Putting people first: a primary health care success in rural India

Voices of care: unveiling patient journeys in primary care for hypertension and diabetes management in Kerala, India

Background

Diabetes and hypertension are leading public health problems, particularly affecting low- and middle-income countries, with considerable variations in the care continuum between different age, socio-economic, and rural and urban groups. In this qualitative study, examining the factors affecting access to healthcare in Kerala, we aim to explore the healthcare-seeking pathways of people living with diabetes and hypertension.

Methods

We conducted 20 semi-structured interviews and one focus group discussion (FGD) on a purposive sample of people living with diabetes and hypertension. Participants were recruited at four primary care facilities in Malappuram district of Kerala. Interviews were transcribed and analyzed deductively and inductively using thematic analysis underpinned by Levesque et al.'s framework.

Results

The patient journey in managing diabetes and hypertension is complex, involving multiple entry and exit points within the healthcare system. Patients did not perceive Primary Health Centres (PHCs) as their initial points of access to healthcare, despite recognizing their value for specific services. Numerous social, cultural, economic, and health system determinants underpinned access to healthcare. These included limited patient knowledge of their condition, self-medication practices, lack of trust/support, high out-of-pocket expenditure, unavailability of medicines, physical distance to health facilities, and attitude of healthcare providers.

Conclusion

The study underscores the need to improve access to timely diagnosis, treatment, and ongoing care for diabetes and hypertension at the lower level of the healthcare system. Currently, primary healthcare services do not align with the "felt needs" of the community. Practical recommendations to address the social, cultural, economic, and health system determinants include enabling and empowering people with diabetes and hypertension and their families to engage in self-management, improving existing health information systems, ensuring the availability of diagnostics and first-line drug therapy for diabetes and hypertension, and encouraging the use of single-pill combination (SPC) medications to reduce pill burden. Ensuring equitable access to drugs may improve hypertension and diabetes control in most disadvantaged groups. Furthermore, a more comprehensive approach to healthcare policy that recognizes the interconnectedness of non-communicable diseases (NCDs) and their social determinants is essential.

Adding screening for "end organ damage" to the noncommunicable disease package in primary care

There are several global and local initiatives aimed at screening for noncommunicable diseases (NCD). The fundamental health system strengthening to achieve this goal is by developing the primary care infrastructure. Most newly developed or improved primary care centers focus on maintaining an NCD register for onward reporting. However, the register is also the cornerstone for implementing systematic screening of all complications of NCDs. With epidemiologic transition, end organ damage due to NCDs is one of the most common causes of morbidity and mortality. Screening for end organ damage and early identification of treatable complications are far more impactful than waiting for self-reported symptomatic complications. Here, we show an example of how the Government of Kerala utilized the NCD register to implement a systematic diabetic retinopathy screening that allows for annual or biennial re-call in the primary care and refer treatable eye conditions to secondary care. The success of this program enabled the Government to initiate a holistic approach to screen for other complications of diabetes.

Primary health care contributions to universal health coverage, Ethiopia

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

Structural quality of healthcare facilities in India

Purpose Although India has a number of health issues, the healthcare facilities in India are insufficient due to poor quality of care. The purpose of this paper is to examine the factors affecting the structural quality of healthcare facilities in India. Design/methodology/approach This study used the medical facility data from the India Human Development Survey-II, 2011-2012 (ICPSR 36151) ( n=4,218). Logistic regression was conducted to predict structural quality of healthcare facilities. Findings The results suggest that it is difficult to have all standard resources available at health care facilities in India. Surprisingly, having a drinking water source inside the health facility appears to be an indicator of poor structural quality of health care facilities. Having a water source inside a health care facility is associated with not having a separate exam room and not having a sink to wash hands. A higher registration fee was associated with good structural quality and with having a separate exam room and having a sink to wash hands. Originality/value This study shows the complexity of providing quality health care to the poor, particularly in developing countries. Research on quality of healthcare facilities in India is needed to improve the health of the population. Little research has been done on the factors influencing the structural quality of the healthcare facilities in India. This study is an important contribution to the current knowledge of structural healthcare facility standards and its influences in India.