The importance of primary care

IT IS MONDAY morning at Connaught hospital in Freetown, the capital of Sierra Leone, and the accident and emergency department is abuzz. One of only four specialist hospitals in the country, it should provide the sophisticated care not available elsewhere. Instead, like many urban hospitals in poor countries, it is full of people with simple problems that should have been dealt with through primary care (the generalist branch of medicine), or patients with complex conditions that should have been treated earlier.

For many patients Connaught is a last resort. If they find themselves ill, their first response is to hope that their symptoms will pass; their second is to self-medicate. This may involve a visit to a drugseller, perhaps buying a “shotgun bag” containing a few days-worth of antimalarial medicine, antibiotics and painkillers. If that does not work, they go to Connaught. A board in the entrance of the A&E ward lists prices, from 10,000 leones ($1.30) for catheterisation to 30,000 ($3.90) for a transfer to a bed. Once admitted, patients have to pay extra for food and supplies. About half of the nurses are not on the payroll but come in the hope of picking up work. Consultation can easily turn into negotiation. That can harm patients. And if clinicians do not treat what they have diagnosed, they will be slower to learn.

If you fall ill in Sierra Leone, Connaught is one of the better options. But both its staff and its patients are victims of the sort of dysfunctional health system common in poor countries. In November the IHME and the University of Washington published the latest volume of its Disease Control Priorities report (known as DCP3), one of the most influential documents in global public health. It tries to set out which treatments and policies poor countries should prioritise, based on the most cost-effective ways to improve healthy life expectancy and prevent financial catastrophe. “Unfortunately,” notes the report, “most countries lack health systems that meet this standard.”

In many developing countries people get their health care mostly from informal private providers such as drug shops or unqualified practitioners. In India, informal providers account for three-quarters of all visits. The figures in other countries are similar, if mostly less extreme: 65-77% in Bangladesh, 36-49% in Nigeria and 33% in Kenya. Often these markets exist side by side with public-sector providers who rely on patients paying for drugs and tests, as in China, despite a spate of recent regulations.

It is easy enough to measure how long patients have to wait or whether drugs are available. In rural India, for example, 66% of the population does not have access to preventive medicines, and 33% must travel more than 30km to get treatment. But answering the most important question—whether a problem is diagnosed and treated correctly—has proved harder. That is why recent research by Jishnu Das of the World Bank and colleagues is so welcome. Inspired by “mystery shoppers” who visit supermarkets, they send “standardised patients” to clinics across the world. These patients present with symptoms that are specific to particular diseases. After the consultation they are quizzed on whether the health workers adhered to clinical guidelines.

The findings show widespread woefulness. In one Chinese study the average consultation time was a minute and a half. In India the average length was double that, but one-third of the visits lasted just one minute and featured a single question: “What is wrong with you?” Only 30% of consultations in India and 26% in China resulted in correct diagnoses, and patients were more likely to receive unnecessary or harmful treatment than the correct sort. Studies in Paraguay, Senegal and Tanzania have produced similar results.

Before 1995 just 25% of Costa Ricans had access to primary health care; by 2006 the share was 93%

The consequences of such ineptitude are severe. In India about half a million children die of diarrhoeal diseases every year. In a study in Delhi only 25% of providers asked parents whether there was blood or mucus in the child’s stool, a clear symptom of such disease. Health workers who had undergone more training provided more accurate diagnoses, but that alone is not enough. Curiously, Mr Das and his team also found that, even when clinicians know what treatment should be given, they often do not provide it. In one study 74% of Indian clinicians were able to tell researchers how to deal with patients suffering from angina, asthma or diarrhoea, but when visited by mystery “patients” presenting with exactly these symptoms, just 31% treated them correctly. One explanation for the “know-do gap” is that patients generally know far less about the best course of action than clinicians, who can get away with under- or over-treatment when they are not held accountable for their work.

Other developing countries provide much better care at low cost. An exemplar is Costa Rica, whose model shows the benefit of high-quality primary health care. This is often ignored as countries splurge on big hospitals. “Primary care is not heroic,” explains Asaf Bitton of Ariadne Labs, “but it works well.” Between 1995 and 2002 Costa Rica established more than 800 “Equipos Básicos de Atención Integral de Salud”, or integrated primary-health-care teams, each looking after 4,000-5,000 people. The teams are made up of a technical assistant, who visits patients at home; a clerk who keeps up-to-date records; a nurse; a doctor; and a pharmacist. The doctors have a lot of scope to run the teams the way they think best, but the health ministry holds them accountable for their patients’ outcomes.

Before the programme was in place, just 25% of Costa Ricans had access to primary health care; by 2006 the share had risen to 93%. It was introduced in stages, which enabled researchers to assess its impact. A study in 2004 found that for every five years it was in place, child mortality declined by 13% and adult mortality by 4%, compared with areas not yet covered. Another study estimated that 75% of the gains in health outcomes resulted from the reforms.

Supply-side reforms to health care in other countries have also brought dramatic improvements. Thailand in the 1980s froze capital investment in urban hospitals and reallocated the funding to primary-care centres, which cut mortality rates. Ethiopia since 2004 has trained more than 38,000 “health extension workers”, rural high-school graduates who undergo a year’s training before being sent back to their local area. They have helped cut child and maternal mortality by 32% and 38% respectively. In Rwanda each village has to have three community health workers, elected by their peers, who offer basic services and make referrals. “People who have a minimum education can do a lot,” says Agnes Binagwaho, a former health minister.

One lesson from countries like Rwanda is that closing the gap between knowledge and action requires reforms far beyond the consultation room. Training helps, but so do incentives and accountability. When Rwandan health workers were paid to adhere to clinical guidelines, their performance improved. And when rural Ugandans were given more information about the quality of local health services, clinicians did a better job.

But care needs to be taken to set the right incentives. Doctors who are rewarded for prescribing medicines will overdo it. One study from 2013 found that more than half of all outpatient prescriptions in China contained antibiotics (the WHO suggests the share should be less than 30%). China has also rapidly expanded hospitals over the past 20 years; today it has more hospital beds per person than Britain or America. Yet between 2002 and 2013 the number of primary-care providers actually fell.

Have you taken your medicine?

Aid organisations can make matters worse. If you drive from Freetown to Kono in the east of Sierra Leone, you will pass a graveyard of failed projects. Signs mark clinics built but never staffed. But in Kono, with the help of Partners in Health, an American charity, Dr Barrie is trying to buck the trend. This region of 500,000 people has just two doctors who are paid by the government. That makes the job of Mabel Konoma, a community health worker, even more vital. Every morning she visits patients with tuberculosis or HIV. As she goes from house to house, she asks people whether they have taken their medicines. One woman with HIV says she has struggled since villagers started shunning her rice stall because of the stigma attached to the disease. No custom means no money, no food and no medicine. Mabel takes a note and arranges for the woman to receive food.

When patients need further care they are referred to the Wellbody clinic, a primary health centre. Unlike most in Sierra Leone, it does all of the basics well. On arrival, patients are screened for signs of Ebola as a precaution, and triaged. They receive an electronic record number so their cases can be tracked. This is useful in Sierra Leone where many first-born children are given the same name: Sahr for boys and Sia for girls. Because of the shortage of doctors, Wellbody has trained “associates”, somewhere between a nurse and a doctor.

It also has an obstetrics wing, where pregnant women with potential complications wait to give birth. Sierra Leone has one of the world’s highest rates of maternal mortality, partly because most women would rather give birth at home with the help of traditional birth attendants than go to a clinic far from home that may lack trained midwives or perhaps even electricity. Wellbody is properly equipped, and to encourage women to give birth there it allows the birth attendants to come, too.

DCP3, the value-for-money report, says that for maximum cost-effectiveness, poor countries would spend about 50% of any increase in funding on primary care and 18% on community care. Yet although these are the building blocks of strong health systems, by themselves they are not enough. Hospitals will always be needed to provide emergency and specialist care. This is particularly true in a field that campaigners for universal health care rarely mention: surgery.