Family Medicine in the Middle East: Reflections on the Experiences of Several Countries
Total Page：16
File Type：pdf, Size：1020Kb
J Am Board Fam Pract: first published as 10.3122/jabfm.9.4.289 on 1 July 1996. Downloaded from FAMILY PRACTICE-WORLD PERSPECTIVE Family Medicine in the Middle East: Reflections on the Experiences of Several Countries A. Abyad, MD, MPH, AGSF Family medicine is strongly influenced by the 3. Countries whose extensive medical service country in which it is practiced. There are lessons plans have been halted or greatly decreased in to be learned from examining other health care scope because of civil strife or war, such as systems as well as the experiences of family physi Iraq, Lebanon, and Iran. cians in different countries. A changing trend in the delivery of medical care around the world and Israel the acceptance of the principle "health for all by Since the State of Israel was established in 1948, year 2000" have resulted in a shift of health care the Jewish population has increased sevenfold, delivery from hospitals and allied facilities to mainly as a result of successive waves of immi community health centers. At the same time, grants and refugees. Israel, with the financial sup family medicine has been recognized as a spe port of the United States and the Jewish commu cialty in its own right. Because this specialty is the nity around the world, has passed through a rapid cornerstone for developing a community-based process of industrialization. Modernization and health care system, training family physicians is urbanization were accompanied by extensive edu more important than ever. cational, social, and welfare programs, which During the past two decades most Middle transformed Israel into a modem welfare state. Eastern countries have placed increasing empha In the health care field comprehensive hospital sis on improved health care. Delivery of health and community health services grew rapidly. The care in the region interrelates strongly with other authorities were able to eradicate the major en factors, such as food and nutrition, sanitation, wa demic infectious and tropical diseases. Health in ter supply, literacy, and income distribution. In dices compare favorably with most developed http://www.jabfm.org/ general, the government is the main provider of countries (fable 1).1-4 The population reached health care, and social insurance is viewed as a 4.3 million by 1987.5 public responsibility. Primary health care services are provided to al The countries in this region can be divided into most 96 percent of the population through pre the following groups: paid health insurance. The premium is usually based on income, and there are fixed maximum on 26 September 2021 by guest. Protected copyright. 1. Countries typified by substantial capital, payments.6 High levels of manpower have been rapid development, and a small indigenous established, with a physician to population ratio population, such as Saudi Arabia, Kuwait, of 1:45 O. The medical community is supported by and most Persian Gulf states four medical schools that graduate 300 physicians 2. Countries with less capital, more people, a annually and by immigration. Health services quantitatively larger medical infrastructure, have several problems, however, including serious and more trained medical personnel, such as organizational problems, a structural split be Egypt, Israel, and Algeria tween preventive and curative services, fragmen tation, and lack of coordination. In addition to overutilization in the absence of cost-contain Submitted, revised, 16 April 1996. ment measures, there is an irrational bias in the From the Department of Family Medicine, American Uni distribution of medical resources toward hospital versity of Beruit, Beruit, Lebanon. Address reprint requests to services.7 A. Abyad, MD, the Department of Family Medicine, American University of Beruit, CIO AUB Office, 850 Third Ave, 18th General practice was recognized as a medical Floor, New York, NY 10022. specialty in 1963.7 Initially the specialty failed to Family Medicine in the Middle East 289 J Am Board Fam Pract: first published as 10.3122/jabfm.9.4.289 on 1 July 1996. Downloaded from Table 1. Health Indices of Some Middle Eastern Countries. Per Capita Life Expectancy Infant Mortality Gross National Index of Country at Birth (years) per 1000 Product (US$) Social Setting Bahrain 69.2 32 9,280 High Israel 75.5 11 6,210 High Kuwait 71.6 23 19,870 High Lebanon 65.0 48 1,013 High Libya 58.3 97 8,510 Upper middle Saudi Arabia 60.9 85 16,000 Upper middle United Arab Emirates 67.6 38 23,770 High United States 75.0 10 17,430 High From references 1-4. attract local graduates and was treated as an infe ment. Successful completion of the program enti rior specialty. Community-oriented health care tles residents to specialist certification by the was started through the pioneer health center in Health Ministry. Kiryat Hoyovel in Jerusalem as a model teaching Radical reorganization of the health care system unit for the University Department of Social is needed to increase resources and support for Medicine.6,s Currently there are 66 programs family and primary care medicine. 13,14 The quality with a total of237 residents.8 of residency training could be greatly improved, as The first department of family medicine was es traditional hospital rotations are more oriented tablished in the Univeristy of Tel Aviv, Saclder toward service rather than toward the objectives Faculty of Medicine,9 where all students under of residency training. The relevance of hospital went 4 years of training and an obligatory clinical experience should be viewed in relation to the clerkship.9,JO This unique department provided clinic setting in which the residents will ultimately the major inspiration for family medicine for practice. Recertification is not mandatory for many years. Later academic family medicine de maintaining professional licensure or specialist partments were established in Jerusalem, Haifa, certification; nevertheless, the Scientific Council http://www.jabfm.org/ and Beersheba, II one with an integrative commu of the Israel Medical Association has acknowl nity-oriented undergraduate curriculum. In 1975 edged the importance of regular continuing med national examination boards were established, and ical education in maintaining professional compe the Israel Association of Family Physicians was tence. The progress and the development of created in 1977. In 1980 the Department of F am family medicine as an independent academic and ily Medicine at Tel Aviv introduced the first aca clinical specialty in Israel has been very impressive on 26 September 2021 by guest. Protected copyright. demic study program leading to a postgraduate during the past two decades. diploma and a masters degree in family medicine. The residency curriculum training, which ex Lebanon tends for a 4-year period after completion of the Accurate demographic data in Lebanon are diffi mandatory internship year,12 involves the follow cult to acquire. The Lebanese population was es ing rotations: (1) full-time hospital rotations (27 timated to be 2.6 million in 1975. WIth the popu months); (2) full-time clinical practice (21 lation growing by an estimated 2.1 percent per months), including assistantship in the tutor's year, the present Lebanese population is believed practice and independent practice with tutelage to be 3.4 million.ls Estimates are 30.3/1000 for (12 months); (3) postgraduate diploma studies re crude birth, 7.7/1000 for crude death, and 49.21 lating to family practice concepts and skills, fam 1000 for infant mortality rates,16 reflecting an in ily and community-oriented health care, and termediate level between developing and devel practice organization; and (4) board examina oped countries (Table 1).1-4 tions: The primary examination is usually writ In 1983 the number of physicians in Lebanon ten, after which there is an oral clinical assess- was estimated to be 2950, about 1 physician for 290 ]ABFP July-August 1996 Vol. 9 No.4 every 1000 persons,l7 The current specialist when other sectors of the Lebanese economy J Am Board Fam Pract: first published as 10.3122/jabfm.9.4.289 on 1 July 1996. Downloaded from physician population in Lebanon is 57 percent; were declining because of the war. For example, 43 percent of physicians have a medical degree 55 new hospitals, or one fourth of all hospital fa without additional formal training in a primary cilities, were licensed within the first 6 years of care specialty and work as general practition the current turmoil. 17,23,24 ers. 15,17 It has recently been estimated that there The health care system is mainly oriented to are now 10,000 working physicians in Lebanon, ward therapeutic and episodic care, with occa representing about 1 physician per 340 persons. A sional attention to disease prevention, health pro cross-sectional study involving general practi motion, and primary care. The entire range of tioners in Beirut found that the concepts of family public health activities accounted for only 2 per medicine are not adequately practiced by general cent of the operating budget of the Ministry of practitioners and that this specialty needs to be Public Health in 1982,17,25 developed in Lebanon.ls Since its establishment in 1866, the American Mter gaining independence in 1943, a full University of Beirut has played a leading role in fledged Ministry of Health and Public Relief was Lebanon,l7 The university initiated a family created. A network of public hospitals was con medicine residency program in 1979 with the in structed, totaling 21 hospitals within 15 years. 17,19 tention that the program would graduate physi The National Social Security Fund was estab cians who would meet many of the health needs lished in 1964 as an adaptation of the European of the community. Since that time the residency model of social security schemes.17,20 The Na program has been graduating 3 to 6 family physi tional Social Security Fund adopted the fee-for cians per year.