Prioritising Good Quality Comprehensive Primary Health Care in India

Prioritising Good Quality
Comprehensive Primary Health Care in
India: the Kerala pilot
Workshop on Quality of Health Care:
Measurement & Efforts to Improve Quality
Professor Mala Rao OBE, MBBS, MSc, PhD, FFPH, Hon FFSRH
Senior Clinical Fellow
Imperial College London
30 June 2015
Comprehensive primary care
development a priority for
health in India
• The Indian government has announced
plans to build up the country’s
healthcare services by strengthening
and investing in primary care.
• Health minister J P Nadda told
parliament on 10 March, “The draft
National Health Policy 2015 envisages
healthcare services being built on the
bedrock of high quality comprehensive
primary healthcare services that are
universally accessible, are free, and are
provided as close to where people live
and work as is feasible.”
Why strengthening
primary care is important
Why strengthening primary
health care is important
The impact evaluation of the Aarogyasri health
insurance scheme of Andhra Pradesh showed
• Out of pocket expenditure does decrease a little
• But a strong platform of primary care is needed to
 improve access to care for the poor, but also the rich
 educate people regarding their entitlements,
 help them navigate themselves through complex
hospital care and
 make universal health care affordable
The importance of health promotion, prevention and primary,
secondary and tertiary care provided as a continuum
dialysis, CABG
We usually
intervene here
Care: laser for
Primary care: screen all
30+s, treat diabetics
Promotive care: smoking, alcohol,
diet, activity
The benefits of a primary care based
health system are proved
Barbara Starfield’s evidence
Better health outcomes at lower cost
Lower infant mortality
Higher life expectancy
Greater patient satisfaction
Better self-perceived health status
Total UK NHS spending. Wanless report 2004
Reduced utilisation of emergencydepartments and
hospital care
• Greater health equity, access and social justice
• Healthier populations and greater cost-effectiveness
Taking forward the development of
primary care in India
Drawing on the best of what we provide in the NHS
• Invited by the Wellcome Trust,
DH and DFID to lead a White
paper on Primary care
• Led to an invitation to establish 3
primary care pilots PHCs in
Trivandrum, Kerala
How did we define primary care ?
Barbara Starfield
First contact
Whole person-focused
Ongoing care over time
Referring to hospital only those conditions too
uncommon to maintain competence
• Coordinates care
WHO’s 2008 Primary Care Now More Than Ever
• Addresses the social determinants of health
• Involvement of the citizen patient and
Where did we develop the pilots?
Pilots developed at Trivandrum:
CHC Venpakal population 63,733 - 7 doctors
PHC Kallikad population 20,000 - 2 doctors
PHC Chemmaruthi 33,643 - 2 doctors
CHC Venpakal - Develop into a satellite
training centre for field workers and other
supporting staff for the district
We co-designed new ways of working
building on good/excellent practice
Developing academic primary care had
been part of our plans
• Crucial first step
• Trivandrum Medical College, Achutha Menon Centre of the
SCTIMS, SIHFW, Trivandrum Nursing College
• Infrastructure development - facilities, IT, pharmacy and
• Initial tasks were expected to include
– Identify gaps in the knowledge and skills
– Shift tasks and train the team
– The community as a partner
Multi-disciplinary mainly work-based
• 6 topics were selected by an academic
• antenatal care, childhood immunisations
(MDGs), hypertension, diabetes (NCDs),
depression, managing fever (diagnosis
and treatment aspects of primary care)
• Trainers were specialists,
even cobblers
Evidence-based care
• Developed new protocols
and updated existing ones
• Established computerbased patient registration
and management system
• Continuous supply of
• Stop useless
• Promoted the PHC lab for
basic diagnostic tests
• Encouraged referral
The panchayats as the
bridge between the
public and the PHC
• Encourage local
population to use the PHC
• Discuss population
problems/concerns with
PHC staff and help
address them
• Promote health in the
Formal before-after evaluation
• Structure – facilities, staffing
• Staff – attitudes and knowledge
• Outcomes:
BP and diabetes management in
‘intervention’ and matched
Community and panchayat knowledge
of and attitudes on primary care
What worked?
• Closer links and friendships between
hospital clinicians and primary care – greater
knowledge sharing bodes well for referral
• Work-based and multi-disciplinary learning
worked well
• Primary care people became important,
were suddenly valued, discovered they could
do hugely more, understood how to become
team problem solvers and review their own
work through audits
• Panchayat understanding of how they could
lead this movement was transformational
So how are the pilots different now?
•The PHC has become the ‘guardian’ of health
of its host community, registering the
population and providing proactive and
comprehensive care
•Care is no longer merely focused on treating
patients who refer themselves for treatment
•The team has individual roles and
responsibilities but these add up to a team
based service
•Crucial need to continue to encourage, train,
develop the system and the staff – academia,
practitioners, policy need to work together