Diagnostics in primary healthcare in India

If you or I went to a doctor with symptoms other than a common cold, we would expect the doctor to take a history, do a physical examination, and possibly send us for various kinds of tests. In modern healthcare, it is expected to combine patient history with physical and laboratory findings. This helps us understand what is wrong with a patient and how to treat them. If a doctor were to prescribe treatment, particularly for any illness lasting longer than a week, or not monitor a pre-existing condition with appropriate testing, that would be unacceptable to most patients.

Beyond care for individual patients, for any healthcare system, it is important to have an accurate measure of the patients and diseases that are expected to be handled. It involves an understanding of what is common and what is seen in a particular area. This is essential to plan activities and direct resources.

It is equally important for the public healthcare system, where service delivery processes are less agile than those accessible to private providers. Planning for personnel, facilities, drugs and vaccines is well-recognized and acted on within the health system at all levels of healthcare. However, provision of access to diagnostics in primary healthcare is limited. When available, it is of uncertain quality.

Diagnostics are essential tools for improving health outcomes, optimizing health spending, and enhancing health security. However, diagnostics remain underutilized and underfunded in low and middle income countries (LMICs). This is especially so in primary healthcare settings.

The Lancet Commission on Diagnostics, which published its report toward the end of 2021, reported that almost half of the global population had little or no access to diagnostics. The COVID-19 pandemic showed us that diagnostics was critical to patients and the public health system. It was essential to be able to deliver care appropriately, and monitor the disease and the emerging variants.

The 2022 revision of the Indian Public Health Standards mandates the continuum of healthcare to be provided through a referral system. This is supposed to start at the Health and Wellness Centre to the Primary Health Centre, the Community Health Centre, and the District Hospital for the twelve care packages.

This provisioning of care is planned to extend beyond the provision of maternal and child health services such as antenatal care, delivery and immunization. It includes screening for non-communicable diseases, cancer, and mental health.

The proposed comprehensive provision of health services includes early identification, basic management, counseling, ensuring treatment adherence, and follow-up care. This is envisaged to ensure continuity of care through a set of interventions. These include appropriate referrals, optimal home and community follow-ups, and the surveillance of diseases. Thus, the Health and Wellness Centers and Primary Health Care centers are expected to be the backbone of healthcare in India. They are supposed to provide care and play an important role in undertaking public health functions.

India has a central role in the LMICs in the provision of vaccines and drugs. Therefore, it raises an obvious question. Is it possible for India to play a major role in diagnostics development and use?

The COVID-19 pandemic showed what was feasible in India. With the right resources and support from the government, we were able to drop the cost of testing to one-twentieth of where we started. We were also able to scale testing to a level unimaginable at the beginning of the pandemic.

However, drugs and vaccines are high volume markets than diagnostics, at least now. Therefore, there are doubts about whether the many diagnostics companies that sprang up during the pandemic will be able to survive.

The margins that are afforded by government tenders are slim and the market is competitive. This results in a reluctance to invest in quality systems, and in research and development. Nonetheless, if an appropriate diagnostic test allows for a disease to be identified early in the illness, the treatment becomes easier and faster.

Take what happens with tuberculosis now. A cough and fever are frequently treated with antibiotics. The diagnosis of tuberculosis is often made late. Many a times the person has already been debilitated.

At this stage, they are often unable to handle the many months of the required treatment. And that is when, it is not drug-resistant tuberculosis.

Similarly, diabetes, hypertension and anemia are all too common conditions in India. These are often not identified until the disease has progressed. With early diagnosis in primary care, we could change the trajectory of illnesses.

To deliver on the promise of diagnostics, we need multiple stakeholders to address the challenges. These include governments, manufacturers, researchers, healthcare planners, and providers. Collectively they need to make diagnostics an essential part of primary healthcare.

Thus, we need to truly unleash the potential of diagnostics. For this, we must first understand that equity in healthcare requires that diagnostics be available and used everywhere to inform both treatment and public health. India can, and must, become a pathfinder and enabler of this vision.