Dr Richard Stevens: The international GP educator

Oxford GP Dr Richard Stevens is working to raise the status of primary care in Myanmar.

Doctors can make good use of donated diagnostic equipment in a country where resources are limited
Doctors can make good use of donated diagnostic equipment in a country where resources are limited

I was recently part of an RCGP delegation which helped to run workshops to support the development of primary care in Myanmar.

A goal of the doctors who arranged the visit is to set up a Myanmar college of general practice and to raise the standard and status of primary care.

It has been said that an unintended consequence of five decades of military rule and relative international isolation has been the preservation of Myanmar's culture and antiquities.

One feature of this land-that-time-forgot scenario is a health service in urgent need of modernisation, which has been seriously underfunded and underinvested in all areas.

Healthcare spend

The average healthcare spend per head of population is $25, which, although a 10-fold increase over the past 10 years, is still pitifully inadequate to meet the population's needs. The health budget is one of the lowest in the world.

Staffing is also a problem; there are 0.6 doctors per 1,000 population - the comparable figure for the UK is 2.8. Most doctors in Myanmar are homegrown and train in one of the four civilian and one military medical schools, in one of the major cities. Almost all secondary care services are also based there.

The largely rural population has to rely on a very thin scattering of polyclinics and primary care doctors, or monasteries and traditional healers.

Primary care as a discipline is not recognised. The day you qualify, you either are awarded a hospital job and commence specialist training or you are, by default, a GP.

In theory, you may never have any further professional education. You start your practice, almost certainly singlehanded and with no nursing or administrative support.

Funding is from the direct payments received from patients. This too is a problem. It is well recognised that in the UK, the paymasters can dictate terms and steer the direction of a service (QOF, for example), but in Myanmar, the patient holds the pursestrings.

Prescriptions, especially for antibiotics, and injections are popular with patients. A doctor who does not give these loses a fee and the prospect of that patient reattending.

Notekeeping is unusual, as are many of the features that we take for granted in primary care - patient lists, disease registers, chronic disease monitoring, prevention, shared care and diagnostic equipment, for example.

In the past, acute illnesses, often infective, have predominated, but this is changing. Increased life expectancy has brought with it the prospect of an increasingly ageing population, while increased prosperity has brought attendant chronic diseases, such as diabetes and heart disease.

This twofold change in the nature of those needing healthcare has made the case for effective primary care services more pressing. These long-term, non-infective conditions are most effectively and efficiently managed in primary care.

Against this background, a number of Myanmar GPs have started to work towards developing primary care. A longer-term goal is the establishment of a college of general practice to support the development of primary care as a discipline in its own right. In future, a diploma in primary care medicine could be awarded, which would drive postgraduate study and raise the status of the specialty.

How then to support this initiative? Without doubt, it would save lives and unnecessary suffering. It would be cost-effective and suited to the changing demographic.

At present, a few NGOs have projects in Myanmar that encompass primary care elements. Boston University, the Australian College of GPs and the RCGP (via the Thames Valley and East Anglia faculties) are involved in various degrees. The latter offer a programme of visits to deliver workshops, an exchange programme, whereby Myanmar doctors observe services in the UK, and the development of webcasts and distance learning modules.

Key elements

To be successful, two key elements are needed. First, this cannot be imposed; sustainable change must happen from the inside out.

Second, there must be rollout of the programme. Of necessity, the initial contacts are enthusiasts who speak English and are from the cities. The programme of education and development must be applicable to the whole country. 'Training the trainers' must be the approach.

Resources are limited, which risks causing divisions. One way to avoid this is by using donated equipment from manufacturers such as Welch Allyn, which has set up projects with Myanmar healthcare centres as part of its centenary celebrations.

There is no doubt that even simple equipment such as ophthalmoscopes would be helpful - in a population of 55m, about half a million are estimated to have cataract-related blindness - but the donation could be tied to becoming a training practice, undergoing training and even an audit of the use and impact of the instruments. Small steps, but the start of a worthwhile journey.

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