the British Medical Association published in June 2011
,
In UK

12. In USA an additional of 21,000 FPs is necessary.
The annual production of new FPs would have to
increase by an average of about 65 each year,
increasing from 3,500 today to 4,475 by 2025.”
AAFF 2015
Faisal Alnasir 2017 12

13. Universal Health Coverage
(UHC) is not a new concept,
but its inclusion in the
Sustainable Development
Goals (SDG) agenda is a
significant acknowledgment
by the nations of the world
that progressing toward UHC
will not only improve the
health of millions, but will
also contribute to reaching
many of the other SDGs.
Faisal Alnasir 2017 13
Marie-Paule Kieny,
WHO Assistant Director-General,2016

14. So What is the Ideal Health
System?
Is the one that:
“Secure the Health of
the Whole Population”
© WHO C Centre, Imperial College London
Faisal Alnasir 2017 14

15. Improve Health
Responsiveness to needs
Financial Protection
And its Goals:
WHO C Centre, Imperial College London
Faisal Alnasir 2017 15

16. Faisal Alnasir 2017 16
Reiter Syndrome

17. 17
Comprehensive and not disintegrated
Health coverage:
Faisal Alnasir 2017
Family Medicine

18. Family Medicine is not
new.
Since ancient times, doctors
have been using the holistic
approach while practicing
medicine.
Avicenna, Alrazi and other
ancient doctors were
implementing the concepts of
family medicine while caring
for their patients. They were
adopting a holistic approach.
However, with the
disintegration of medicine into
various specialties and sub-
specialties this concept was
lost overtime
Alnasir Faisal ,2010
18Faisal Alnasir 2017

19. 19
• Family Medicine (FM)
Is the fifth medical specialty that provides
the individuals and the whole family;
primary, personalized and continuous health
care. It offers comprehensive care ie.
responsible for offering a total health care
from the first contact and initial assessment
to the management of acute & chronic
problems. With emphasis on prevention and
early recognition of disease.
Faisal Alnasir 2017

20.  It is the care that (PPCM):
-Promote health
-Prevent illness
-Provision of care for acute
& chronic illnesses
-Manage ongoing health
problems (Psych-social)
Primary Health Care
20Faisal Alnasir 2017

21. 21
Principles of Primary Health Care
P H C
Affordable &
Sustainable
Family &
Population
Health
Personal care
Continuous
Care
Accessible
Intersectoral/
Interdisciplinary
Appropriate
Efficient
Faisal Alnasir 2017

22. • Family Medicine Should
Shape the Reform of any
health system Not Vice
Versa.
22Barbara Starfield ,2009Faisal Alnasir 2017
• Family physicians have
to be in the forefront of
any health care reform.

23. Health Care Reform
(With PHC Concept)
23
Medical model Primary Health Care
 Illness  Health
 Cure  Prevention, care
 Treatment  Health promotion
 Episodic care  Continuous care
 Specific problems  Comprehensive care
 Individual practitioners  Teams of practitioners
 Health sector alone  Inter-sectoral collaboration
 Professional dominance  Community participation
 Passive reception  Joint responsibility
Barbara Starfield, Johns Hopkins University, 2009Faisal Alnasir 2017

24. Faisal Alnasir 2017 24
PHC
SHC
THC
Provision of health care in many
countries
SHC: Secondary Health care
THC: Tertiary Health Care
PHC: Primary Health Care
Alnasir F,2014

25. Faisal Alnasir 2017 25
PHC
SHC
THC
The optimal health care
provision
PHC: Primary Health Care
SHC: Secondary Health care
THC: Tertiary Health Care
Family Medicine is the foundation of any health system
Alnasir F,2014

26. Faisal Alnasir 2017 26
Why Is PHC Important?
•Better Health Outcomes
•Lower Costs
•Greater Equity

27. 27
Health systems oriented to
primary health care is able
to respond continuously to
the new challenges in all
countries, whether
developing or developed,
rich or poor and in conflict
or in peace.
Regional Committee for the EM/RC55/INF.DOC.6(a)
Eastern Mediterranean September 2008
Faisal Alnasir 2017

28. 28
People living in
countries with an
abundance of primary
care physicians have a
better quality of life
Dr. Muntazar Bashir KFSH & RC2007
•Better health outcomes
Faisal Alnasir 2017

29. 29
A well-trained family
physician is able to deal
with eighty percent of
health problems that affect
the human being, whether
the person is a child, adult,
male or female.
AUB Dept of Family Medicine
•Greater equity
Faisal Alnasir 2017

30. Faisal Alnasir 2017 30
•On average each one
additional family
physician per 10,000
people is associated
with a 5.3% reduction
in mortality
Ian Scott, Goldis Chami CCFP

31. 31
Cost of health services in Bahrain 2009
Heath center visit cost US$ 14-20
Hospital OPD visit cost US$ 130 ( 600%)
Admission per night cost US$ 530-660
Admission intensive care US$ 1300
Alnasir F, 2009
Faisal Alnasir 2017

32. 32
Cost-Effectiveness (Intervention cost/case):
•Telephone Call £16
• Family Physician £15
• Walk-in-Centre £55
• FP with Special Interest £75
• Hospital Outpatient £150
• Day Care £500
• One-Day Admission £1,000
• Inpatient (2ndary Care) £5,000
• Tertiary Care £20,000
PHC
2 Care
3 Care
WHO Collaborating Centre, London Source: Rawaf, Dubois, 2007
Faisal Alnasir 2017

33. 33
Although it is very
economical, PHC is
not an approach for
poor countries, for
poor people or for
diseases of the poor.
Regional Committee for the
EM/RC55/INF.DOC.6(a)
Eastern Mediterranean September 2008
•Lower Costs
Faisal Alnasir 2017

34. 34
Current Demand for
Family Physicians
“According to Merritt, Hawkins
& Associates’ 2005 Survey of
Hospital Physician Recruiting
Trends, More hospitals are
actively engaged in recruiting
family physicians than any
other type of physician.”
Family medicine was the
fourth most heavily recruited
specialty
Of the 85% of hospitals recruiting physicians in the 2003
Merritt, Hawkins hospital survey, 45% were actively seeking
family physicians.
Leslie Champlin – AAFP News Now
(7/25/06)
34
Faisal Alnasir 2017

35. MOST WANTED
For the first time in six
years, general internists
and family physicians are
at the top of the ‘in
demand’ list for hospitals
and medicals groups,
according to a review of
2,840 Merritt, Hawkins &
Associates’ listings.
Here by year are the
number of physician
searches by specialty
starting in 2002-03 and
continuing through 2005-
06.”
AMA News June, 2006
35Faisal Alnasir 2017

36. Fifty percent of the
physicians’ work force
in any country should
be constituted of
Family Physicians.
Barbra Starfield 36Faisal Alnasir 2017

37. Why is the demand increasing
for FDs ?
• Population growth
• More health awareness
• Ageing Population
• Ageing doctors
• Change in the illness trends NCD
• Less graduates choose FM (Less reward ) (we
have to figure out a way to reward primary care providers so more
will enter that area)
• Growing number of female GPs, many of whom
work part-time because of family commitments
37Faisal Alnasir 2017

38. 38
Providing optimal generalist
care requires broad and
comprehensive training that
cannot be gained in brief
and uncoordinated
educational experiences.
(Kimball and Young,1994)Faisal Alnasir 2017

39. • The Arab Health Ministers in Kuwait in February 1978, decided
to establish the
Arab Board for Health Specializations
It aims to:
 improve medical services in the Arab world
 raising level of professional skills
 develop and institute guidelines for training in different medical disciplines
 maintain quality by periodic review.
• Only around 1567 physicians (FD) have graduated
since its foundation 28 years ago.
ABHS 2014
39Faisal Alnasir 2017

40. • World-wide, the optimal
Family doctor/patient
ratio is 1800 people.
• With the realization that
its population is over
three hundred and
seventy million, the Arab
World now needs more
than 205600 FD
specialists.
40Faisal Alnasir 2017

41. • Continuation at the current production
rate of Board qualified FD by the ABHS,
(150 to 200 per year);
Arab countries would require
1030 -1370years
to have optimum number of
immediately required FDs!!!
41Faisal Alnasir 2017

42. 42
Shortage of family doctors
leaves health care in crisis.
The NHS is facing a
chronic shortage of family
doctors after official figures
showed some GPs were
responsible for 9,000
patients.
The Telegraph
In UK
Faisal Alnasir 2017

43. 43Building primary care in a changing Europe Case studies. European
Observatory on Health Systems and Policies. 2015
Faisal Alnasir 2017

44. Faisal Alnasir 2017 44
Projecting the Supply and Demand for Primary Care Practitioners
Through 2020: HRSA 2013

45. Why isn’t it
implemented?
Is it costly? 45Faisal Alnasir 2017

46. Cost of a program with the intake capacity of 20 intake:
 Number of trainer to trainee 1 to 4 (Total 5 Trainers FD)
 Cost of 5 Trainers salary US$ 10500 x5= 52500 /month =630000/year)
 Cost of trainee (Monthly salary=US$ 2200x 20=44000 per month= 528000 per year)
 Arab Board fee US$ 250/candidate per year= 300 x20= 6000
 Administrative expenses US$ 100000 per year
 Total= 630000+528000+100000+ 6000= US$ 1264000
Cost per Graduate = 1264000/20= 63200x 4 years= US$252800
BD 95600
46Faisal Alnasir 2017

47. What is the solution
47Faisal Alnasir 2017

48. Faisal Alnasir 2017 48
“It must :
• Be comprehensive.
• Start with medical
school recruitment .
• And continue through to
an improved practice
environment that gives patients
access to timely, comprehensive
and high quality care.”
Reid Blackwelder Board Chair AAFF 2015

49. Solution:
The strategy is to focus on 4
areas:
•Policy makers, MPs and the public
•The Training Centers/ Programs
•The doctors (trainer & trainee)
•General
49Faisal Alnasir 2017

50. 1)Policy makers, MPs and the public:
 Conviction by the policy makers about the
importance of FM
 Admiration that FM is the foundation of all of
provided health services
 Recognition that FM is the fifth specialty in
Medicine
 Political determination to implement FM
 Increase budget pertained to FM (training, health
centers)
 Increase public awareness about the importance
of FM in order that they form political pressure on
policy makers to implement strategies favoring
FM
 50Faisal Alnasir 2017

51. 2)-The Training Programs/Centers:
 Increase number of training programs
 Increase the capacity of existing ones
 Establish ideal training PHC centers
 Improve the work environment
 Increase the incentives to FD
 Opportunities for FD to acquire foreign
experience
51Faisal Alnasir 2017

52. 3)-The Doctors
 Have in-depth knowledge of Family Medicine
 Have interest in joining the program
 Realize that FD status is no less or different than
other specialty
 On going, on job continuous medical education
programs
 Self satisfaction (payment, rewards, working
environment)
52Faisal Alnasir 2017

53. 4)-General:
 Increase number of medical schools and its
intake
 Establish departments of Family Medicine in
every medical school
 Adopt Community oriented curriculum.
 Support Arab Board for Health Specialties
 The Arab Board Qualification should not be
underestimated or downgraded
 Intensive training programs for the existing
PHCs’ doctors
53Faisal Alnasir 2017

54. 54
The family unit is the
backbone of any country.
Looking after the heath of
this unit is of paramount
importance. And family
practice should be in-built
within the national health
policy.
Prof. Lalitha Mendis, Director, Post-Graduate
Institute of Medicine (PGIM), University of Colombo,
Faisal Alnasir 2017

55. Primary care everywhere in
the world is most of the care,
for most of the people,
most of the time.
Barbara Starfield
55Faisal Alnasir 2017

56. © WHO Collaborating Centre, London Source: BMJ, 2008
Faisal Alnasir 2017 56

57. 57
Representing some 500,000 family doctors in over 130 countries
Faisal Alnasir 2017

58. • In conclusion
The concept of Universal Health Coverage will be
affected dramatically and may be in danger due to
severe shortage in FD.
A courageous and immediate decision ought to be
taken and efforts ought to be made in order to
establish more training programs and to increase the
capacity of the existing ones to produce larger
number of skilled FDs needed to maintain and
upgrade the health of nations in the EMRo region.
58Faisal Alnasir 2017

59. 59
Thank
you
Family
Doctor
leads the
way
Faisal Alnasir 2017