By Ravikumar Chockalingam, Advisor – ICTPH
You see things; and you say ‘Why?’ But I dream things that never were; and I say ‘Why not?
George Bernard Shaw
Health services provisioning, which includes primary, secondary and tertiary care, is one of the components of a health system. Other than this critical piece, several other components of a health system have drawn a lot of attention in health systems research in recent times. These include resource production, health systems management, funding and financing of health care services, designing, implementation and evaluation of programs etc. Interventions that influence as well as address some or all of these core components of a health system are systemic interventions and have invoked enormous attention globally in the field of public health. Innovation, which often is an adaptation of what already exists to suit a given geography, culture and contextual belief, is part of the thought process driving some of the interventions designed at ICTPH.
As India transcends demographic and epidemiologic transition of disease, the emergence of newer diseases is of profound significance. Despite efforts by federal and state governments, gaps still exist in rural India, which comprises of close to 600,000 villages, where diagnostic and assessment capabilities are lacking. This not only skews health burden towards urban areas but also has enormous consequences in well-being and quality of life for close to 700 million people living in India. Further compounded by human resource crisis and infrastructure availability, primary care has often been a mirage to millions in India.
In an effort to fill some of these gaps and to identify the true burden of disease, a population level screening package has been designed at ICTPH. It incorporates best available evidence from the US Preventive Services Task Force, NICE guidelines from NHS as well as learnings from the Disease Control Priorities for the developing world to identify disease conditions that are of significant burden where recommendations exist towards screening at a population level. Another key criterion to this screening tool is the use of validated and standardised tools that are cost effective and easy administrable with structured training by community health workers. Examples include conditions such as hypertension, diabetes, obesity/overweight/underweight, refractive error/visual acuity, nicotine dependence, alcohol addiction, mental health issues, communicable diseases etc. Diseases were identified based on burden and tools were identified based on usability, cost effectiveness and validation studies. Although it may not serve as an answer to every gap in primary care in rural India, it will serve as a starting point as an exploration into health in rural India.
As a next step the Electronic Health Record and the primary care providers at ICTPH will help in identifying individuals who are at risk or diseased from the information that is collected through the population level screening package as well as walk-ins to the clinic. This process will drive the issue of evidence based medicine in creating protocols and providing a care continuum for those conditions that are screened and other conditions that are presented at the clinic. An alternative human resource design coupled with innovations in program design and implementation, a viable design of a business model and a health management team in the field makes this cohort of constructs into an ideal and much needed health systems intervention in the area of primary care. The list of conditions to be screened by Community Health Workers will continue to evolve over a period of time based on emerging evidence in an effort to bring more individuals and families into the health care system. There will be a conscious and systematic shift from the conventional illness focus to a comprehensive wellness focus in an effort to promote wellness for all, preventing morbidity for those who have preclinical or early signs of disease, as well as preventing morbidity and mortality for those who have established disease.
As one of the unique organisations that practices evidence based medicine and public health practice and uses transdisciplinary mechanisms in solving problems, the journey towards understanding and serving the vulnerable populations in India has begun. As the model has recently gone live, the true test has begun and this exploratory research will, we hope, drive much further and cause more profound ideas and innovations to sprout.