Family Practice Specialization in India

Written by on May 30, 2014 in Features - No comments

The Long Way Home

A few months ago we were a part of a very interesting study. It was a primary care design initiative for one of the states in India. It was an attempt to pilot an initiative with a creative as well as a curative approach to heal the ailing primary healthcare system in this state. The findings from the literature were rather startling. Most of the states are unable to deliver cost effective care, have a severe dearth of human resources, lack any standard regulatory mechanisms and grievance redressal. Information asymmetry causes lack of community engagement, accountability and voice.

IndianDocWEBTo further our search for an ideal primary care model, our team started studying innovative practices attempting to resuscitate primary healthcare, especially for the bottom of the pyramid. We came across a few organizations who attempted to provide primary healthcare by reviving family medicine, especially in the era of super-specialization in medicine.

Most of these innovators mentioned about the vicious cycle these families have to undergo in the absence of family physicians (FP) and a good public system of primary healthcare. Many studies have pointed out that a single episode of hospitalization can push a lower middle class family below poverty line. Most of the diseases that are a cause of hospitalization in India like diarrhoea, complications of diabetes mellitus, malaria, typhoid and other infectious diseases like tuberculosis (unlike the western world, these still exist in India) are rather easily curable at the primary care level if the FP or even the health worker takes care of the early symptoms. It is also rather unfortunate that in the absence of a community based FPs, the lower quintiles of income resort to costly specialists (especially for the earning member for the fear of income loss and children). Over medicalization of healthcare, unnecessary hospitalization not just causes impoverishment but also the indiscriminate use of antibiotics causing multiple drug resistance. It is estimated by the Medical Council of India (MCI), nearly 42,000 medical graduates are added yearly to the Indian pool of doctors. About 10,000 of them migrate abroad and 20,000 take up postgraduate courses in India, and nearly 2,000 MBBS graduates diversify to allied or unrelated fields. Eventually, only about 8,000-10,000 take up general medical practice as a profession. (Source – DNA-INDIA).

Hence in a country which is obsessed with hospitalization, even for simple fevers and stomach upsets under the pretext that they would “get well soon”, reviving the family practice seems to be the long road ahead.

Organizations We Visited

Many private organizations have felt the need to encourage the general physicians, hence creating a family practice in their area. Swasth India for example, targets the urban poor in Mumbai, India. A Swasth Health Center is located in low income areas, where the patients fight for both access and affordability to good healthcare. The general physician specifically works in that area and ensures that even drugs and diagnostics are available if necessary. They also provide day care and dental treatment. They have ensured referral linkages for hospital care. Healthspring on the other hand is a patient centric family medicine model in urban settings. The focus is providing not just primary healthcare, but also diagnostics, referral linkages and emergency care at the level that the clinic itself avoids patient distress. This organization is committed to reduce the abuse of specialist care by treating the patients at the level of primary care itself. MeraDoctor’s health plan under which the family gets a card (by paying  one time annual fees of INR 3000). The plan has four components. First, is a doctor which four family members can use for unlimited advice over the phone. The second is a discount at empanelled network providers for drugs, diagnosis and hospital care (MeraDoctor forgo their cutback which may range from 10-60% depending on the network and hence the patient receives a discount). Third is a hospicash plan under which in case of hospitalization the patient gets a cash back of INR 500 per day irrespective of the hospitalization to a maximum of INR 90000.  And lastly, a personal accident cover under which a patient gets INR 3,00,000.

Rural healthcare foundation on the other hand has brought a general practitioner in the most backward areas of West Bengal, India. They have ensured provision of affordable medical care at INR 50 (less than a dollar) for consultation with either a qualified allopathic doctor or a qualified ISM (Indian system of medicine) practitioner, including medicines for a week. Cataract, cleft lip and cleft palate operations are performed free of cost at various charitable hospitals, to the patients referred from their Centres.

Long way home

India’s public health training has been historically centered on medical colleges, prioritizing clinical training over social and preventive medicine. The Medical Council of India (MCI) does not regard primary care as a specialty beyond the graduate level and there is no Masters degree for family medicine (we thankfully have diplomas now) leaving the doctors with minimal career progression (Rao & Mant, 2012).  Most of these organizations which we had visited receive little or no support from the government and work on the philanthropic zeal of the owners. Yet it has to be acknowledged that the vision of achieving Universal Healthcare is dependent on the strengthening of primary care via the family practitioners in India. The concept of general practice is lying dormant below the demons of globalization, quick fixes to health, medical tourism, lack of accountability and regulation, which have all led to specialized industry like hospitals. The government may consider the gold standard of primary care to achieve a healthier nation.

Reference: Rao, M., Mant, D. (2012). Strengthening Primary Healthcare in India: White Paper on Opportunities for Partnership. BMJ, 344- e3151. Doi: http://dx.doi.org/10.1136/bmj.e3151

By Anuradha Katyal and Sahitya Reddy

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