Retooling primary care to tackle chronic diseases

February 13, 2015 — Primary care can be redesigned to combat the burgeoning global epidemic of noncommunicable diseases (NCDs) in developing countries by promoting healthy lifestyles, preventing disease complications, and other strategies, according to an article by Margaret Kruk, associate professor of global health.

How is primary care falling short in controlling NCDs—such as cardiovascular disease, cancer, chronic respiratory disease, and type 2 diabetes—in low- and middle-income countries?

Primary care—traditionally focused on providing patients and the community access to care, preventive services, and basic services like maternal and child health—has the potential of leading the fight on NCDs, which over the next 15 years are projected to cost low- and middle-income nations $21 trillion in medical costs and lost productivity. However, primary care in those countries must be better funded and retooled so that it can be more prepared to care for people with NCDs. Health ministries in low- and middle-income countries have traditionally focused on infectious diseases like malaria, tuberculosis, and HIV, but eight in ten deaths from NCDs are in these countries. Changing demographics contribute to the growth of NCDs: populations are aging, and people are moving from rural to urban areas. City life is more sedentary; there is more smoking; and diet quality tends to decline as people eat fewer fruits and vegetables and more sugar­—a triad of risk factors for high blood pressure, heart disease, and type 2 diabetes. What’s more, one in three deaths related to NCDs in these nations occur among people under age 60 and in the prime of their productive lives.

What are some innovative ways these nations can use to boost primary care when funding is short, health systems are strained, and infectious diseases remain prevalent?

My co-authors, Felicia Knaul, associate professor at Harvard Medical School and director of the Harvard Global Equity Initiative (HGEI), and Gustavo Nigenda, formerly of HGEI, and I found in many cases low- and middle-income countries are leading the charge on innovative care delivery by delegating tasks to nurses and community workers to do prevention and screening and to refer complex cases to doctors. This is helpful because doctors are scarce in these countries and non-doctors can be used to reach out to people. For instance, teachers and trained community workers can raise awareness of NCD risk factors, help people stay on medications, and screen for depression, cancer, and other NCDs, using low-tech tests that give immediate results. In Brazil and Costa Rica, teams of nurses, outreach workers, and health educators often go into homes in small towns and villages. They are effective at reducing hospitalizations and under-age five mortality. They are bridges between the community and the health system.

Your article notes the important role technology can play in improving primary care. Explain.

Primary care can’t stay rooted in the 1970s, when the field generally first rose to prominence. Increasing the use of mobile technology, including cell phones, to get health information to people over long distances and remote areas should be part of the strategy to reinvigorate primary care. In low- and middle-income countries, about one-third of people living in rural areas and 90% of people in cities have access to a cell phone. In rural Tanzania I saw women checking text messages on their cell phones, which could be leveraged for health-related messages, like tips on quitting smoking, or reminders to take medicine or go to appointments. By harnessing communication technology, providing team care, and focusing more on the patient and community, primary care will be well-positioned to be the main platform for the health system response to NCDs.

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Marge Dwyer

photo: Emily Cuccarese