Developing Family Medicine in Palestine Samar Musmar, MD,FAAFP

2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Dr. Samar Musmar has indicated she has no relevant financial relationships to disclose.

Learning Objectives Describe the healthcare changes with attention to Primary Health care in Palestine Explain the rationale leading to the development of Family Medicine Training in Palestine Highlight challenges and future of family medicine in Palestine.

Where is Palestine ?

(West Bank and Gaza)

Health System in Palestine Only started to be organized by Palestinians in 1994 Four main health providers of health services MoH—heaviest burden at all three levels UNRWA*– Gaza>WB,1ry,some 2ry NGO’s—10-15%--all levels Private--WB>Gaza—1 ry+ 2ry *United Nations for Relief and Works Agency for Palestine Refugees in the Near East Health annual report Palestine 2012

Ministry of Health Occupied WB & Gaza Established in 1994 after Oslo peace accords Technical and financial assistance from UN(WHO), World Bank, other donors(EU, Japan, USAID, etc) Huge task of : 1.setting up the governmental health care system at all levels (1ry, 2ry, 3ry) 2.setting up health policies 3. national health insurance 4. human resources capacity building 5.all public and community health programs Collaboration with other health system sectors

Palestine Health statistics annual report Palestine 2012

Palestine demography/ health statistics Total 4.3 million (WB—2.68 &Gaza 1.67) 41%--< 15 52% --< 19 Vaccine coverage  99% NCD--↑↑: cancer,cvd Main cause of death—cvd,cva,ca Life expectancy: 74 (♀), 71(♂) Religion:Islam(80%),Christians(10%),Samaritan (1%) Literacy rate:93% annual report Palestine 2012

PHC in Palestine Palestine : total—734 PhC /population-- 1/5400 MoH PHC about 60% UNRWA PHC about 8% NGO’s—27% Population coverage by PHC  85% annual report Palestine 2012

UNRWA PHCs

UNRWA PHC’s

Diabetes nutrition eduation

Services/PHC All acute and chronic medical care Vaccination Health education Community involvement MCH program School health Oral Health program Patient referrals Communicable diseases programs and notifications *annual report Palestine 2012

Manpower in health Palestine Physicians: Total# 8810 (WB+Gaza) Physicians—35% of all healthcare workers in Palestine (71%) –GPs (only 2143(32%)—MoH) Majority with no formal training besides a one year internship No CME Big shortage in # and quality of GP’s—in PHCs annual report Palestine 2012

Developing family medicine around the world Haq C, et,al,Family Practice Journal 1996

Family Medicine in Arab Countries CONCLUSIONS: Family medicine continues to struggle for a clear identity worldwide. In the Arab world, where the specialty is relatively new, steps can be taken to better define our identity as a specialty and increase its desirability as a specialty. Hiba Osman etal, Fam Med Journal, 2011

FM in Palestine / History Since the PNA trials for introducing the concept of family medicine MAPUK program 1998 →11tutors. no full training was provided and no degrees were awarded WHO short term training course 2005 Faculties of Medicine/Palestine-- undergraduate training block (4 weeks) Palestinian Medical Council--1999

Medical education Palestine First medical school –1994 First graduate medical education in primary care –FM program(ANU)—end of 2010 Recognized by PMC Total 20 residents enrolled First residents (4) to be graduated in December 2013

FM training curriculum Arab Board/ Palestinian Board Requirements 4 year training Research component Comprehensive family centered continuity of care 3 goals : knowledge,skills, attitude

Discipline Year 1 Year 2 Year3Year4Total Internal medicine 2m ward + 1m card 1m ICU + 1m pulm+ 1 m Rhem --6 months General Surgery1m GS -- 2 months Pediatrics2m ward+ 1mNICU 1m peds clinics -- 4 months OBGYN2m obs1m gyn clinics-- 3months Psychiatry--2m comm.. psych 1m comm. psych--3 months Med subspecialties --1m rads+ 1m derm months Surgical subspecialties --1m ortho1m ENT+ 1m ophth --3 months Emergency med1month-- 1 month Community med-- 3 m--3 months Elective-- 2 m--2months Family medicine1m intro--3m FMI11m FM II15 months Total11 m 44 months+ 4 months vacation

Academic courses yearNotes Credit H Course 4 th compulsory6Research 3rd 3rdcompulsory3 Clinical Research Methods 1stoptional3 Applied epidemiology Applied epidemiology 1stoptional3 Clinical nutrition 1stcompulsory3 Medical ethics

Developments Mo H -- primary care/ family medicine as priority for development in the next 3 years Local workshops and discussions about importance of family medicine WHO – report about moving towards family medicine in Palestine IDFMP David McRay

IDFMP International Development of Family Medicine in Palestine Group of UK primary care academics who have a desire to volunteer their expertise in order to develop family medicine in Palestine Most are active in the SAPC (Society of academic Primary Care) and are university professors and researchers They are also active in WONCA

IDFMP Activities: 1.International course in family medicine – November 2013—at An-najah university— preperation for the Palestinian board exam for the first group 2.Clinical supervision 3.Fellowship in Primary Care 4.Student and resident exchange 5.International and regional participation

David McRay JPS Health Netwrok— FortworthTx Director of MCH Past two years –short visits US residents coming to Palestine working on strengthening the exchange between Palestine Fm and US

Challenges Palestine FM Health system transformation towards family medicine National Health coverage? Medical records Training—doctors and other HCW Where are the trained doctors going to work?

Needs Training sites—MoH+ future ANU teaching hospital Training centre Trainers Research

My personal experience Trained in Florida Started the UCHC in Jax/FL— Moved to Palestine 1996 Opened private family medicine clinic 1997 Started first FM residency program in 2010

My story

Thank You 31