By The Society of Family Physicians of Nigeria with contributions and assistance from Dr. Akin Moses, Dr. Sodipo Oluwajimi, Dr. Andrew Enegela, Dr. Achiaka Irabor, Dr. Blessing Chukwukelu, Dr. Henry Akujobi and Dr. Magnus Oluwafemi
The Nigerian health system has over the years been characterized by increasing morbidity and mortality despite investments and training of specialists within the health care system. This is further worsened by the loss of confidence by patients with the attendant increase in medical tourism outside the country.
The WHO and UNICEF statistics on health reveals that Nigeria has an increasing communicable and non-communicable disease pattern. Hitherto uncommon medical conditions such as cancer, Diabetes Mellitus, Hypertension, chronic kidney disease amongst others have an increasing prevalence rate. The increase in the number of persons with infectious diseases such as Hepatitis B and C, Lassa fever etc. is also a challenge. This is coming at a time of reduced government spending on health and worsening per capita income of patients. The poor level of health insurance and the predominance of out of pocket spending on health have all combined to make the situation dire indeed.
In the midst of all these, the model of training medical doctors in Nigeria tends to emphasize the role of “specialists” as being best to treat most of the common ailments affecting the average Nigerian patient. The counterproductive notion that treatment of Asthma must be by a chest physician, Hypertension by the cardiologist, Diabetes Mellitus by endocrinologists, all deliveries taken by Obstetrician amongst others is a favorite among both doctors and patients alike.
This has led to a major shortsighted orientation on health management logistics and reduced health benefits, knowledge deficiency and poor outcomes as the number of these specialists tend to be regionalized and most are concentrated in major cities with the majority of patients in resource-constrained settings having little or no access to good health care. This is in addition to the exorbitant ‘costs’ associated with having a “specialist review”.
The Teaching Hospitals and specialist centers have become overburdened with managing common ailments with long waiting times and poor productivity whilst the primary and secondary levels of care are largely neglected and ignored by the government and patients alike. Worse still, the complex conditions that should be managed at the teaching hospitals are not, as the staff are already overburdened by treating “common ailments”.
To illustrate this, a common clinical scenario of a stable diabetic, hypertensive patient with mild symptoms of knee joint pain would still require to have 3 to 4 different monthly clinic visits to the average teaching hospital to get “specialist” care, causing a delay for other patients with severe symptoms who get denied more timely referrals and reviews.
In the developed world the over reliance on “specialists” to treat every disease condition has led to astronomical increases in spending on health and over fragmentation of health care delivery services. They have also realized that there is a need to change that model of care as studies have shown that 80-85% of disease conditions do not need that super specialist input.
All these led to the establishment of Family Medicine as a medical specialty in 1969 with the special role of evaluating the total health needs of individuals and families irrespective of age, sex, disease or stage of illness in the context of their unique environment. The practitioner of the specialty is called a Family Physician.
The Family Physician accepts everyone seeking care whereas other health providers limit access to their services on the basis of age, sex and/or diagnosis. Family Medicine is a specialty aimed at training medical doctors to become “Generalist Specialist” who has the ability to manage most common diseases in the community due to their broad knowledge base with special emphasis on providing patient centered care in the context of the individual, family and community.
To proceed with this unveiling of this specialty, the following definitions and understanding of the concepts of Family Medicine, Primary Care, Primary HealthCare and the Family Physician will be helpful.
Definition of Terms:
Family Medicine: can be defined as the medical specialty that provides continuing and comprehensive health care for the individual and the family. It is the patient centered specialty that integrates the biologic, clinical, and behavioral sciences into a new whole.
The unique, holistic consideration of the effects of disease on the individual in the context of his psychosocial and even spiritual circumstances is championed by Family Medicine, and has been the driving force for excellent care in the most effective healthcare systems in the world today.
It provides care for individuals and families whether in illness or health, with the goal of achieving and maintaining an optimal status of function acceptable to the individual(s), and also hinges the achievement of this goal on good patient-physician relationships and the effectiveness of the clinical team.16, 17
The need for coordinated, continued and patient-centred care is one of the defining goals of the World Organization of Family Doctors, which includes Family Physicians and general practitioners from over 130 nations of the world.21 This body of Family Doctors pursues continuous professional development through her numerous activities around the globe.
The considerations of healthcare financing, beliefs and spirituality, and their impact on healthcare are key to the management of patients in Family Medicine, as the aim is to achieve and maintain wellness and function. The need for this approach is fueled by variable perceptions and arguments concerning the definition of health in recent times.23, 24 Arguably, no other specialty provides such coordinated and comprehensive care with an ultimate goal of optimizing patient function and well-being.
A recent independent review of health systems by the Legatum Institute showed that France, Germany, Singapore and Australia consistently ranked high in consonance with the earlier World Health Report 2000 publication on the status of health systems.25,26
These countries have common features, namely the achievement of universal healthcare access, delivered by generalist physicians through robust health insurance systems. These nations have higher numbers of physicians dedicated to primary care than other specialist care areas.
In the United States, annual uptake into residency training positions in Family Medicine have continued to soar beyond all other specialties year-on-year, due to a realization of the need for a stronger backbone of the healthcare sector.27
Family Physician: In Africa and the United States of America, the term ‘Family Physician’ is used unlike the practice in the United Kingdom of “General Practitioner”. A “GP” in Africa is most of the time a ‘medical officer’ working in private or public practice without any further training after the undergraduate medical curriculum. In Nigeria, a Family Physician has been trained in an accredited postgraduate medical institution (National Postgraduate Medical College of Nigeria and/or West African College of Physicians) using an approved curriculum and certified after passing a Fellowship examination.
A Family Physician is however a multi-competent specialist who is trained to provide comprehensive health care both at first contact and in continuity.2 The American Academy of Family Physicians (AAFP) defines a Family Physician as one trained in the discipline of Family Medicine. Family Physicians possess distinct attitudes, skills, and knowledge that qualify them to provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of a family regardless of gender, age, or type of problem (i.e., biologic, behavioral, or social). These specialists, because of their background and interactions with the family, are best qualified to serve as each patient’s advocate in all health related matters, including the appropriate use of other consultants, health services, and community resources.1
Family Physicians identify and prioritize patients’ problems, and take a holistic view of such complaints towards understanding the patient. This understanding underscores the satisfaction of patients’ needs, and paves the way for a life-long relationship with the doctor and the healthcare system. Even in wellness, the role of primary care further extends to the coverage of preventive and anticipatory care of patients.
Primary Care (PC) :
This is defined as the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community.3 Notably in Nigeria, Family Physicians make up for the dearth of specialists in other areas such as General Surgery, Obstetrics and Gynaecology, Internal Medicine and Paediatrics in the underserved areas.28 The multiplicity of skills gathered in the intensive and robust training are put to good use in the community. Such skills are particularly life-saving, and may well hold the solution to the high maternal mortality and perinatal mortality rates in the country.
The characteristics of a good primary care system include the following: 3
Integrated care is intended to encompass the provision of comprehensive, coordinated, and continuous services that provide a seamless process of care. Integration combines information about events occurring in disparate settings and levels of care as well as over time, preferably throughout the life span.Comprehensive care addresses any health problem at any given stage of a patient’s life cycle.Coordinated care ensures the provision of a combination of health services and information to meet a patient’s needs.
It also refers to the connection between, or the rational ordering of, those services, including the resources of the community and the tertiary health system.Continuous care is a characteristic that refers to care over time by a single individual or team of healthcare professionals (“clinician continuity”) as well as to effective and timely maintenance and communication of health information (events, risks, advice, and patient preferences – “record continuity”).Accessible care refers to the ease with which a patient can initiate an interaction for any health problem with a clinician (e.g., by phone or at a treatment location) and includes efforts to eliminate barriers such as those posed by geography, administrative hurdles, financing, culture, and language.
Primary Health Care (PHC):
The World Health Organization (WHO) describes Primary Health Care as essential healthcare based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community by means acceptable to them and at a cost that the community and the country can afford to maintain at every stage of their development in a spirit of self-reliance and self-determination.
It forms an integral part of both the country’s health system (of which it is the central function) and a main focus of the overall social and economic development of the community. It is the first level of contact for individuals, the family, and the community with the national health system, bringing healthcare as close as possible to where people live and work, and constitutes the first element of a continuing healthcare process.4
The terms Primary Care (PC) and Primary Health Care have been used interchangeably and while similar, they are slightly different as noted above.
The Primary Care team is the point of access to medical care for the whole community and functions as ‘navigator’ through secondary and tertiary care and other sectors. The vast majority (over 90%) of presented problems — all the ‘common’ illnesses – can be managed at the inexpensive primary care level.5 It has been estimated that 75% to 85% of people in a general population require only primary care services in a given year; 10% to 12% require referrals to short-term secondary care services; 5% to 10% use tertiary care specialists.5
Difficult or uncommon problems are referred by the Primary Care team, who lead the patients through the complicated medical maze of specialists and procedures, thus making sure that the patients receive the most appropriate care, and avoiding unnecessary costs due to a mismatch of specialist and medical problems.
Studies carried in different countries have demonstrated the importance of Family Medicine to their health care system. They have been found to amongst other things reduce cost, improve health care access in the rural areas and reduce morbidity and mortality.6, 7
Another study in the United States found that an increase of one Family Physician per population of 10,000 is associated with a reduction of 1.44% deaths, a 2.5% reduction in infant mortality, and a 3.2% reduction of low birth-weight babies on average in the population.8
In Nigeria, Family Medicine, though a growing specialty, has been making giant strides and can expand its capacity to perform more of the following roles:
The Family Physician has the capacity to play preventive roles through health screening including coordinating pre-employment, pre-school enrolment, NYSC orientation camps etc. amongst others. This will help to stem the flow of illegal, fake and embarrassing reports that emanate from a lot of hospitals.Expanding the vaccination policy in the country, in a multidisciplinary and collaborative effort.
Currently the vaccination policy in the country is largely directed at the pediatric age group, however there is a need to expand to the adults and geriatric groups, which would have attendant benefits of reduced morbidity and ultimately reduce health care costs. The use of vaccines against HPV, pneumococcal etc. are very relevant in the adult and geriatric populations. Family Physicians who treat all age groups are in the best position to coordinate these.
Health Insurance and advocacy
Advocacy is a key role of Family Physicians, and bears immense benefit in health policy formulation and implementation. In the Nigerian situation, universal healthcare coverage has not been achieved. The National Health Insurance Scheme (NHIS) put in place to provide health insurance coverage, has a dismal 4% coverage rate, with majority of the enrollees being workers in the formal sector, largely within the Federal Civil Service.29 Health disparity due to catastrophic out-of-pocket expenditure on healthcare has prevailed in the country.
In recognition of these burgeoning issues, the Society of Family Physicians of Nigeria (SOFPON) presented a memorandum for the review of the operations of the Health Maintenance Organizations and the incorporation of reinforced measures to guarantee healthcare access for the Nigerian population. The implementation of this memorandum will galvanize community based social health insurance, which is undoubtedly the way to go in assuring access for rural populations.
Also, SOFPON undertook community advocacy activities, educating the public on depression as part of her World Family Doctors’ Day Celebration in 2017. This sensitization was timely for a country in economic recession.
Collaborative activities with the National Emergency Management Authority (NEMA) in Nigeria has poised Family Physicians as prime actors in the Emergency Response System for the country, including the areas of armed conflicts, natural disasters and infectious disease outbreaks. The latter is of utmost importance in the West African Sub region, given the recent outbreaks of Lassa and Ebola viral haemorrhagic fevers, and meningitis.
Treatment and Referral System
The Family Physician is best suited to drive the primary and secondary health care system in the country. The proficiency of the Family Physician to carry out emergency and elective surgical procedures whilst being able to treat most common ailments makes them key in achieving timely and cost effective health care for all citizens.
With the Federal Government plan to refurbish and build 10,000 Primary Health Care centers, there should be primary care teams, which should be led by Family Physicians due to their multidisciplinary training.
A recent model in Mozambique found that by equipping PHCs and having qualified health care personnel, the migration of patients to Teaching Hospitals greatly reduced.
The recent decision of the Federal Ministry to Health to mandate that the clinics in NYSC camps be coordinated by Family Physicians has led to improved health care for youth corpers and forms a template for its expansion into primary and secondary care levels.
The referral system in the country is largely ineffective, chaotic and disjointed. This has led to a mismatch of skill and resources with overburdening of the tertiary level with cases that should naturally be managed at primary and secondary levels of health care. This has fueled medical tourism abroad with its waste of precious resources. The Family Medicine specialty has been an advocate of the two way referral system where triaging is initially done at the primary and secondary care levels, with a review by the relevant specialist if needed and then patients are referred back to their Family Physicians for continued care.
This model has been shown to lead to increased patient satisfaction, reduced costs and more efficiency.The management of chronic medical and infectious diseases is a critical area where Family Medicine can play a role. The current trends in outpatient and short hospital stay geriatric medicine, HIV/AIDS and lifestyle medicine are areas where the increased participation of Family Physicians has and will continue to improve health care delivery.The global and national trends show increased survival among PLWHA with the consequence of such patients developing age related medical conditions like Diabetes Mellitus, Hypertension etc.
This finding led the South African government to mandate that HIV patients be managed largely by Family Physicians as they have the skills to treat the comorbid conditions at the primary and secondary care level and this has led to improved care. Such a model will be beneficial in Nigeria.There is an increasing geriatric population in Nigeria with its attendant complications. The Family Medicine specialty has played a leading role in driving geriatric knowledge and promoting multidisciplinary care model coordinated by Family Physicians. The Tony Anenih Geriatric Center in UCH, Ibadan, is the first of its kind in Nigeria and is coordinated by Family Physicians.
This institution has started the first certificate course in geriatric medicine in Nigeria, which is improving knowledge and geriatric care and management of geriatric patients.There is a paradigm shift in disease pattern in Africa and Nigeria from communicable to non-communicable diseases like Diabetes Mellitus, Obesity and Cancers. This can be prevented and managed using principles of lifestyle medicine, which is a field that Family Medicine specialty in Nigeria has been working on, and promoting.Improving the enrollment and service delivery in the National Health Insurance Scheme.
The enrolment and satisfaction of enrollees in Nigeria has remained low despite efforts of the government to improve its uptake. The Family Medicine specialty is best placed to manage and improve confidence in the scheme due to their multidisciplinary training as clinicians and managers of resources.
The Family Physician has a great role especially in training undergraduate medical students to equip them with the skill of diagnosing the “undifferentiated” patient, providing holistic and continuing care. The Patient Centered Care Model used in General Outpatient Clinics which are coordinated by Family Physicians is quite different from other specialty outpatient clinics, where disease oriented treatment are carried out without actively seeking and considering other ailments/mitigating factors the patients might have.
These formed part of the reasons for the recent recommendation of the National University Commission to mandate all medical schools in Nigeria to have Departments of Family Medicine.
The Family Physician also has a role in training of other doctors at the post graduate level (i.e. residency training). This also includes a diploma programme to impact skill and knowledge to medical doctors who may not be able to undergo the more rigorous residency training. Currently the Family Medicine Faculty of the National Post graduate Medical College of Nigeria has been running the Fellowship training in Family Medicine that is largely run by Family Physicians with collaboration from other specialists; and the diploma programme in Family Medicine with demonstrable improvement in the knowledge and skill base of participants with expected reduction in morbidity and mortality rates.
The South African government had from the year 2008, instituted a plan to have Family Physicians trained and work at all district hospitals (equivalent to our PHC’S and general hospitals), this has improved health care delivery in their country.
Policy Formulation and Research
The Family Medicine specialty has a unique role in helping government at all levels formulate health care policies. In developed countries like the United States, United Kingdom, Australia, the respective associations and societies of Family Medicine (e.g. American Academy of Family Physicians) are part of policy think tanks that yearly formulate guidelines and policy direction for government.
The Family Physician is uniquely placed because they manage patients irrespective of age, gender or disease condition. In Nigeria, the Society of Family Physicians of Nigeria (SOFPON) has played a role in policy formulation, and amongst other laudable initiatives recently advised the government of Nigeria on health care delivery in NYSC camp treatment. This advice and collaboration has improved health care delivery to the corpers in various parts of the country.The determination of morbidity and mortality pattern, and research to achieve best clinical practices in the country which would allow the government to allocate resources appropriately is a key role that has been played by the Family medicine specialty through both post graduate colleges and SOFPON.
The Family Physician as custodian of the health care system at the primary and secondary level where most patients present has the necessary skills for research. SOFPON currently has a journal named the Nigerian Journal of Family Practice, which has been publishing important research largely carried out by Family Physicians.
Ultimately, Family Medicine is the specialty of the future. In the words of Margaret Chan, “out of the ashes built up by highly specialized, dehumanized, and commercialized medical care, Family Medicine rises like a phoenix, and takes flight, spreading its comprehensive spectrum of light, with the promise of a rainbow. This is the ancient historical covenant between doctors and patients, and this is where the health and medical professions need to return.”31 Any nation which seeks to provide universal healthcare of high value cannot afford to choose a foundation devoid of Family Medicine.
The American Academy of Family Physicians site with information for members, residents, students, and patients. Publishes the American Family Physician, Family Practice Management Journal, Annals of Family Medicine, and AAFP News Now. Available at www.aafp.org
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** Reactions to the above article should be addressed to: Dr. Akin Moses, President, Society of Family Physicians of Nigeria. He can be reached at firstname.lastname@example.org
By The Society of Family Physicians of Nigeria with contributions and assistance from Dr. Akin Moses, Dr. Sodipo Oluwajimi, Dr. Andrew Enegela, Dr. Achiaka Irabor, Dr. Blessing Chukwukelu, Dr. Henry Akujobi and Dr. Magnus Oluwafemi