A Clinic with a Doctor is not Primary Care
Nachiket Mor
Health services have traditionally been understood to be about patients reaching a clinic, hospital or a defined place of diagnosis, treatment, or care. However, unless we feel very ill, our instincts that have evolved over millennia and were necessary for the survival of our species predisposes us to think that we are perfectly healthy. This includes those of us who have a little discomfort from what we might think of as minor ailments and all those who suffer silent diseases that become unmanageable health burdens over time.
As a direct result, even in States with relatively good health systems, such as Kerala and Tamil Nadu, the proportion of men who have diabetes but are not on treatment has doubled over the last five years. It has gone from 6 to 7% in 2015-16 to 12-14% in 2019-21 and continues to rise rapidly. In the districts of Thiruvananthapuram and Pathanamthitta in Kerala, it has already crossed 20%. Such high levels of diabetes, if not urgently managed, can trigger an epidemic of blindness, strokes, and amputations in these regions.
In our Northern, less prosperous States, despite the best efforts by their governments spanning over decades, more than 60% of women and children continue to be anaemic. In the Jamui district of Bihar, Dakshin Dinajpur district of West Bengal, and Chhotta Udaipur district of Gujarat, these proportions are more than 75%. Such high levels of anaemia are associated with, among other things, extreme tiredness, low weight gain, and, most worryingly, poor mental development in children across the entire region.
Fortunately, with the advancements in our understanding of medicine, many high-burden illnesses, such as anaemia, high blood pressure, diabetes, and several infectious diseases, are now relatively easy to diagnose with low-cost instruments and treat with readily available medicines. The medical challenges for these high-burden diseases are no longer such that we need to depend solely on highly trained physicians to examine us in person and tell us what to do. With well-defined protocols and a direct phone discussion between the patient and the physician, a reasonably trained health worker can help figure out what is needed in most cases. However, our steadfast refusal to recognise that something may be wrong and to follow medical advice faithfully remains an insurmountable obstacle.
To address this, countries like Iran and a highly rural state like Alaska in the US have, over the last 50 years, entirely transformed the way they provide primary care to their populations. Recognising that protocols and diagnostic instruments in non-physicians’ hands can do an adequate job some 80% of the time, they have moved physicians to the periphery and requested them to play a supportive role. Instead, they have assigned a defined group to each health worker and required them to take responsibility for every group member’s complete health and well-being.
In Iran, these health workers (called a Behvarz in Farsi – a person with “beh”, good, “varz” skills) are identified by the local community. The government employs them to serve the community full-time after giving them two years of training. With the help of these Behvarz’s, Iran has kept its disease burdens low even in its most remote regions. The Alaskans similarly identify a Community Health Aide (CHA), train the Aide over four four-week modules, and require the Aide to strictly adhere to a Community Health Aide Manual, a book of detailed protocols. The CHAs have effectively brought comprehensive primary care even to their remotest communities.
To discharge their responsibility, these workers first thoroughly study the families assigned to them and figure out what each person needs by way of medical treatment and lifestyle change. They then track, coax, and cajole each person to do what is required. The greater the risk exposure of the person, the more intense the follow-up. With this “denominator” oriented approach, i.e., the entire population assigned to them and not just those who happen to show up at the clinic (the “numerator”), they have successfully dealt with these common but debilitating (if left unattended) conditions.
Even in India, there are examples of organisations that have shown durable hypertension control using this approach. An organisation that has rolled this model out in, among others, the Satara district of Maharashtra, has, working with the community, identified and trained a group of local health workers. Each health worker, having been assigned a set of families to serve, goes to every home at a frequency dictated by the family’s risk levels. In a cohort of 3900 individuals, they found about 1,400 (35%) to have stage II hypertension, of whom 100 (2.4%) were in a hypertensive crisis. This medical emergency can lead to a heart attack or stroke. Using established protocols and working closely with the team doctor, these health workers responded as needed with the result that, at the end of four months, risk levels had come down for 46% of those at stage II and 70% of those in crisis.
It is becoming increasingly clear that the doctor-plus-clinic model, which is nothing but a reduced-form hospital providing outpatient services, can no longer be considered primary care. Good primary care instead involves well-trained and technologically equipped non-physician providers who consult a physician when a prescription is needed but are otherwise fully responsible for ensuring, using any means necessary, that the population under their care remains well. This approach is equally required for young women with anaemia who refuse to take iron tablets because they feel nauseous, for middle-aged men who refuse to take metformin for their diabetes and walk every day for at least 30 minutes because they do not feel sick, and for women over 40 who are too frightened to have their breasts examined for early signs of cancer. What needs to be done medically in each case is relatively easy to determine, but the real challenge is getting it done and completing the loop with the individual being served.
India has no shortage of young people with high-school diplomas willing to serve populations assigned to them within even tiny tribal communities, as the experiences of Swasthya Swaraj in Kalahandi in Odisha, a predominantly forested district with a high tribal population, have revealed. Training and offering them a “Community Health Practitioner” diploma, as Swasthya Swaraj has done in partnership with a local university, is the first step in converting these available human resources into powerful agents of good health and well-being for entire communities. It also offers these young people a job that they so urgently need in which they can serve their communities and even go on to pursue more advanced nursing and medical careers should they so desire – a classic win-win for all concerned if ever there was one!
(Dr. Nachiket Mor is a former director of NABARD and former India Country Director of the Bill & Melinda Gates Foundation)
(Syndicate: The Billion Press)
