What is primary care? What are consumers looking for in primary care? How do you know if your primary care innovation works? Innovations in Healthcare had the good fortune to sit down recently with Dr. Onil Bhattacharyya, a family physician who studies innovative health service delivery models in both high- and low-income settings, who answered all these questions and more. He is committed to using health services research to make a more effective, responsive, and integrated health care system.
Dr. Bhattacharyya is the Frigon-Blau Chair in Family Medicine Research at Women’s College Hospital. He is also an associate professor in the Department of Family and Community Medicine and an assistant professor at the Institute of Health Policy, Management and Evaluation, University of Toronto. He received his medical degree at McGill University, has a PhD in health services research from the University of Toronto and was a Takemi Fellow at the Harvard School of Public Health.
He is co-lead of the Toronto Health Organization Performance Evaluation group (T-HOPE), which brings together medical students and MBAs to study social enterprises in health in low- and middle-income countries and has published more 40 peer-reviewed papers and numerous book chapters.
JC: Speaking to primary care innovators working in a low- or middle- income countries, what are the key takeaways from your research that can guide their work?
OB: There are a couple of visions of primary care that are important to frame if you’re going into the business of primary care. First, do you see it as a solution shop? Is it a service where whatever comes through the door, you are going to try to manage that problem? That’s an important decision because that means you are looking for people at a certain level of training and you are going to be open to whatever the population might need. That determines your processes. It makes it harder to “protocolize” things, but it builds confidence in primary care. So that’s the first framing. Are you going to try to do most things and build a referral network that connects to other levels of care, so that the entirety of people’s problems can be addressed?
The other way to think about primary care is to identify in your region the high burden conditions with cost effective interventions that are simple and easy to do and deliver and build a system around just those. This is a value-added process model. I think those are alternative visions of primary care and I think you could move from one to the other as your staff rises in sophistication, but if you’re doing the value added process the referral path for those conditions is more straight forward. If you’re not connected to a system in a robust way then each effort to coordinate is huge.
The other piece that is embedded in both of those framings is that primary care is never going to do everything and coordination is part of its job. The coordination with other services should be seen as part of your job. You don’t just hang a shingle and deal with some specific problem and that’s the end of it. One of the fundamental problems in low and middle income countries is that primary care is not valued. People don’t routinely seek those services. They’d rather go to a pharmacy and buy drugs instead of going to a consultant.
JC:So what value do you add when you are being humble enough to say “I can’t solve all your problems”?
OB: I think the basic solution from our research so far is to focus on the relationships. The relationship is fundamental to primary care and you need to build that in. It’s not a purely technical discipline. Continuity is a feature of primary care and so you want to build relationships with people over time, understand their preferences and advise them because most of the problems in primary care are self- limiting. There are nonspecific symptoms that are not easy to diagnose and sometimes you never get a diagnosis. You need to comfort people and say ‘I don’t know why you have a tummy ache today, but if it gets worse come back and see me tomorrow.’ With that kind of wait and see conservative element of primary care, if people don’t value the relationship in primary care, they won’t value what you are doing.
One of the harms of health services in low- and middle- income countries is over-prescription and unnecessary interventions that waste peoples’ money, but if you trust the doctor enough when she says that your runny nose is viral, people will be less likely to intervene unnecessarily. That’s why primary care is associated with better population health and lower costs because it’s conservative.
JC: Low- and middle-Income countries more often have doctor shortages. Is that an advantage or disadvantage when you are building these relationships in primary care?
OB: That’s a good question. It depends on how you structure availability of health care human resources. In remote parts of India, access to doctors is poor and in urban areas it’s better. One way around that is to build teams with health workers, nurses and doctors and people get triaged to the appropriate level of care. Literature from high-income countries shows that it’s possible to develop a relationship with a team if it’s the same people you interact with, if you respect the skillsets of each team member, and trust that they will communicate with each other and refer internally when appropriate.
JC:In the U.S., even with the move toward teams, often there is still a preference for the doctor. Do you find this preference as an obstacle to teamwork in other places?
OB: It’s true. That’s the initial reaction. It’s hard to start with the nurse referring to the doctor. But if the doctor is referring to the nurse, then patients build a relationship with a nurse and the nurse, over time, is trusted as the gatekeeper. As that builds out, you need to change attitudes towards that but I’ve seen it happen in my experience as a physician and I think you see the same thing in a low- and middle income setting.
The widespread use of informal healthcare providers who essentially have limited or no training suggests that the relationship is valued. In India the use of informal health workers is huge. It’s a high proportion of the health care workforce. They are accessible at any time, they are nearby, they are from the community, they understand you, and they are particularly good at building relationships. The problem with informal health workers is that they are not connected to health systems, they are isolated. Some of these informal providers are practicing western medicine in an ad hoc way so to leverage that relationship and then incorporate them into a team is quite promising. World Health Partners makes extensive use of informal healthcare providers. I think that informal health providers aren’t going to be good at most problems but they might be particularly good at the psycho-social problems.
Some technical things could be embedded into teams and soft parts of primary care can be made into protocols. Screening for mental health conditions, basic health care counseling, behavior change – for all these you could use tablets, which are more expensive as an intervention but at a certain level of economic development, it’s going to be easier to get the technology than the trained medical staff. It will be a price point of when the technologies are robust enough and cheap enough and then we will see this as a real viable alternative.
JC: What advice do you have for our innovators about evaluation?
OB: I think one of the fundamental reasons to evaluate is that you are an innovator and you are doing something new and different which is of unknown value. If you care about the impact of what you are doing then you need to study it, understand what’s working, what’s not and then change. And this is one of the challenges of social enterprise: it’s possible to be financially sustainable and to grow without actually having any impact. There are lots of things in healthcare that are of marginal value that may waste money and are yet still routinely done. That’s the first reason for me: You should be worried that what you are doing is not going to work. Most start-ups don’t work. Even the ones that just want to make money have this challenge. If you want to have social benefit it is even more difficult.
The second reason for evaluation is that it allows you to communicate your value to others. I think the people that fund and support these things might be more skeptical. Some people will be brought in by charisma and touching stories but that community is becoming increasingly sophisticated. The work by IRIS [Impact Reporting and Investment Standards] on impact metrics haven’t been widely taken up but at least there is increasing recognition that we can attach a value to impact. We can measure it and we can attach some value to it. I think that means opportunities for growth for these enterprises.
The downside of this is that the more you spend on evaluation, the more likely you will see a negative result. If the trend of the condition you are trying to study is toward improvement for a whole range of reasons (which is true in many areas of health) then if you use a design that doesn’t control for this trend, you’re going to show benefit even when there is none. So that’s safer. In that instance, the added value of rigorous evaluation may be less obvious. But when the natural trend is decline, if you have a more rigorous evaluation design, you’re more likely to see benefit. So it depends what you are studying. For example, my work on high users in a health system, many of them are in a rapid downward decline. An uncontrolled study will show that you made it worse.
JC: How do innovators balance the risk of negative results with the benefits?
OB: If the purpose is marketing, it’s trickier. But if the purpose is having an impact then it’s worth doing. We go back to the first question, is what you are doing having impact? It might not. Just take the example of microfinance. Microfinance works in the sense that it’s a financially sustainable model and it scales as a business. But does it reduce poverty? Randomized trial results are very mixed. So if your goal is to alleviate poverty and you have a very financially successful microfinance operation with high loan repayment rates, I would worry about that. Microfinance when consistently evaluated doesn’t show the benefits we thought they had. Many things are worth doing. We just don’t know the exact way to do it yet and that’s another reason to evaluate.
There are internal reasons, marketing reasons, and benchmarking reasons which are fundamentally useful. The internal motivation to do good is the primary thing. No one is requiring you to do this. Pharmaceutical companies do this because they have to.
The last thing to say on evaluation: I don’t think we have the methods right for innovative models that have diffuse effects. If you’re trying to do one thing, decrease child or maternal mortality or some kind of specific benefit, it’s easier. But if your intervention does 10 things, we don’t have great study designs to measure the impact on 10 things. A good health intervention shouldn’t do just one thing.
To move evaluation forward, we need investors to put a bit of pressure on entrepreneurs and for entrepreneurs to push back a little bit so you don’t have an excessive burden and to find a sweet spot where we have data that is feasible to collect, comparable across organizations and credible. We’re definitely not there yet.
JC: Thanks for your time Dr. Bhattacharyya!