Waiting to succeed: doorstep delivery of primary healthcare

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, we tend to avoid seeking medical advice. Those with limited income and the rural populace are even more likely to avoid going to a clinic. In many cases, minor ailments and silent diseases thus 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, from 6–7 per cent in 2015-16 to 12-14 per cent in 2019-21, and continues to rise rapidly. In the districts of Thiruvananthapuram and Pathanamthitta in Kerala, it has already crossed 20 per cent. Such high levels of diabetes, if not urgently managed, can trigger an epidemic of blindness, strokes, and amputations.

In our northern, less prosperous states, despite the best efforts by their governments spanning over decades, more than 60 per cent of women and children continue to be anaemic. In Jamui district of Bihar, Dakshin Dinajpur district of West Bengal and Chhota Udaipur district of Gujarat, these proportions are more than 75 per cent. Anaemia results in extreme tiredness, low weight, and poor mental development in children.

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 easier to diagnose at low cost. Medicines to treat these ailments are also readily available. In other words, we no longer need to depend solely on highly qualified physicians to take care of these high-burden diseases.

With well-defined protocols and a direct phone discussion between the patient and the physician, a reasonably trained health worker can figure out in most cases what should be done. 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 past 50 years, transformed the way they provide primary healthcare to their populations.

Recognising that protocols and diagnostic instruments in non-physicians’ hands can do an adequate job in most cases, they have fielded community health workers, with each one of them being responsible for a certain number of families in their area. The qualified physicians are there in a supportive role.

In Iran, the government employs health workers after giving them two years of training. With the help of these workers, Iran has kept its disease burdens low even in its remote regions.

The Alaskans similarly identify a community health aide (CHA), train the aide over four 4-week modules, and require the aide to strictly adhere to CHA protocols in dealing with community health. The CHA have effectively brought comprehensive primary healthcare 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’ approach), they have successfully dealt with these common but potentially debilitating (if left unattended) conditions.

In India too, there are examples of organisations that have shown durable hypertension control using this approach. An organisation that has rolled out this model in, among others, the Satara district of Maharashtra, has trained a group of local health workers to work with their community.

Each health worker, having been assigned a set of families to serve, goes to every house at a frequency dictated by the family’s risk levels. In a cohort of 3,900 individuals, they found about 1,400 (35 per cent) to have stage II hypertension, of whom 100 (2.4 per cent) 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 ensured that at the end of four months, risk levels had come down for 46 per cent of those at stage II and 70 per cent 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 healthcare instead involves well-trained and technologically well-equipped health workers who consult a physician when a prescription is needed but are otherwise independently responsible for the primary healthcare of the population under their charge.

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 or 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. This approach also offers these young people meaningful employment and opens doors for them to pursue more advanced nursing and medical education should they so desire — a classic win-win for all concerned if ever there was one.