1
From chronic conditions to chronic diseases:
a primary health care research agenda
Vikram Patel
London School of Hygiene & Tropical Medicine Sangath, Goa, India
2
The ‘categorization’ of human health
conditions
“Group 1”: communicable, perinatal and
nutritional disorders
“Group 2”: non-communicable disorders
3
‘NCD’ to ‘chronic diseases’
Reflecting the need for classifications to be
pragmatic and relevant to health service contexts
….but, in reality, ‘chronic diseases’ has become equivalent to cardiovascular diseases and
metabolic syndromes
…and the most vivid health outcome of CVD- infarctions and strokes, are ‘acute’ conditions
4
Whats missing from the agenda?
Disabling consequences of CVD/diabetes
Mental, neurological, substance use
disorders
Cancers
Palliative care
Chronic infectious diseases (notably
HIV/AIDS)
5
What do they share?
Co-morbidity due to shared risk factors, for e.g. alcohol and tobacco use
Co-morbidity due to interactions, for e.g. depression and diabetes
One condition affecting the course and outcome of another, for e.g. CVD and depression
Co-morbid influences on household members, e.g. stroke in person leading to depression in caregiver
6
Most importantly
Principles of management in primary care
Proactive or opportunistic detection
Complex interventions combing pharmacological
and psychosocial treatments delivered in a tailored, stepped care manner
Long-term monitoring and adherence support
Active participation of patient in self-management Concern with clinical and social outcomes
7
Research agenda
An integrated approach to delivery
of care for people with chronic
conditions or associated risk factors
in primary care
8
Extremely cost effective interventions
(<US$ 100 per DALY averted)
Patel et al, Lancet Series on Universal Health Care in India, in preparation
• Control of tobacco, alcohol use • Dietary salt reduction
•programme
• Screening for refractory error and provision of glasses
• Preventive drug treatment for high blood pressure
• Metformin and lifestyle interventions for diabetes
• Treatment of stage I breast cancer
• Extensive breast cancer program
9
Cost effective interventions
(US$ 100-1,000 per DALY averted)
Patel et al, Lancet Series on Universal Health Care in India, in preparation
Treatment of acute MI with aspirin or streptokinase
Treatment of post-acute MI with aspirin / ACE-inhibitors / beta-blockers / statins
Treatment of post-acute ischaemic stroke with aspirin or statins or blood pressure reducing drugs
Treatment of CHF with ACE-inhibitors or beta-blockers Extra-capsular cataract extraction using aphakic glasses • Preventive drug treatment for high cholesterol
• Preventive combination therapy for high CVD risk
• Flu vaccination (aged 60+ years) and smoking cessation programs for persons with COPD
• Brief interventions for heavy alcohol users • Depression treatment
11
Key primary health care research
questions
1. How to improve detection through opportunistic and pro- active case finding
2. How to improve initiation of evidence-based treatments, typically a combination of health education, generic drugs and counselling tailored to individual needs.
3. How to maximise optimal outcomes and reduce risk of acute events/relapses through proactive monitoring and adherence support
4. How to reduce disabilities and support affected family members through community based rehabilitation
5. How to involve the private and non-profit sector in a population based chronic condition health care program
12
Delivery in primary health care
13
Barriers to scaling up to PHC
Weak human resource capacity and
development
Difficulties in integration in PHC; management
focused on ‘acute’ care, lack of time, weak
impact of training medical practitioners etc
14
Potential solutions
Task-shifting
15
Task shifting to scale up chronic
disease management
16
What is task-shifting
Old wine in a new bottle!
the strategy of rational redistribution of tasks
among health workforce teams
specific tasks are moved, where appropriate,
from highly qualified health workers to health
workers with shorter training and fewer
qualifications in order to make more efficient
use of the available human resources for health.
18
The evidence for chronic conditions:
examples from mental health care
19
Lay health workers delivering group Interpersonal
therapy for depression in rural Uganda
20
Lady health visitors using CBT to treat
postnatal depression in rural Pakistan
21
Community mental health workers delivering
care for schizophrenia in rural India
22
Community health workers supporting
caregivers of persons affected by dementia
24
Application of ICT
25
Telemedicine
Computerized DSS
Stand-alone software on PDAs
web enabled
Mobile phone Technology
26
Mobile Phone Technology
Ubiquitous Technology
Launch of 3G/4G mobile Networks
Support Higher bandwidth
Faster Internet capabilities
Cost of Smart phones/PDA
Two Way Communication
28
Potential of mobile phone technology in
Chronic Diseases
Improving Primary health care delivery
through CHWs
Screening: Risk factors, integrated
physiological assessments
Decision support algorithms
Monitoring and surveillance
29
An ICT system for detection and care
Development and evaluation of an Information and Communications Technology (ICT) system for the early detection and management of a range of chronic diseases and their risk factors
30
From chronic diseases to chronic
conditions in primary care
A biomedically driven approach to CDs risks further verticalisation and fragmentation of
primary health care systems; let us not repeat the mistakes in the fields of maternal, newborn and child health
Chronic conditions are those which, irrespective of diagnosis, require a package of treatments with both facility and community based elements,
tailored to the needs of the individual, and
delivered over extended periods of time to achieve optimal health outcomes
31
