Primary Healthcare and the Emperor’s New Clothes II

In a recent article, I wrote about the lamentable state of primary healthcare, cautioning against steeply escalating healthcare costs, the deteriorating primary care infrastructure and the perils of not enacting urgent reform. The problem hasn’t gone unnoticed. Several initiatives within and outside India are approaching the lack of primary care infrastructure from different perspectives. These include attempts to bolster the supply side by increasing the number of workers providing primary care. Other initiatives focus on addressing patient demand – by nudging patients to access health needs when it is addressable at a prevention or primary stage. This article discusses some of the experiments that are trying to strengthen the supply side primary healthcare touchpoint for patients.

The goal of primary healthcare is to serve as the first checkpoint for patients so they don’t need to seek care from more expensive interventions. The inadequate supply of healthcare professionals in India is well known and documented. The problem is compounded by the concentration of most workers in urban areas. It is estimated that less than 25% of allopathic doctors practice outside of the urban areas, worsening the supply of healthcare providers for the over 800 million Indians in rural India. The government has responded by formalizing primary healthcare services by doctors trained in alternative systems of medicine, the AYUSH doctors. There are over 770,000 AYUSH doctors practicing in India. Besides, there is a cadre of over a million accredited social health activists (ASHA workers) that augment the government infrastructure, especially in rural areas. These additional workers are used in different ways. The AYUSH doctors are more focused on health delivery, either privately or by working in hospitals. The ASHA workers are primarily tasked with creating awareness, generating demand and guiding it towards existing government infrastructure.

Doctors trained in AYUSH systems of medicine are not restricted to rural India. Walk into many of the swanky new hospitals in urban India and while most (if not all) consultants will be trained in western medicine, many "junior and resident" doctors are often AYUSH trained. Allopathic doctors represented by the Medical Council of India have generally challenged the role and the legitimacy granted to such doctors, arguing they are trained inadequately and in systems of medicine that are not consistent with modern medicine. While there may be some truth to the contention of the Medical Council, the supply of healthcare workers cannot be seen as a zero-sum game. Learnings from countries around the world have shown the value of allied healthcare workers in augmenting healthcare supply. The US has over 100,000 certified physician assistants and in the UK deliveries are largely the domain of the over 20,000 mid-wives. These health workers are well trained and take on significant responsibilities, alleviating burden on doctors. There are countless examples of well-trained healthcare workers in parts of Africa and China have been able to lower the burden on doctors. The key to expanding the supply lies in mapping resource needs and using workers trained differentially to shift tasks from doctors to other workers. This is done commonly in other countries so there’s no reason we can’t replicate it in India.

Knowing which healthcare workers need to be trained is the start. Figuring out what they need to be trained on is the second step, and requires a holistic view of the supply chain and mutual respect for the roles of the different players. The biggest challenge, however, is executing high standards of training and retraining at the right scale. The general assumption in India (across disciplines) is that work life begins once student life ends. Most disciplines are beginning to realize that learning needs to be lifelong and this could not be truer for healthcare. Setting up systems to keep healthcare workers trained on new advances and guidelines is a massive undertaking. Complicating this task is the diversity of the workforce (consider the disparities in language, social norms and variable quality of secondary school education) and the scarcity of good trainers as well. The increasing adoption of mobiles across India as well as the paucity of trained medical educators is an area begging for technology led approaches for medical training.

While shifting tasks to individuals with lesser training is a model to emulate, another one to watch for is the shifting of healthcare work to artificial intelligence. Several disruptors have long held the view that much of the patient diagnosis and management can be triaged into simplified algorithms. These algorithms could guide the role of a worker with lesser training or they could be executed with bots, aided by AI. Babylon is a UK-based digital healthcare startup that is using AI and remote consultations to address patient needs. Earlier this year, Babylon starting a pilot in London to trial its AI-powered chatbot ‘triage’ service as an alternative to the NHS’s 111 telephone helpline that patients call to get healthcare advice and be directed to local and out-of-hours medical services. The service is intended to be an automated first checkpoint for patients to seek advice on common symptoms. Some optimists wonder if such capabilities could in fact, replace the role of the GP. This experiment is an important one to watch out for. If it succeeds, it has significant implications for the primary healthcare workforce and will unlock resources needed to provide higher care (with the appropriate training).

Telemedicine has often been talked about to increase the supply of health workers, but these examples have typically been used for secondary and tertiary care. Besides, the telemedicine model primarily addresses access issues by moving supply from an area with limited supply to areas with slightly better supply. The aggregate resource crunch remains unaddressed.

Most of the solutions discussed so far focus on training more workers, more type of workers and shifting tasks to less expensive human or technology resources. These interventions will require considerable resources, both political and financial and even with those, there’s a good chance we may not have adequate workers to meet our primary healthcare needs. As the cost of healthcare escalates in a supply constrained environment, it will become imperative to boost demand side solutions and co-opt patients into the healthcare process. My next follow-up article will discuss several demand side initiatives and how they are so critical to ensure adequacy of healthcare at primary community touchpoints.

Step back a bit from this conversation to consider the primary healthcare touchpoints for us in the future. There will be more wellness and preventive programs making us empowered, informed health seeking consumers. Public health programs will nudge us towards early diagnosis. First level of interventions will be delivered by diverse healthcare workers, human or robots and what we considered primary healthcare touchpoint will in fact, follow all the interventions discussed here. Primary healthcare physicians will need to be trained to layer their skills on top of the other interventions. That means finding the brightest minds in our society and offering them financial and social incentives to choose primary healthcare as a profession. And then we must skill them on wellness, preventive health, workflows, task shifting, technology tools, machine learning and artificial intelligence, on top of their medical curriculum. The path to redesigning our healthcare future is not easy, but there’s no way we can get to the future without first redesigning the primary healthcare experience.

Dr Aakash Ganju is a healthcare consultant and entrepreneur, focused on increasing transparency, access, and convenience to health providers and consumers. He is the Co-founder of Avegen and lives in Mumbai, India.

Dr Aakash Ganju is a healthcare consultant and entrepreneur, focused on increasing transparency, access, and convenience to health providers and consumers. He is the Ceo of Mirai Health and lives in Mumbai, India.