The locus of health care is moving increasingly towards the community. In high-income countries (HIC) the greatest burden of health falls to frail elderly people with multiple chronic diseases. Hospital is often bad news for such people, both from a psychological and physical point of view. There are good arguments for avoidance of admissions, and for increasing care provision in the community in HICs. In low- and middle-income countries (LMICs) there are also good arguments for community care. The WHO estimates that over three-quarters of all care could be most appropriately delivered in the community. The Declaration of Alma Ata and the Bamako Initiative from the United Nations both support the development of community care for LMICs. In this News Blog I wish to probe this subject more deeply. I will argue that community care is entirely appropriate for preventive outreach care. However, I will argue that we should re-examine the case for promoting community over hospital settings for demand-led care, especially in deprived urban environment.
My re-examination of this subject came about as a result of recent tours of eight slums within Nigeria, Kenya, Pakistan and Bangladesh. While all of these areas have a strong need for supply-side preventive care in the community, I have come to question the wisdom of trying to develop demand-led care within slum localities. My misgivings are based on a number of personal observations and from a reading of the relevant literature.
On site observations suggest that local residents prefer to use hospital facilities, even when this is less convenient than a more accessible community clinic. Some, but not all, slums are reasonably well supplied by local clinics. These clinics are usually staffed by medical officers or nurses rather than doctors. In many cases they have been provided by NGOs. I have observed that these clinics do not have many clients. When I draw attention to this, I am often told that this is because I have come at a quiet period. However, when I probe more deeply, I learn that the outpatients departments of nearby hospitals receive the bulk of the patients. Certainly that is my impression on visits to hospitals in LMICs where outpatient departments ‘heave’ with patients. This finding triangulates with work that colleagues and I have carried out in India under MRC sponsorship.
Not only do local residents seem to prefer hospital-based outpatient’s care, but my reading of the literature suggests that they are right to do so. Working with colleagues, I am carrying out a review of the quality of care provided in local settings in LMICs. The literature shows that such care is almost universally of a low standard, irrespective of whether the provider is private or public. Care given by doctors is generally better than that given by non-medical personnel, but even so is of a poor standard when delivered in the community. The quality of care across both settings is a topic of enquiry in the NIHR Unit on Health Service Provision in Slums that I direct. However, I suspect that the hospital will come out on top.
The corollary of the above, rather preliminary findings, is that we should be cautious about wholesale, and perhaps ideologically-driven, policies to deliver demand-based healthcare coverage in community settings in low-income urban environments. Pending further research I hypothesise that it may be better to improve access and quality in hospital settings, at least in the first instance. Before taking fixed positions on these important issues we need to understand more about access to healthcare at the demand-side, the quality of such healthcare, and the most-cost effective approaches to driving up the quality of health care.
Please note that all of the above remarks apply to healthcare at the demand-side. That is to say, where a person has sought care for a perceived health problem. We fully support outreach primary preventive services to ensure vaccination, detect malnutrition, and ensure that people stick to their HIV and other treatment regimes.
Box A. Section VI of the Declaration of Alma-Ata
“Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community [emphasis added] through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”
— Richard Lilford, CLAHRC WM Director
- Lilford RJ. Intensive Care Harmful in Elderly Patients. NIHR CLAHRC West Midlands News Blog. 7 December 2017.