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What’s driving people to private healthcare?

Study investigates how successful Primary Healthcare Centres are, in tackling diabetes and hypertension.

Non-communicable diseases -- diseases that do not spread from one person to another -- like diabetes, hypertension, Parkinson’s etc., are a major public health challenge today. In India, almost one in three have hypertension (increased blood pressure) and about 8% are diabetic. A way to address this growing epidemic is to build a strong healthcare system, supported by the government, where medicines to such diseases are accessible and affordable for all. The primary health centres (PHCs) are established for the same reason. But how effective are they? A new study funded by the World Health Organisation (WHO) examines this.

“India has launched a national programme to address several non-communicable diseases, including diabetes and hypertension, in 2010. It stresses the need for a comprehensive management strategy for such diseases, including risk reduction for prevention, early diagnosis, appropriate management and specific intervention strategies for different levels of health services”, informs Dr Prashanth N S, Head of Health Equity and Evaluation team at the Institute of Public Health, Bangalore, and the lead researcher of the study.

This study, published in the journal BMJ Global Health, found many loopholes in the healthcare delivery system to combat diabetes and hypertension, in Tumkur district of Karnataka, where the study was conducted. “We chose for diabetes and hypertension because these conditions are considered low hanging fruits among non-communicable diseases; one expects that care for diabetes and hypertension is fairly universal and available at primary care levels”, says Dr. Prashanth about the choice of the diseases for the study.

The researchers selected a random sample of 1157 diabetic and/or hypertension patients, conducted a household survey, and interviewed them. They also held focussed group discussions with patients, health workers, PHC medical officers and pharmacists to understand and assess the preparedness of local health system in PHCs for addressing diabetes and hypertension.

The results revealed that less than 10% of the survey respondents got their medicines from the PHCs and 76% of them brought their medicines from private pharmacy. Although healthcare costs in a private hospital was expensive, the respondents felt that it was of a better quality. They also believed that care in PHCs was inconsistent, and required multiple visits which hurt their pockets. In addition, they preferred to go to private care also because medicines at PHCs were either unavailable or of poor quality. Nearly a third of the PHCs investigated didn’t have a doctor, pharmacist or a functional laboratory, which further accentuated the dependence on private care. Also, some of the PHCs were running out of stock of medicines for nearly 6 months!

The study also found that at a governance level, diseases like diabetes and hypertension did not appear to be among the top priorities for medical officers or health managers. Their focus was usually on mother and child care and communicable diseases. In addition, the allocation of financial and managerial resources for non-communicable diseases in general, and for diabetes and hypertension in particular, was relatively low. “The allocation of resources or activities to address non-communicable diseases at the primary healthcare level in villages is minimal, whereas the focus remains on identifying activities for the care and prevention of such diseases at the taluka and district level”, says Dr Prashanth.

To add to this, the doctors at PHCs were found to refer private care to some patients, and prescribed combination medicines -- drugs containing two or more compounds like Imol plus that contains paracetamol to reduce body temperature, ibuprofen that acts as a painkiller, and caffeine to induce sleep. Also, rampant corruption and demand for informal payment further pushed patients towards private healthcare. “Diabetes and hypertension are perceived as serious diseases, and the villagers chose to go to private sector. However, they would still receive care for non-threatening conditions like vaccinations and child care at the local PHCs”, remarks Dr Prashanth, about the findings of the study.

Health systems in low and middle-income countries are struggling to organise and manage care for diabetes and hypertension within their public health systems. Like the study found, gaps in infrastructure, human resource availability, performance and governance of local health systems were stumbling blocks in delivering good quality healthcare against non-communicable diseases. “The non-communicable disease program plan clearly mentions services for these diseases at PHC, but our study has found out otherwise”, says Dr. Prashanth.

The study highlights the urgent need for local health system planners and managers to prioritise care for diabetes and hypertension by investing in infrastructure, in improving the availability and performance of human resources, as well as in improving the credibility of government primary healthcare systems. “Our study has shown that patients, especially the poor, have to depend on expensive care in private facilities for simple and essential medicines and treatment for diabetes and hypertension in Tumkur, and possibly in several other rural areas in the state. The findings need urgent attention from the state government in ensuring basic treatment and follow-up for non-communicable diseases in government primary health centres”, signs off Dr. Prashanth.