In a country like Sudan where there are significantly wide inequalities in wealth and access to health, Family Medicine (FM) can provide the platform on which social justice and health for all can be achieved.
Like the rest of the world, the Sudanese people are getting older with all the recognised degenerative conditions and the co-morbidities that follows. With years of lack of investment and mismanagement, the infectious diseases are getting more endemic and the resistance to antibiotics is fast becoming a serious problem. Decades of wars and economic difficulties led to lack of services, internal migration, urbanisation and unhealthy lifestyles.
This led to the recognised physical infirmities and serious psycho-social problems that need to be addressed holistically and comprehensively. Depression and mental trauma is affecting millions of people. Obesity, lack of exercise, smoking and other harmful habits coupled by wrong health believes and lack of awareness led to significant rise of non-communicable diseases that with proper systematic approach can be prevented and managed cost-effectively.
These challenges and more, need a community-based system where the person, not the disease is the focus, a system which delivers continuous and not episodic care and views health as a resource for living and not an end in itself. This is the concept of Generalism and the philosophy of FM.
Barbara Starfield, an American senior Paediatrician studied for years the different healthcare systems worldwide and concluded that systems with a strong generalist approach work best for access, equity, and cost-effectiveness. She argued strongly that the supply of Family Physicians (FPs) is associated with improvements in population health inequalities and by contrast, specialist groups make little difference to health inequalities or cost-effective care.
After years of advocacy the policymakers in Sudan have accepted this concept and there is a serious attempt to re-establish FM as an important and in some regions, the only provider of healthcare. In spite of very good efforts, there are still major challenges facing Sudan in achieving its goals. Although it is possibly the most important speciality for a country like Sudan, FM remains an alien speciality and unlikely career to pursue as it forms no part in the undergraduate curricula of all the medical schools. Community Medicine/ Public Health is important but it is and not FM.
Even if it became a career choice for some, the system failed to retain them. The first batch of postgraduate trainees successfully gained their MDs from the Sudan Medical Specialisation Board in 2006 and hundreds more did since. Today there are only 12 FPs in the whole of the country. They crossed the Red Sea to work in Kingdom of Saudi Arabia and the Gulf region. This is also true for nurses and other allied healthcare workers.
The natural result of this brain drain is difficulty in delivering the service and a serious shortage of trainers. FM trainees continue to train mainly in hospital settings and the time they spent in the health centres is largely unsupervised. Moreover, the hospital consultants do not yet grasp the concept of the generalist and do not appreciate the role of the FPs in the healthcare delivery. This unfortunately means that all the trainees finish their four years required for the MD without receiving any meaningful training in their discipline.
Visiting several training health centres over the years it is obvious to me that although a lot of improvements were made, there are still serious deficiencies in the infrastructure and the human resource. To date there are no medical notes, hardly any equipment and diagnostic tools. There are no nurses, no counsellors and other therapists that are all necessary and crucial for an appropriate, effective service.
Family medicine if executed properly will transform the healthcare delivery in Sudan. It will ensure access to high quality care to millions of people who otherwise cannot afford to access care and enables them to lead healthy, meaningful lives. It will allow thousands of doctors and other healthcare workers to fulfil their ambition for a rewarding career that gives them professional satisfaction and the much deserved recognition and status in their communities and by their colleagues
Dr. Nassif Mansour FRCGP MRCP DGM DRCOG DFFP General Practitioner – SW London Chairman of the British-Sudanese Academy of Medical Specialities