The evolution of primary care is the most critical aspect of healthcare – the foundation of the very health of nations. While the focus till now has been on building hospitals (secondary and tertiary care, with higher etches of research leading to quaternary care) and curative side of diseases, it has now been recognised that to have healthier nations – healthy beings as well as healthy economy, it critical to have a sound primary care system to ensure wellness, prevention and early detection of diseases – nip the evil in the bud!
We, the urbanites, can we imagine a world without a doctor? In fact, vicinity to medical care and education facilities are part of the top key factors on deciding where to buy our new home….And yet, just the mere availability of good primary care (which actually meets from 80-90 per cent of a human’s healthcare needs) still remains a distant dream for many even in our community as well as country.
A sound primary care setup can serve as a gatekeeper and whistle blower to the mass health issues and trends in health parameters faced by different populations—rural, urban around the geographic spreads. Growing insight from North America and Europe has spelled this out; however, there still is scanty data from other regions.
Focus on availability of primary healthcare is a global strategy for the World Health Organization (WHO). Aided by Bill and Melinda Gates foundation, WHO is facilitating case studies across twenty nations to help understand and strengthen the systems through aggregated knowledge. Towards this pursuit, the World Organization of family doctors (WONCO) has been urging its members to participate and support WHO on this. In significance of this goal, they are increasingly encouraging family medicine to be promoted seriously.
There are great examples of health systems that have kept primary healthcare as their core focus and the resulting health outcomes standout. An interesting model to look at is Cuba’s primary healthcare system with a focus on disease prevention. Cuba requires that all medical school graduates first go through a successful family medicine training before they can specialise. As a result, 70 per cent physicians remain in family medicine as primary care providers. In comparison, in US only 10 per cent work in family medicine.
Of course, the world’s largest and most talked about healthcare systems (US healthcare and NHS) miss out from the list of top ten healthcare systems. In fact, there are great examples of Asian nations that boast of sound healthcare systems with a sound focus on primary care like Singapore and Qatar.
In the current age, another aspect to be factored in creating a good healthcare system is the population dynamics as it changes with a growing geriatric populace the world over. Focus is required to facilitate these needs with care. And then there are multiple aspects of this not only within the non-communicable and life style disease spectrum with an increased life span, but also the fact that in the world of growing ‘nuclearism’ in the traditional family structure, there is a rise in the number of elderly living alone. In the west the concept of old age homes supported by medical care and hospices is common, it is indeed a need to adopt these kind of models in our world as well. With Geriatrics as one of the core of primary care, this can help curtail spend owing to illnesses that grow out of neglect by education, regular health tracking, and, timely care.
Evolving models of ambulatory care for primary care as well as specialised needs supported by sound technology are definitely helping in bettering outreach as well as costs. Sleep labs, outpatient dialysis centres etc. are also making care more personalised as well as specialised. A few years ago I had the opportunity to visit Singapore’s out of hospital dialysis centres run in different condominiums and communities. It was a very impactful experience, not just looking at the passion of the medical teams, but also the stunning outcomes. It was touching to see the depth of thought that went into customisation of dialysis chairs so patients could sit, aquariums place next to each chair as the sound of water and seeing fish can be a soothing sight.
The evolution of ambulatory care has helped build many specialised primary care models which can help in bettering outcomes as well as bettering outreach and availability. So, like the west we have seen many service providers in this space for Opthalmology, dentistry, IVF, mental health etc. A few of these providers work as a chain across the country / going international now — I wonder if the learning came from the early junk food chains! On a serious note, the strategy is working well for many of these providers as well as the patients. So, frankly, kudos to them!
Digitisation needs to be better adopted as that can greatly impact cost and outreach and also aid in statistical analysis of trends. Some regional private companies in India have come up with very interesting low-cost offerings for primary care based on technology to reduce dependence on specialised manpower, enabling quality medical care for patients, speed to care, and, collect data to track patients’ health. Think about walking into an ATM like enclosure for basic diagnostics and a video consult with the physicians and then getting medicine from an automated pharmacy. Yes, this is happening now. Of course, there are many more digital models emerging for specialised uses and adaption of these can be a game changer —think of attending a doctor’s consult sitting in the comfort of your drawing-room.
There are many models of tele-health / - medicine, E-health that have come up. While technology has made a lot of things possible, adoption is key. Also to aid adoption, localisation of the concepts is key. One needs to understand the culture, and the infrastructure and availability of talent to introduce a new concept in any geography. There is a great benefit in cross pollination of ideas as different health systems try different strategies to overcome their challenges. Also as this happens, the governments and the private sector should ideally work more closely to create an ecosystem that is suitable for growth as well towards creating a homogenous spread.
Logically, the basis of improvement in the health indices lies in strength of the primary care that targets wellness, early detection and cure. There is a growing focus on ‘living healthy’ now against the backdrop of many unhealthy trends that are visible to the naked eye — obesity being a glaring example. Again, with Family and Functional medicine being brought to focus, this hopefully will show us the light —not only in bettering general health of people but also in hugely reducing costs. This needs to percolate down to the far flung areas as well.
Over 25 per cent of the world's population lives in South Asia, with many people living in dire poverty with limited or no access to health care. While we boast of quaternary care, we cannot afford to turn away from this stark reality.
Different medical organisations have been working over the last few years to better the understanding of the policy makers across the south Asian countries. A lot of facilitation by South Asian region of WONCA (with many participating nations, including Bangladesh, Nepal, Sri Lanka, Pakistan, and India) has helped bring primary healthcare to the centre of attention by pointing this out as the core of good healthcare. The key objective has been to make healthcare sustainable with the foundation of a sound system of primary healthcare needs — this as a global strategy.
The spectrum of primary care in private healthcare as a structured line of service has picked up pace in India over the past few years taking a cue from the west. Yet there are miles to go before it takes the shape of ambulatory care as it exists in the west. We should be drawing our learnings in implementing best practices early on as our overall health infrastructure matures. This would need a sound policy backing to ensure that all players follow standardised norms allowing further analysis of the health data aiding and impacting the national health challenges.
Educational institutions need to help expand the primary care sector by introducing and enforcing courses for family medicine, functional medicine etc.
Despite progress, and with states like Tamil Nadu setting examples, much remains desired because of a disproportionate health spend and the largest share of disease burden with lowest bed count per thousand people.
While there is an effort on to increase the bed count and availability of care, a little focus on primary care infrastructure can go a long way to help better the health outcomes by way of preventive measures and early detection.
It is time to recognise the support that care provision can derive, driven by technology, owing to lack of trained medical professionals in far flung and rural areas. With well-developed Clinical Decision Support Systems, point of care devices, connected systems etc. to support better and quicker diagnosis, the world is indeed becoming a smaller place.
Last but not the least, in this age of consumerism, we need to adopt an all-inclusive approach with doctor and patient responsibility to make informed decisions and track health indices.
The health care index of a country is not defined on the basis of what kind of superspecialties and advance care centres the particular country has but instead the primary health care robustness decides that and that is the primary domain of health standards and happiness quotient of the population living in.
So let’s expand the reach of care…