Primary care should cover the growing tribe of non-communicable diseases: diabetes, cancer and heart disorders

Dr Aarti Sahasranaman & Dr Zeena Johar

For a number of reasons, it seems pretty clear that any durable solution to the challenges of healthcare in India will involve a massive expansion in the infrastructure and personnel in primary healthcare.

The government has emphasised vaccination, reproductive and child health, and the control of infectious diseases such as tuberculosis and malaria, in its interpretation of primary care.

However, it is far from obvious that this is indeed an adequate definition of primary care. A 2010 study of the Global Burden of Disease found that non-communicable diseases are now responsible for 53.8% of all deaths in low- and middle-income countries, as well as 48.9% of all days lost to disability.

These diseases include neuropsychiatric disorders, cardiovascular diseases (CVD), cancers and sense organ impairment. Depressive and anxiety disorders are common. Within CVD, high blood pressure is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India.

The WHO estimates that India had 32 million people living with diabetes in 2000, and this number is projected to rise to 80 million by 2030. Within cancers, cervical and oral cancers are the most prevalent forms among women and men, respectively, in India, and both these cancers are highly amenable to primary prevention.

Sense organ impairment primarily includes vision disorders such as glaucoma, cataract and refractive errors, and adult-onset hearing loss. The prevalence of, say, refractive errors in a rural south Indian population was demonstrated to be about 31% for myopia and 18% for hyperopia.

A study based on around 4,000 patient visits to six primary healthcare clinics being operated by Sughavazhvu Healthcare in rural Tamil Nadu also reveals some corroborative trends. While more than 30% of men seeking primary care were 50- to 69-years-old, about 40% of the women were aged 30-49 years.

The top four complaints were cold, body pain, multiple joint pain and weakness. However, when analysed by age, the proportion of complaints indicative of chronic conditions — such as osteoarthritis and pain — increased: rising from 33% in patients aged 30-49 years to 51% in patients aged 50-69 years. The four most common diagnoses were pharyngitis, allergic bronchitis, osteoarthritis and non-specific body pain.

While acute, episodic conditions constituted 48% of all diagnoses, chronic conditions such as osteoarthritis, body pain, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and diabetes represented 29% of all diagnoses. In fact, hypertension, hyperlipidemia and diabetes, three modifiable risk factors for CVDs, together contributed to about 30% of all chronic diagnoses for those over 30.

In short, since it is the first point of contact that a person has with the health system, it is imperative that primary care services provision a much broader range of offerings taking the disease burden into account.

The six clinics mentioned earlier operate using a model of primary care in which a well-trained and legally-qualified physician (who does not have an MBBS degree), assisted by a locally-hired health extension worker, provides the broadest range of healthcare services, including dental fillings and scaling, cervical cancer screening, vision screening and dispensation of glasses, and management of chronic diseases.

Prior to establishment of each of these village-based health centres, the entire catchment population is geo-mapped, and each household issued a bar-coded enrolment ID containing all family details. Community-based risk profiling of all adults is then performed anto identify high-risk individuals who have modifiable risk factors for non-communicable diseases.

Identified highrisk individuals, for example, for CVD — based on height, weight, blood pressure, tobacco consumption, and waist and hip circumference as risk markers — are then exhorted to seek treatment at the health centre immediately, and are followed up until they do so regularly.

The Health Information Management System ensures that there is a strong control environment within which each health centre operates. It is clear that the need for such a model of primary care exists; it is also clear that at least in small and controlled settings, this care can be provided at a modest cost, optimally utilising qualified and formally-licensed manpower that is relatively easily available and is willing to serve in remote locations.