Showcasing primary care models in South Asia: sharing experiences from India, Pakistan, and Sri Lanka

Hina Jawaid is a family physician, an associate professor, and head of the Family Medicine Department, Health Services Academy, Islamabad, Pakistan.

Gobith Ratnasingam is a family physician and lecturer at the Department of Community and Family Medicine, University of Jaffna, Jaffna, Sri Lanka.

Mohan Kubendra is a consultant in family medicine and director of Spandana Health Care, Bangalore, with a special interest in diabetes management and geriatric care.

Abdul Jalil Khan is a consultant family physician, and director of the Institute of Family Medicine, Khyber Medical University, Peshawar, Pakistan.

Jyotika Gupta is a consultant family physician and diabetologist at RxDx Samanvay, Bangalore, with a special interest in preventive medicine.

Vandana Boobna is a consultation physician and director of Clinic Viva and Max Super Specialty Hospital, Shalimar Bagh, Delhi, India, with a special interest in diabetes and non-communicable disease prevention and early detection.

In the dynamic landscape of healthcare delivery, South Asia stands at the forefront of transformative change, particularly in the realm of family medicine. This article explores and elucidates the diverse models of family practice emerging across the region.

With a focus on integration, collaboration, and technological advancement, these models represent a fundamental shift from illness-centric to wellness-oriented care. As we delve into the intricacies of these models, it becomes apparent that family physicians are no longer confined to the traditional role of treating ailments but are instead catalysts for holistic wellness and preventive care. The interconnectedness of physical, mental, and social wellbeing takes centre-stage, highlighting the importance of proactive measures to optimise health outcomes and enhance quality of life.

Representatives from India, Pakistan, and Sri Lanka come together to showcase their respective models, spanning private and public sectors. Each model offers unique insights into the evolving landscape of primary care delivery, underscoring the significance of collaborative practice and technological innovation.

Against the backdrop of limited resources and burgeoning populations, these emerging models signify a beacon of hope for the future of health care in South Asia. By embracing innovation and collaboration, we can navigate this era of change and forge a path towards a healthier, more resilient future.

India — Integrated primary care clinical services: sharing experience from privately run healthcare facilities in urban settings

Exemplar 1: In an urban setting, a collaborative model between primary care physicians (PCPs) and tertiary care centres can be highly effective in addressing the diverse healthcare needs of the population. This model typically involves a network of primary care clinics working closely with specialised hospitals and medical centres. PCPs serve as the first point of contact for patients, providing preventive care, managing chronic conditions, and addressing common health issues. When patients require specialised or advanced treatment, PCPs can refer them to tertiary centres, where specialists, advanced diagnostic tools, and specialised treatments are available. Key components of this model include:

1. Integrated care coordination: seamless coordination between PCPs and tertiary centres ensures smooth transitions for patients requiring specialised care. This includes timely referrals, sharing of medical records, and collaboration on treatment plans.
2. Telemedicine and e-consultations: utilising telemedicine technologies allows PCPs to consult with specialists remotely, reducing the need for patients to travel to tertiary centres for every consultation. This enhances accessibility to specialised care, particularly for patients in underserved areas.
3. Shared decision making: collaborative decision making involving PCPs, specialists, and patients ensures that treatment plans are tailored to individual needs and preferences. This promotes patient-centered care and improves treatment adherence.
4. Education and training: continuous education and training programmes for PCPs ensures they stay up to date on the latest medical advancements and treatment protocols. Tertiary centres can also provide specialised training opportunities for PCPs to enhance their skills in managing complex cases.
5. Data sharing and analytics: sharing of healthcare data between primary and tertiary settings facilitates population health management, predictive analytics, and quality improvement initiatives. This enables proactive management of chronic diseases and identification of high-risk patients for targeted interventions. Overall, a collaborative model between PCPs and tertiary care centres in urban areas can improve access to high-quality health care, optimise resource utilisation, and enhance patient outcomes through coordinated and comprehensive care delivery.

Exemplar 2: Practicing as a family physician specialist at a privately owned primary care clinic in an urban setting, I run a full-day outpatient department (OPD) that includes infectious disease management, vaccinations for adults, health check screening, diabetes, obesity, metabolic dysfunction, nutrition advice, women’s health, and counselling for lifestyle. In parallel, as clinic lead I oversee the day-to-day operations of the clinic, including staffing, scheduling, budgeting, and ensuring regulatory compliance. Strategic planning, implementing quality improvement initiatives, and fostering a positive work environment for staff is also part of the job contract. Ensuring smooth running of clinic and provision of high-quality care to patients can be challenging. Pre-operative and post-operative care of patients coming to specialties like orthopaedics, gynaecologists, and gastroenterologists are given by PCPs along with a team of nurses, lab technicians, and physiotherapists. Home visits are also offered on a need basis.

Pakistan — Multi-pronged strategies: creating community health clinics/primary care centres within secondary/tertiary care hospitals, and introducing capitation model of payment in primary care

Exemplar 1: A family medicine department at a public sector healthcare facility called District Head Quarter hospital in the city of Gujranwala, approximately 60 miles from Lahore. This hospital is a 500-bed tertiary care hospital that caters to a population of 2 million. The outpatient influx of patients is approximately 5000 per day.

Development of this outpatient service included work at multiple levels:

1. sensitisation of all stakeholders and decision makers over a period of years followed by briefing and training of triage staff and other specialities within the hospital;
2. training of nursing staff on how to ensure patients are signposted to services like pharmacy, radiology, and labs, and how to explain medications in the local language; and
3. development of nutritionist services to deal with growing issues of obesity, poorly controlled diabetes, nutritional deficiencies in children, and antenatal issues like anaemia.

The outpatient clinic offered:

1. counselling on lifestyle modifications for unhealthy behaviours, medications review, screening, disease management, and appropriate referrals to specialists; and
2. introducing undergraduate doctors to the discipline of family medicine.

Exemplar 2: To improve access, quality, and equity in health care, various financing and payment models for primary health care (PHC) have been in place in health systems across the world.

While there is no ideal payment method and each model has its strengths and weaknesses, many countries are moving toward some variation of capitation payment for PHC. Capitation is structured around financing all necessary health care for a defined population rather than tying payment to specific diagnostic and curative services when those services are delivered. Among all of the payment methods it is the most consistent with the philosophy of PHC as it can ensure availability of a care package for the entire population.

Capitation models provide a predictable payment structure to primary care providers, incentivising them to offer comprehensive and preventive care services. This can lead to increased access to healthcare services for low-income individuals and families who may otherwise face barriers to accessing timely and affordable care.

A similar model is under consideration by the Sehat Sahulat Programme (social health protection initiative) to provide PHC services for a population registered with the Benazir Income Support Programme in some pilot districts of Khyber Pakhtunkhwa. The PHC centres offering the services will then be linked via both horizontal and vertical referral pathways, with diagnostic and other secondary and tertiary care services. However, there is a risk of under-provision of services and inappropriate referrals. Certain factors including health needs, geography, vulnerability, deprivation, and socioeconomic status should be considered to counterbalance these negative consequences.

Implementing additional measures such as monitoring, penalties, fee-for-service, and performance-based payments will be added to capitation in future to improve utilisation of essential services. These services will then be upgraded in a stepwise manner by ensuring availability of qualified and trained family physicians, having access to an integrated information system, and additional/extra preventive and curative services. The payments can also be adjusted based on demographic variables, geographic differences, poverty, and other factors like provision of medicine, transportation, and other additional services.

Sri Lanka — Primary health care strengthening through a shared care cluster model

Exemplar 1: Sri Lanka’s PHC system is a testament to success, with reasonable health indicators and resolved disputes about low health expenditure. It strongly emphasises preventive care and community health, primarily delivered through state healthcare services. The Medical Officers of Health provide the services and oversee public health initiatives and programmes, including maternal and child health, immunisations, infectious disease control, and primary curative care services provided by Primary Medical Care Units (PMCUs) and divisional hospitals (DHs), supported by OPDs in secondary and tertiary care hospitals. Private practitioners also play a significant role, contributing to almost half of PHC consultations in the country.

Sri Lankan health authorities are concerned about strengthening the primary care system, with notable implementations such as the Primary Health Care System Strengthening Project and the Health System Enhancement Project. One successful initiative is the Shared Care Cluster Model, where secondary and primary hospitals are grouped together to serve a defined population. This model includes an apex hospital, typically a base hospital or higher, and cluster hospitals are like DHs and PMCUs. The cluster model aims to ensure coordinated and accessible healthcare services across different levels of care, particularly benefiting rural areas. It also enables more efficient resource utilisation to achieve universal health coverage in the defined population.

In conclusion

The panel discussion on the emerging models of family practice in South Asia has shed light on the transformative journey underway in healthcare delivery. From successful implementation of shared care clusters to an innovative capitation model linked with social health protection, each model offers valuable lessons and insights for shaping the future of family medicine.

As we navigate the challenges posed by limited resources and burgeoning populations, it is imperative that we continue to champion patient-centered approaches and embrace the opportunities presented by technology and collaboration.

We call for a policy document to carry forward the spirit of innovation and collaboration, leveraging these emerging models to shape a healthier, more resilient future for all in South Asia. We also emphasise that low- and middle-income countries’ issues must be addressed at a local or regional level without being affected by external (to the region) factors.

Featured photo of the Badshahi Mosque in Lahore, Pakistan by Nouman Younas on Unsplash.