Shift focus from hospitals to primary care

CAPTION: The picture on the home page is of a "Amrit" clinic in Bedawal, Rajasthan run by the Basic Healthcare Services, a non profit founded by the lead author here. "Amrit" clinics aim to provide low cost, high quality health care with dignity to the remote, rural, and underserved populations.(Source: https://bhs.org.in/the-amrit-solution/)

The detection, isolation and management of coronavirus-infected people in India has so far been largely dependent on hospitals. This must change, given the evidence that is coming across.

Bergamo is a small town in Italy. which became the epicentre of the epidemic. Based on their own experience, doctors in Bergamo caution against the hospital-based approach to fight the epidemic. There is fear that hospitals may be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to others.

Western healthcare systems have been built around the concept of patient-centred care, but an epidemic requires a change of perspective toward a concept of community-focussed care. There is an urgent need for India to heed and act on this advice coming from Italy.

Risk of infection

In India, to test for the coronavirus, people either come to laboratories located in tertiary hospitals or they visit district hospitals, where samples are collected and transported to the laboratory. In both cases, the person has to travel large distances, and risks exposure to infection during transit and in the hospital. If infected, there is a high chance of the person contributing to the risk of transmission among lay public and healthcare providers. The only exceptions are some accredited private hospitals, who for a fee, offer to collect the samples at households. Even for isolation, many States rely on specially designated areas or wards within tertiary hospitals, or create new large hospitals or isolation centres.

An epidemic requires a change of perspective toward a concept of community-focussed care

India is also preparing for the eventuality where many people will be ill enough to require admission. Based on experience from China and Italy, we know that about 5-10 per cent of all infected patients will become severely ill and require admission. However, about 70 per cent of them would require supportive care and oxygen and the remaining 30 per cent might require more advanced critical care such as ventilator support and extracorporeal membrane oxygenation (ECMO).

While the States and the Central government are creating additional capacity in hospitals (or setting up new hospitals), availability of equipment and skilled personnel will soon overwhelm the hospitals, just like in countries with much more robust and resourced health systems.

Safe community practices

Sowmya Swaminathan, Chief Scientist at World Health Organization, who earlier headed the Indian Council of Medical Research, has warned that with large-scale movement of migrants following the sudden lockdown, the disease may spread in rural areas. Rural populations live far from tertiary hospitals and any strategy of testing and management that is based on large hospitals is not likely to be effective or sustainable. What then?

In this scenario, the role of personal and community behaviour emerges as extremely critical for managing the pandemic. We know that physical distancing and hand-washing will have significant impact on slowing the spread of the epidemic. As the epidemic is evolving, fear of disease (may-a-times unfounded) as well as that of stigmatisation also affects individual and collective behaviours. Merely imposing restrictions will not promote safe behaviour.

There is a fear among the public health circles that excessive focus on managing coronavirus is likely to diminish care of people suffering from other health conditions, and result in higher mortality. The fear is not unfounded. We know from previous epidemics that reduced access to care, medicines and diagnostics for people with life-threatening conditions, such as TB, which in India causes about 1,200 deaths per day, can lead to an increase of deaths from these underlying conditions.

In Guinea, one of the countries at the epicentre of the 2014-2015 Ebola epidemic, reduced health services led to a 53 per cent decrease in the diagnosis of TB, and a doubling of the mortality rate from it from direct and indirect impacts on TB health services, according to a paper published 2006 in the International Journal of Infectious Diseases.

Primary care management

India has an extensive network of about 25,000 primary health centres and 5,300 community health centres spread across all regions and States. In addition, large numbers of private and non-governmental organisations provide primary healthcare in urban and rural areas. At this juncture, they can play a critical role in managing the epidemic and providing continuity of services. An investment in strengthening primary healthcare at these times will also go a long way in rejuvenating and creating resilient health systems.

Recover at home: It is advisable that most patients with probable or confirmed coronavirus infection rest and recover at home. However, they need to be counselled and followed up with for deteriorating symptoms, and supported for home isolation. More than 90 per cent of all such patients could be managed at households with support of the primary health care providers. Primary healthcare providers can also triage the patients requiring tests or ‘visit’ the health centres over phone.

Supportive care and oxygen: PHCs, CHCs and small nursing homes and hospitals can also play a significant role in caring for a large proportion (about 70 per cent) of the remaining patients who need supportive care, but do not require critical care. Standard protocols and oxygen would be essential for such care, and should be provided urgently. Regular availability of oxygen would save many lives from other respiratory or cardiac causes now and later.

Expand detection: Laboratory tests are still conducted at the district hospitals, which dissuades many people from getting tested, and increases the risk of transmission in transit or at hospitals. Primary healthcare providers can offer sample collection closer to families and communities. Such samples can be transported to the laboratories. It would require immediate training of primary healthcare staff in collecting samples and setting up a system for transportation.

Provide continuity of healthcare: During the epidemic, there are early signs that outpatient and “routine” services are restricted within the public and private sector. Because of the lockdown, there is also a difficulty in accessing healthcare for many patients in rural areas. For those with chronic illnesses, such as tuberculosis, diabetes and hypertension, restricted access to drugs and services could be life-threatening. By the nature of being closer to the communities, PHCs and other primary care providers can significantly ameliorate the situation.

To perform all of the above functions, there is an urgent need for the States to ramp up the primary healthcare systems. It would go a long way in not only managing the epidemic but also strengthening the health systems in the medium and long run.

(Mohan, formerly of the child health and health systems portfolio at UNICEF India, is a paediatrician, public health expert and co-founder of Basic Health Care Services. Mor is a visiting scientist at The Banyan Academy of Leadership in Mental Health)