Lall Dorothy, Engel Nora, Devadasan Narayanan, Horstman Klasien, Criel Bart
Institute of Public Health, 2nd Cross, Girinagar, 1st Phase, Bengaluru, 560085, India.
Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, P.O. Box 616 6200, MD, Maastricht, The Netherlands.
BMC Health Serv Res. 2019 Jan 18;19(1):44. doi: 10.1186/s12913-019-3876-9.
Chronic diseases have emerged as the leading cause of death globally, and 20% of Indians are estimated to suffer from a chronic condition. Care for chronic diseases poses a major public health challenge, especially when health care delivery has been geared traditionally towards acute care. In this study, we aimed to better understand how primary care for diabetes and hypertension is currently organised in first-line health facilities in rural India, and propose evidence-based ways forward for strengthening local health systems to address chronic problems.
We used qualitative and quantitative methods to gain insight into how care is organised and how patients and providers manage within this delivery system. We conducted in-depth interviews with the medical doctors working in three private clinics and in three public primary health centres. We also interviewed 24 patients with chronic diseases receiving care in the two sub-sectors. Non-participant observations and facility assessments were performed to triangulate the findings from the interviews.
The current delivery system has many problems impeding the delivery of quality care for chronic conditions. In both the public and private facilities studied, the care processes are very doctor-centred, with little room for other health centre staff. Doctors face very high workloads, especially in the public sector, jeopardising proper communication with patients and adequate counselling. In addition, the health information system is fragmented and provides little or no support for patient follow-up and self-management. The patient is largely left on their own in trying to make sense of their condition and in finding their way in a complex and scattered health care landscape.
The design and organisation of care for persons with chronic diseases in India needs to be rethought. More space and responsibility should be given to the primary care level, and relatively less to the more specialised hospital level. Furthermore, doctors should consider delegating some of their tasks to other staff in the first-line health facility to significantly reduce their workload and increase time available for communication. The health information system needs to be adapted to better ensure continuity of care and support self-management by patients.
慢性病已成为全球主要死因，据估计20%的印度人患有慢性病。慢性病护理构成了重大的公共卫生挑战，尤其是在医疗服务传统上以急性病护理为主的情况下。在本研究中，我们旨在更好地了解印度农村一线卫生机构目前是如何组织糖尿病和高血压的初级护理的，并提出基于证据的方法来加强当地卫生系统以解决慢性病问题。
我们采用定性和定量方法，以深入了解护理是如何组织的，以及患者和医护人员在这个服务系统中是如何运作的。我们对在三家私人诊所和三家公立初级卫生中心工作的医生进行了深入访谈。我们还采访了在这两个部门接受护理的24名慢性病患者。进行了非参与性观察和机构评估，以验证访谈结果。
当前的服务系统存在许多问题，阻碍了慢性病优质护理的提供。在所研究的公立和私立机构中，护理过程都非常以医生为中心，其他卫生中心工作人员的空间很小。医生面临非常高的工作量，尤其是在公共部门，这危及与患者的适当沟通和充分咨询。此外，卫生信息系统分散，几乎没有或根本没有为患者随访和自我管理提供支持。患者在很大程度上只能靠自己去理解自己的病情，并在复杂分散的医疗保健环境中找到出路。
印度慢性病患者护理的设计和组织需要重新思考。应给予初级护理层面更多空间和责任，而给予更专业的医院层面相对较少的空间和责任。此外，医生应考虑将一些任务委托给一线卫生机构的其他工作人员，以显著减轻他们的工作量，并增加可用于沟通的时间。卫生信息系统需要进行调整，以更好地确保护理的连续性并支持患者的自我管理。
