By Dr. Aarti Sahasranaman and Dr. Zeena Johar 1
For a number of reasons, it seems pretty clear that any durable solution to the challenges of healthcare in India will involve a massive expansion in the infrastructure and personnel engaged in the task of providing primary healthcare. Given their undoubted importance, the government has emphasised vaccinations, reproductive and child health, and the control of infectious diseases such as tuberculosis and malaria, in its interpretation of primary care. However, as we think through models of primary care that will become an integral part of universal healthcare in India, it becomes necessary to examine if this is indeed an adequate definition of care that needs to be provided at the primary level.
A study of the Global Burden of Disease published in 2010 found that non-communicable diseases are now responsible for 53.8% of all deaths in low and middle-income countries, as well as 48.9% of all days lost to disability. These diseases include a wide variety of conditions, the most prevalent among them being mental health issues (neuropsychiatric disorders), cardiovascular diseases, cancers, and sense organ impairment. Within mental health issues, common mental disorders including depressive and anxiety disorders have the highest prevalence rates. Within cardiovascular diseases, high blood pressure is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India. Similarly, diabetes has seen a rapid explosion in India in terms of numbers of people affected. The WHO estimates that India had 32 million people living with diabetes in 2000 and this number is projected to rise to 80 million by 2030. Within cancers, cervical and oral cancers are the most prevalent forms among women and men, respectively, in India and both these cancers are highly amenable to primary prevention. Sense organ impairment primarily includes vision disorders such as glaucoma, cataract, and refractive errors, and adult-onset hearing loss. The prevalence of, for example, refractive errors in a rural South Indian population was demonstrated to be about 31% for myopia and 18% for hyperopia.
A study based on approximately 4,000 patient visits to six primary healthcare clinics being operated by Sughavazhvu Healthcare in rural Tamil Nadu also reveals some interesting trends which corroborate the findings from the Global study mentioned earlier. In these six clinics, while more than 30% of men seeking primary care were between 50 – 69 years old, about 40% of all women seeking primary care were between the ages of 30 – 49 years. The top four complaints with which all patients presented to the clinics were cold, body pain, multiple joint pain, and weakness. However, when analysed by age, the proportion of complaints indicative of chronic conditions (such as osteoarthritis and pain) increased – going from 33% in patients aged 30 – 49 years to 51% in patients aged 50 – 69 years. The four most common diagnoses were pharyngitis, allergic bronchitis, osteoarthritis, and non-specific body pain. While acute, episodic conditions constituted 48% of all diagnoses, chronic conditions such as osteoarthritis, body pain, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and diabetes represented 29% of all diagnoses. In fact, hypertension, hyperlipidemia, and diabetes, three modifiable risk factors for CVDs, together contributed to about 30% of all chronic diagnoses made in patients over the age of 30 years.
From all of this discussion it is immediately apparent that since it is the first point of contact that a person has with the health system, it is imperative that primary care services provision a much broader range of offerings taking the disease burden into account. The six clinics mentioned earlier operate using the IKP Centre for Technologies in Public Health (ICTPH) model of primary care in which, a well-trained and legally qualified physician (who does not have an MBBS degree), assisted by a locally-hired health extension worker (HEW), provides the broadest possible range of healthcare services. In addition to treatment for acute conditions, these include dental fillings and scaling, cervical cancer screening, vision screening and dispensation of glasses, and management of chronic diseases. Prior to establishment of each of these village-based health centres, the entire catchment population is geo-mapped, and each household issued a bar-coded enrolment ID containing all family details. Community-based risk profiling of all adults is then performed to identify high risk individuals who have modifiable risk factors for non-communicable diseases. Identified high risk individuals, for example for CVD (based on height, weight, blood pressure, tobacco consumption, and waist and hip circumference as risk markers) are then exhorted to seek treatment at the health centre immediately, and are followed up until they do so regularly. The Health Information Management System ensures that there is a strong control environment within which each health centre operates.
It is clear that the need for such a model of primary care exists; it is also clear that at least in small and controlled settings this care can be provided at a modest cost, optimally utilising qualified and formally licensed manpower that is relatively easily available and is willing to serve in remote locations. The challenges that need to be addressed are those of financing and scale-up or replication of these models. It is our view that these challenges are possible to address but will need an organised response from the corporate sector and / or the government and that spontaneous efforts by individual physicians or non-profits will simply not be able to mount an adequate response.