Strengthening primary care should be the top priority for reforming India's healthcare system. This would lead to multiple benefits: (1) addressing health problems earlier to improve population health and productivity, (2) reducing overall healthcare expenses by preventing disease progression, and (3) reducing patient loads on hospitals. Primary care must focus on communication, availability, and building trust with patients. Technologies like mobile apps and call centers could help extend primary care into communities in a proactive way. Elevating the roles of nurses and pharmacists, and deploying them as physician assistants, could also deliver significant results for primary care.

1. Policies & Regulations: Transforming healthcare delivery
How strengthening the primary care system would help…
The Indian healthcare system is undergoing a paradigm shift with many Stage 4: Go to a private village/nearby
reforms taking place simultaneously; be it universal coverage, rural clinic or government run healthcare facility.
Stage 5: ‘Rush’the patient to the district hospital.
health, expanding Rashtriya Swasthya Bima Yojna (RSBY), mother and Most of the time when the patients reach
child health, chronic diseases or telemedicine. Under such a scenario, the district hospital, they go with their
ideally there should be ‘rolling priorities’. That means that set up one families and so, the source of ‘earning stops’
priority, address it and then move on to the next one…and the first and the ‘spending starts’ the moment a
relative lands in the hospital. Also, most of
priority should be transforming the primary care system. the time the disease has become irreversible
and both the money and the lives are lost,
leading to a distrust in the healthcare
facilities in the system.
How to build trust in primary care?
In 2010-11, I was co-architecting a Bottom
Of The Pyramid (BOP) healthcare model
for a FMCG global giant. During this
time, I was travelling to rural villages in
Karnataka (Hunsikatti in Belgaum and
Holalu village in Mandya district). I went
to the government run village healthcare
Doctor available centre and was shocked to see that there
were no patients at all. The doctor-in-charge
informed that since it was ‘festive season’
(Ganesh Chaturdashi) there were no patients
and the doctor and the nurse were sitting
idle. As we walked out of the government
run facility, just a few meters away, we
walked past a clinic of one Dr Sudheendra
K Shetty, B.M.A.S (I guess there is no such
degree like B.M.A.S; but if there is one,
please pardon me for my ignorance!). I was
surprised to see that outside this clinic there
were at least 60 pairs of slippers, indicating
that at least 60 patients or relatives were
waiting to be examined or being treated
I
inside the clinic. I could not hold myself
f we address the primary care and India between a sub centre at the village from entering this clinic and introducing
reform it, the benefits are multi fold. and the district hospital, though some myself to Dr Shetty. I apologised for coming
First, the healthcare problems of district hospitals are about 100 kms from directly to him without an appointment or
the population can be addressed at the village), if a person falls sick , what are following the queue, but I praised his work
an early stage, so the population becomes the various stages of treatment? and practice. I told him that never in my
healthier and more productive. Second, Stage 1: Do nothing for few hours hoping working in rural India, I had come across
the overall expenses on healthcare can be that the problem will subside or cure on its such a successful rural practitioner. I asked
reduced by preventing the aggravation of own. Offer prayers…ironically, prayer is the him a few questions about his practice, fees
the disease, and so, as people would get first line of treatment in India. etc. Dr Shetty informed me that he had
primary care at the point of illness (village), Stage 2: Seek the guidance of elderly in been working for the past twenty years
patient load on district and tertiary care the family and take to home remedies. and came daily from 60 kilometers to this
hospitals would go down drastically. Traditional system of medicine is the village to ‘practice’ here from 8 AM to
Let us take an example; in a village second line of treatment. 8 PM and some times, even stayed late in
which is about 60 kilometers from a district Stage 3: Reach out to the village doctor or the night. On being asked about his fees,
hospital (this is the average distance in the nearest chemist and seek treatment. he informed that he charged ` 20, but if
66 I April 2013

2. Transforming healthcare delivery
the patient is poor he accepts even ` 10 can have every rural Indian taking to reduced, as an OPD consultation would cost
and sometimes even treats for free. I saw ‘self care’ for a common ailments, and not even less than ` 100. So, the right inputs
that some patients were lying on wooden get panicked or not take any medication, at the correct time can prevent a chronic
benches with a drip (IV) outside his clinic if unwell. If this system (Apps on the disease-related emergency condition, which
(in the waiting area). Clearly, what the mobile) is linked to the nearest cell today sends 40 million people below the
doctor at the government run Primary network (cell phone tower can direct it to poverty line every year in India.
Healthcare Centre (PHC) told me was not the nearest sub-centre/health volunteer), It is a known fact that 80 per cent of the
true. Seeing the number of patients at this and the medication supplied at his home funding of National Health Service (NHS)
clinic, it was evident that despite the ‘festive through the ASHA or health volunteer UK under the NHS reforms, was meant for
season’, this ‘rural doctor’ saw 120 patients in the village, it would be a good start the Primary Care Trusts (PCTs) and GP
a day and had built the ‘trust’ among the to clinical primary care. This way, we will consortia. A healthcare system with weak
people . I had asked Dr Shetty at the time build the trust with the village residents primary care can never be strong and will
that why do people come to him and not go and also save them from aggravating always fail to deliver, no matter how much
to the PHC? And he told me that, ‘he had their problem by not doing anything percentage of GDP is allocated for healthcare
been serving these people for over 20 years and waiting for the worse to happen Also, primary care must focus on
and was available when they needed him!’ and rushing in the last moment to the prevention and wellness and not on
This is one major reform is missing in the district hospital! Moreover, the cost treatment. Today’s primary care is more of
primary care in rural India and also among a first line of treatment for an illness. May
the urban poor – ‘Availability’. India must seriously consider be, it would be a good idea to consider
The healthcare systems are not geared to pay Family Physicians and General
elevating the role of nurses and
towards ‘serving’, ‘communicating’ and Practitioners (GPs) more salaries than
building trust with the care seekers. So, pharmacists in primary care. This specialists, and this way, we can encourage
what can we do to reform primary care in one step of deploying nurses and more medical graduates taking to these
India and build trust. pharmacists for primary care as ‘specialties’ . It is time to think radically
Build a primary care delivery model Physicians Assistant will deliver different to revive primary care.
where people do not have to come tremendous results. Also, technology can come as a saviour
to the doctor when ill, but a system for reviving primary care and this must
which proactively reaches out to people be leveraged
and focusses on communication, of this technology intervention would India must seriously consider elevating
communication and just communication! be very low. If just by taking the OTC the role of nurses and pharmacists in
Because knowledge transfer plays a key medication they get well, fine. Else, they primary care. This one step of deploying
role in an outcome-driven healthcare can SMS to a toll free number and they nurses and pharmacists for primary care
system. Communication can be a 360° will get a call from the nearest health as Physicians Assistant (in addition to
communication, which means it can be centre to guide them on the next steps. doctors) will deliver tremendous results.
powered by ICT, Flip charts, call centres If the problem is serious, the call centre Private sector must show its commitment
and one-to-one communication about can book their appointment at the to Public Private Partnerships (PPPs) by
issues related to health. The person who nearest PHC or empanelled hospital for taking primary care as its challenge. There
does one-to-one communication should treatment and the ‘clinic on ambulance’, should not be a PPP in tertiary care without
be available when needed. We should can ferry them. Following this system, a PPP in rural sub-centre. We certainly need
think about converting village health we can at least reduce 40 per cent of the a nationwide primary care clinic network
centres into a 24 X 7 service, backed by OPD load from district hospitals and be on a PPP model. Primary care remains the
essential medicine and equipment to more effective in delivering primary care. primary challenge, and it is time to ensure
treat emergencies. It can be onsite or a that primary care is focused on prevention
‘clinic on ambulance’ model. Strengthening the prime factor and wellness. This will be the best gate
We have over 800,000 ASHAs. ASHAs Primary care should be the primary concern, keeper of the healthcare system for ensuring
are class 8th pass married females from as spending more on primary care will lead lower cost and better clinical outcomes
the village who provide advice and to spending less on tertiary care. We know (office@rajendragupta.in)
treatment with OTC medications pretty well that a major heart intervention
(non-prescription products). Why can would cost an average of ` 1.5 lac or a renal
we not have applications loaded in failure can lead to recurring unbearable
cell phones that have the information expenses for a common man, but if primary Rajendra Pratap Gupta
about common ailments with advice and preventive care is available at the right International Healthcare Expert,
and treatment guidelines with respect time, the need for these expensive chronic President, DMAI
to OTC medications? This way, we interventions can be avoided or drastically
April 2013 I 67