Affordable family practitioner service in the offing

A committee appointed by the Health Care & Nutrition Minister Nimal Siripala de Silva to examine a new proposal for an affordable family practitioner service presented by Prof. Herbert Aponso at the Annual Health Forum in

 Feb. 2007 is seeking public views on the project.

Dr. Palitha Abeykoon (WHO Advisor to the Ministry of Health) and Prof. Herbert A. Aponso (Emeritus Professor of Paediatrics) of the Committee which has finalised its recommendation on the proposal in a communication to the Health Watch state “At this stage we are seeking the views of the public on this proposals and we would appreciate the publication of the script in the Health Watch.

While thanking the two members for seeking our cooperation to help in getting the public views, we would appreciate if the Health Watch readers write to us too briefly their views on this proposal.

The proposal in brief

An affordable family practitioner service

A Public/ Private Enterprise

Presented at the Annual Health Forum (Feb. 2007) by Prof. Herbert A. Aponso, on behalf of a Committee appointed by the then Director General of Health Services, Dr. Athula Kahandaliyanage, presently, Secretary, Ministry of Health Care & Nutrition

The Committee

Chairman Dr. Amal Harsha de Silva, Director, Private Health Sector Development

Members; Dr. palitha Abeykoon (WHO), Senior Advisor to the Minister of Health; Prof Herbert A. Aponso, Emeritus Professor of Paediatrics, U, Peradeniya Prof Lalitha Mendis, Consultant Medical Education, Former Dean, F/Medicine and former Director, PGIM, U. Colombo; Dr. W. A. Ferdinand, President, Independent Medical Practitioners Association; Dr. Preethi Wijegunawardena, President, College of General Practitioners; Dr. Leela de A. Karunaratne, Retired Founder Professor of Family Medicine, U. J’pura

Dr. Sarath Paranavithana, Senior Family Practitioner; Dr. Ruvaiz Haniffa, Senior Lecturer in Community Medicine, U. Kelaniya

Introduction

A senior politician, well experienced in financial affairs, in a letter written to the Hon Minister of Health, and distributed by the DGHS to all members of the committee appointed to examine the proposal submitted by Prof. Aponso, has said.

“Free Education and Free Health have been two of the greatest social welfare measures taken in this country for the last 60 years. But the time has now come for us to take a critical, meaningful and objective look at both these wonderful things, and improve, amend, and modify them for the greater good of our country...

Anybody taking a look at our Government Hospitals and their Outpatient Departments today and also taking into consideration the very high fees and charges that people have to pay for good medical care and drugs, should welcome any move to improve the Family Practitioner Service in our country.

It is most gratifying to note that, in the field of Education, far-reaching socio-economic measures have been introduced. These include the Mahapola Scholarships for University students, and for school children a free mid-day meal and a (reported) annually expenditure of Rs. 2.6 billion for textbooks and school uniforms.

This proposal, in the field of health, is a preliminary step to “improve, amend, and modify them for the greater good of our country.”

It has recently been reported that “the government has allocated Rs. 77 billion for nation building activities, and 32 subjects including major social and economic development, rehabilitation, and reconstruction projects.”

Benefits to the State and to the Public

a. The goodwill and support of a large majority of the people in the state’s policy of social and health development

b. The provision of a comprehensive primary health care service, by one’s own doctor, in all parts of the country, including the rural areas that the presently undeserved, in contrast to primary curative service.

This would prevent disease and promote good health considerably, and consequently, in the long-term, reduce the incidence of disease at Primary, Secondary and Tertiary levels.

c. The prevention of the practice of “quacks” who are causing much damage to unsuspecting patients.

In this connection, it should be mentioned that Legislation is being introduced to make it mandatory for all doctors in the private sector to display prominently their qualifications (with the country of the medical school), Registration Number of the SLMC, and Hours of Consultation.

d. Reducing medical expenses by making only an affordable payment for establishment expenses. If a Family Practitioner is available close by, as is being suggested, there would be a considerable saving in terms of time, cost of travel, and incidental expenses, when visiting a hospital OPD, a person often spends about Rs. 50 to Rs. 100.

e. There shall be no privatization of the health services - On the other hand, there would continue to exist an entirely free and less congested state OPD service to those who are unable to make the establishment payment, and the payment of the low-cost medicines that are being suggested, or to those who prefer the OPD service for any other reason

f. Provision of incentives and benefits to doctors so that they would opt for Family Practice as their chosen career; family practice, which is the cornerstone of primary health care, “is fast dying out in our country,”

The Proposal

The main focus is on government intervention to reduce the cost of primary health care, and the provision of self-employment opportunities to doctors

Central Organisation

In the first instance, it would be necessary to set up an organisation such as a Family Practitioner Committee (FPC), and later if reckoned necessary a Corporation, for the following purposes: general organisation, decisions on recruitment and remuneration of doctors and ancillary staff and on special incentives/benefits for the doctors who would opt for Family Practice as their chosen career, establishment of pilot projects and later the permanent stations, and to monitor, evaluate the system and deal with all problems. It would be necessary to appoint sub-committees for each of these activities. (vide annexures 1 and 2 for two such activities)

Professional requirements of a Family Practitioner (in addition to the basic medical qualification)

Those recruited for the proposed FP service should possess a training and experience in Family Medicine. The Diploma in Family Medicine (DFM), or its equivalent should be made mandatory at a later stage

The training should include aspects of professional and ethical conduct. It is further suggested that all medical colleges should be encouraged and supported to provide a training in Family Medicine.

Group Family Practices

Group practices of 4 FPs are recommended, reasons being:

a. to provide a round-the-clock service

b. to facilitate home visits

c. to facilitate doctors to attend medical meetings

d. to reduce the establishment expenses

Only doctors approved by the organisation would be eligible to practice at these clinics

Clinic Staff

For the purpose of efficient management, the FPs should recruit, train, an control the necessary ancillary staff, through the FPC would make the payments through, and on the recommendation of, the FPs.

Preventive Services

It is suggested that each FP should conduct Regular Special Family Clinics which would include areas such as Antenatal & Postnatal care, Family Planning services, Child Welfare (including Immunisations), Screening for the Non-Communicable Diseases (eg, Diabetes, Hypertension, Atherosclerosis), Health and Nutrition Education, etc.

Drugs and Investigations

FPC should facilitate the establishment of people friendly pharmacies, such as State Pharmaceutical (SPC) outlets, at every Group Practice, FPC clinic patients shall be provided free medical investigations at a state institute, at the request of the FP.

A distinct advantage of this scheme is that the FPs (of the FPC), would be motivated to prescribe drugs and request investigations according to an accepted uniform system, thereby avoiding unnecessary investigations and expensive drugs.

The ultimate goal would be for the FPC to have a laboratory and pharmacy for each group practice, these may be established in collaboration with the SPC.

Records

Accurate medical information is essential for, the prevention of unnecessary repetition of investigations and drugs, information on drug history, continuity of health care, referrals, etc.

In this connection, computer facilities are recommended. FPs should be appointed as Registrars of Births and Deaths, when vacancies occur, this would provide more reliable records, which are necessary for Health Planning.

Expenses by the public (for this service)

A basic principle of this public/ private enterprise is that it is obligatory for the users of this service to make an affordable payment, as ‘thutu panduru’, to cover a part of the establishment expenses; suggestion, Rs. 40. In this connection, it should be noted that the government OPDs would still be available to those who wish to seek treatment there.

Financial Provision and Remuneration for FPs

The present private full-time and part-time general practitioners

There would be no interference with their practices.

There is provision for part-time practitioners in the State sector to collaborate with this scheme in various ways, such as:

a. Secondment for service while preserving all the privileges of the state sector employment.

b. Joining this scheme, with the option of reverting back to the State sector, after a period of 5 years, without losing any of the service benefits of employment in the State sector.

c. Doing “locums” in this scheme, while being in the State sector employment

Pilot projects

It would be necessary to start a few pilot projects initially; 5 pilot projects carried out for one year would cost about 30 m (vide annexure 2).

Financial Provision for the proposed plan for a Family Practitioner (FP) Service

Recommendations of a sub-committee. Prof Herbert A. Aponso, Dr. Nimal Sanderatne (Former Deputy Governor, Central Bank of Sri Lanka, and Chairman, Bank of Ceylon), and Dr. Ranil Abayasekara (Senior Lecturer in Economics, University of Peradeniya)

Preamble

In recent times public/ private enterprises have been initiated and supported by the State in order to provide an enhanced cost-benefit to the public.

The introduction of a hospital charge at the Sri Jayawardenapura Hospital, which provides a relatively better service than at other government hospitals, can be considered to be the beginning of this policy change in the health sector.

Thus the suggestion to levy an affordable payment for establishment expenses, for a better service, is not a new concept, it is not a radical change in health policy.

The Main Expenses

These can be categorised as:

a. Initial capital expenditure for buildings, equipment, etc.b. Recurrent expenses for the central administration, and rentals for electricity, etc

c. Payment to doctors and clinic staff The salaries of the clinic staff, are calculated as the mean of the initial and the retiring salaries.

Provision is being made for the payment of 15% for either a Provident Fund or Pension scheme. Provision is also made for locum FPs.

Initial Capital Expenditure

The initial capital expenses for equipment, including computers for a 4 FP group practice would amount to about Rs. 500,000.

It is probably a fair assumption that funding for this non-recurrent expenditure would be available from international organisations or local supporters. Therefore this capital expenditure is not taken into account in calculating the financial provision. It is expected that the State would provide suitable accommodation for the Group Practices, as it would have to do so in any expansion of the health service.

The father of Geriatrics

Eight years ago in an article titled “Ageing: On a full sea we are afloat” contributed by me to an English daily (“The Island” 22nd. February 1999) it was stated that “although an American, Dr. Ignatz Nascher, invented the word geriatrics, the English invented the speciality because geriatrics is one medical speciality where Britain has led the way”.

It is, therefore, interesting to read in a recent issue of the British Medical Journal (BMJ, 9 June 2007, volume 334) of how Ignatz Leo Nascher came to be called the father of geriatrics.

Although, geriatrics has a long and fascinating history, many believe that the field entered the modern era with the publication in 1914 of Ignatz Leo Natscher’s book” Geriatrics : The Diseases of Old Age and their Treatment”. This book’s origins are interesting in that it began with a ward round.

As a medical student in New York Nasher was part of a team that came to an acutely ill woman, whose condition Nascher’s professor described in words that can be still heard today,” Old age”.

When this young student asked what could be done to help the patient, he was shocked by his teacher’s response: “Nothing!”. Several years later Nascher wrote this book, in which he first formulated the term “geriatrics” from the Greek “geron” (old man) and “iatrokas” (medical treatment).

The head of geriatrics, Soroko Hospital, Ben Gurion University of the Negev, Beer-Sheva, Israel, in reviewing this book, has this to say; “The book makes for fascinating reading. Much material, especially that on therapeutics, is of course dated.

However, the clinical approach described, and above all, the spirit of hope expressed in the book, are as relevant today as were almost a century ago.

Just as we have learnt the paediatric patient is not merely a little adult, Nascher’s book shows us that the older patient is in many ways very different from the middle aged person she once was. This book is a testimony to this pioneer’s dedication and an appropriate rejoinder to his pessimistic professor of medicine”.

- Dr. Terernce PERERA

WHO steps into save Asian traditional medicines from piracy

Dr. Viraj PERAMUNA

Traditional medical practitioners (TMP) in Sri Lanka will be glad to hear that the World Health Organisation (WHO) is taking steps to safeguard the traditional medicines and medical practices in the developing world from being pirated by interested groups in the world using Intellectual Property rights.

In a paper on ‘Traditional Medicine Strategy for 2002-2005” the World Health Organisation say:

The World Health Organisation estimates that traditional systems of medicine serve the health needs of about 80 per cent of the world’s population and the goal of health for all can never be achieved without traditional medicines.

Practices of traditional medicine (TM) vary greatly from country to country and region to region, as they are influenced by factors such as culture, history, climatic conditions, personal attitudes, ideology and philosophy.

However, there has been renewed and wider interest in TM not only in the developing countries but also in the developed countries (especially herbal medicine) for many obvious and hidden reasons.

For millions of poor patients in the vast rural areas of developing and under developed countries, the use of TM is the only affordable and accessible source of primary health care. Studies reveal that there are more TM providers than the allopathic providers especially in the rural areas.

The increased use of TM in the developed countries is mainly due to the adverse effects of chemical drugs, questioning of the approaches and assumptions of allopathic medicine, greater public access to information on traditional medicine.

Long historical use of many practices of TM including experience passed from generation to generation, has demonstrated the safety and efficacy of the above.

Despite its existence and continuous use over many centuries and its popularity especially during the last decade, TM has not been effectively recognised by the Ministries of Health in most countries. Consequently, education, training and research in this area have not been accorded due attention and support.

The World Health Organisation (WHO) launched its ‘Traditional Medicine Strategy for 2002-2005’ to enable TM to play a far greater role in reducing excess mortality and morbidity, especially among impoverished communities incorporating four objectives; policy, safety, efficacy, quality, access and rational use.

The paper also emphasises that intellectual property rights issues should be taken into consideration as many developing countries have a wealth of indigenous TM knowledge and/or natural and generic resources used in TM practices.

If not, it will pave way to losing their indigenous knowledge, ownership and right to use TM to ‘bio piracy’ within the worldwide trend and the complex legal arrangements of IPR, which are not well-known to the owners of community knowledge and generic resources.

In conclusion, the paper presents some guidelines to policy and action to promote and encourage TM. Following are some of these guidelines;

* National governments should encourage discussions among traditional healers, health professionals and the general public to formulate and develop public policies including regulations, which address the utilisation of traditional medicines in primary healthcare.

* International organisations, governments, NGOs, manufacturers and traditional healers are to develop ethical criteria for the promotion of traditional medicines and herbal remedies.

* Academic and research institutes, traditional healers, NGOs and community organisations should be supported by national governments to raise public awareness of the benefits and risks of traditional medicines and herbal remedies.

Lankan doctor honoured with the Man of the Year Award

The American Biographical Institute USA has nominated Dr. Terence Perera to be a recipient of this year’s Man

 of the Year Commemorative Gold Medal. It is the wish of the Institute to confer on a small number of men, representing a variety of countries this medal in recognition of contributions made to society.

Dr. Perera served for over 12 years as WHO Senior Advisor in Maternal and Child Health for the South East Asia Region. Prior to that, he was a Consultant Paediatrician in the Ministry of Health, Sri Lanka and was among the pioneers in the field of paediatrics in this country.

He was appointed consultant paediatrician to the General Hospital Anuradhapura in 1962, the first paediatric post for the North Central Province.

Here, as the Chairman to the Committee on Rehabilitation of Disabled Children, he initiated a programme for Education of Disabled Children in Regular Schools, for the province.

In the area of control of infectious diseases and immunization, he was helpful in evolving a scheme for data recording of infectious diseases and immunization in children in paediatric wards in hospitals and child welfare centres in the community.

His active involvement in pioneering work in Oral Rehydration Therapy (ORT) in this country is documented by WHO, including the opening of the first Oral Rehydration Centre at the General hospital, Kalutara in the 1960s as the Consultant paediatrician. ORT is now recognised as a top medical advance that has saved several million lives of children in developing countries, dying from diarrhoea and dehydration.

He was also instrumental in initiating an outreach premature baby service, in collaboration with the then Institute of Hygiene, Kalutara, to follow up the infants after their return home from hospital.

Later, he served as the fist Director of the National Integrated Programme of Maternal and Child Health and Family Planning. At one time, he was the Visiting Professor of International Maternal and Child Health, to the University of California, Berkely, and to the State University of San Diego.

On return to the country, after retirement from the international civil service, he got himself involved in community service working with the underprivileged shanty dwellers in partnership with Rev. Fr. Michael Catalano, a Jesuit priest, the founder of the Shanti Community Animation Movement (Shanti CAM), which is now over 30 years.