Putting the “care” back into healthcare
Updated: Jan 15, 2021
This was originally published in the booklet for the 2016 India Health and Wellness Summit at the Taj Palace Hotel in Delhi, December 15th 2016. At this event, I facilitated a panel called "Putting the Care Back into Health Care". Photos are from the panel session.
The panel title, “Putting the care back into health care” reflects the need to build primary care as a first port of call for patients. Primary care - backed up by a good referral system and delivered as closely as possible to the patient - is the foundation of a functional health system. It has been a tenet of health system planning since independence. And yet, is poorly delivered in both public and private sectors. In the public sector, health worker shortages and absenteeism means there is often no doctor present at PHCs. In both sectors, the quality of primary care is uneven.
Why is it delivered so badly? There are many forces working against it; too few doctors who are qualified as primary care physicians; a strong private sector that finds profit in over-medicalization; and maybe most of all - a lack of appreciation for preventive efforts.
A lack of human resources for primary care
In India, there is very little respect given to family medicine or general practice as a specialty, and few medical schools have proper programs in this area (there is a program in Bhopal and CMC Vellore). Most MBBS degrees do not cover primary care properly. Additionally, other cadres who could fill the gap - such as nurse practitioners or nurse midwives - have not really achieved the same level of respect or coverage as in other countries.
Primary care as a gatekeeper
Poor quality primary care means that people go to secondary and tertiary facilities for minor ailments - leading to over-medicalization, unnecessary procedures and high out of pocket spending. Effective primary care works as a gatekeeper - so people only go to specialists if there is a real need. This is important – we don’t ever want people with minor ailments in a hospital. In the US, the third leading cause of death is medical error. I have not seen data on this for India, but I imagine the risk is similar. Alongside medical error, we have the huge problem here of multiple drug resistant diseases or “superbugs”, such as TB and golden staph, which are often spread through facilities. Keeping patients with minor ailments away from tertiary-level hospitals doesn’t just reduce costs and increase efficiencies, it can save lives.
The gap left by the formal providers
Seeing as the public sector and formal providers in the private sector fail so badly at providing primary care, it is typically provided by informal providers or quacks. We have little data or research on how quacks practice medicine, but anecdotally and through some qualitative accounts we know that they are preferred by many patients because they can assure privacy, they are in a convenient location, they speak the same dialect, are friendly and respectful. Furthermore, they give patients what they want: a quick cure - often high level antibiotics, and vitamin tonics or steroid injections, and at a low price. These care components can have a long term negative effect on health, but they make the patient feel good in the short term. This is attractive for people who can't afford to take the time to rest and let their own body get better (many of us!). It's easier than helping people to understand the importance of good nutrition, sanitation, exercise and rest. In this respect, informal providers operate in a similar way to many doctors. In fact, there is evidence from a number of studies that informal providers deliver care to an equivalent standard to MBBS doctors.
 Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139.
 See for example; Das, J., Holla, A., Das, V., Mohanan, M., Tabak, D., & Chan, B. (2012). In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health Affairs, 31(12), 2774-2784.and Mignone, J., Washington, R. G., Ramesh, B. M., Blanchard, J. F., & Moses, S. (2007). Formal and informal sector health providers in southern India: role in the prevention and care of sexually transmitted infections, including HIV/AIDS.AIDS care, 19(2), 152-158.