|LETTER TO THE EDITOR
|Ahead of print publication
Strengthening the rural primary health care in India: “The community-based nurse-led clinic model”:– A stride toward sustainable development goal 3
Jaison Joseph1, Abin Varghese2, Gigini George2, VR Vijay3
1 Department of Psychiatric Nursing, College of Nursing, Pt. B.D. Sharma University of health Sciences, Rohtak, Haryana, India
2 College of Nursing, Bhopal Memorial Hospital and Research Centre, ICMR, Bhopal, Madhya Pradesh, India
3 College of Nursing, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||29-Mar-2021|
|Date of Decision||17-May-2021|
|Date of Acceptance||31-Jul-2021|
College of Nursing, Bhopal Memorial Hospital and Research Centre, ICMR, Bhopal, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Joseph J, Varghese A, George G, Vijay V R. Strengthening the rural primary health care in India: “The community-based nurse-led clinic model”:– A stride toward sustainable development goal 3. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=339383
A major proportion of India's population lives in rural areas. Even after more than 70 years of the Bhore Committee report, health in India remains a luxury and there is a wide range of disparities in the three-tier model of health-care delivery system in the rural areas [Figure 1]. The availability and accessibility of primary health care in rural areas remain a huge challenge, leading to higher out-of-pocket expenditure and there seems no universal solutions. This is further substantiated by indigent health-care outcome indicators from rural areas; maternal mortality ratio (397), infant mortality rate (29), and under 5 mortality rate (50).,, The broad goal of primary health is to improve the health of rural people by providing optimal public health services efficiently and effectively. There is a need to build a strong comprehensive primary health-care system to reduce the disparities.
Despite the commitment shown by the government for building up and fortifying primary health care through its numerous lead projects and strategies, a significant hole exists in inciting it from papers to activities. Various reasons can be attributed to the malfunctioning health-care system in rural areas. Lack of quality infrastructure and the critical shortage of health manpower and resources were enduring problems throughout the different decades even after revamping primary health care through the National Rural Health Mission in 2005. People are forced to avail of private health-care facilities due to the unavailability of health-care personnel and diagnostic facilities in the rural community areas, resulting in a higher out-of-pocket expenditure (62.6% in 2015) with a catastrophic economic impact (19.2%). Strengthening the existing primary health-care system in rural areas is more important than the creation of new facilities. Upgradation of the health-care personnel by task sharing to nonphysicians at the grassroot level is a well-proven strategy for making health care more accessible and affordable without compromising quality. Surprisingly, 9.6% of PHCs in India are functioning without an allopathic doctor. Nurses, the largest health-care personnel, can certainly ensure the doorstep delivery of health services. The concept of nurse-led-clinics (NLCs) is a new paradigm shift in the nursing discipline that is unique and diverse from the conventional physician-centered model, emerging from a broad perspective around the world. The available evidence suggests that a community-based nurse-led clinic is a safe and cost-effective strategy to improve the performance of the health-care system. The present article aims to describe a comprehensive and pragmatic public health nursing model for improving and furnishing the rural health-care system in India.
| The Community-based Nurse-led Clinic Model|| |
As rural India is facing an acute shortage of physicians, the community-based nurse-led clinic model represents a decentralized and family-centered approach to strengthen the rural primary care setting which is a need of the hour in this dynamic 21st century. The community-based nurse-led clinic is an extension of nursing services to monitor the health status and to deliver the therapeutic interventions within the community setup. The proposed model is conceptualized as pyramid shaped, with a broad “base” in the community at the subcenter level through the community-based nurse-led clinic and telephonic follow-up [Figure 2]. The referral services will operate through primary health centers and tertiary centers. The purpose of the “base” is four-fold: (a) to maximize disease surveillance, (b) to identify and initiate primary treatment, (c) to facilitate access to the services, and (d) to refer patients to either of the two higher levels.
|Figure 2: The community-based nurse-led clinic model for strengthening rural primary health care in India|
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Scope of the model
As per this model, a trained graduate nurse can lead the community-based clinic and the community level workers such as Accredited Social Health Activists (ASHAs), Multipurpose Health Workers (MPHWs), and others would need to sensitize the public to seek the services during their house visits. The graduate nurse should undergo brief orientation programs and training and they should be taught the basics of early identification and management of common and specific illness as per the general and vulnerable population within the community.
The community-based nurse-led clinic is a decentralized team approach strategy, in which the ASHA workers and MPHW identify the priority health needs by periodic maintenance of family folders. The NLC nurse provides need-based care and services at the family or subcenter setting depending on the nature of the illness and priority. Irrespective of the type of care, adherence to the treatment through direct or telephonic follow-up is considered the prime responsivity of the NLC nurse. The following are the proposed job responsibilities of a community-based nurse-led clinic nurse assumed to perform at the subcenter level.
- General clinic:-this is aimed at the management of the most common health-care problems as per the involved community
- Primary care management in common health-related issues such as fever, common cold, and vaccination against animal bites
- Early identification and prompt management of seasonal diseases such as malaria, chikungunya, and dengue fever
- Management of chronic illness such as diabetes and hypertension through screening and referral to treatment services, follow-up care of confirmed cases through regular monitoring
- Maternal and child health-care clinic: -immunization for children and pregnant women, antenatal care including iron and folic acid supplementation, nutritional counseling, and management of general ailments such as diarrhea
- Mental health and de-addiction clinic: -initial management of psychiatric emergencies through various restraint approaches, early identification, and counseling regarding the management of substance use disorders, follow-up care of those with repeated relapses
- Geriatric and palliative care clinic:- need-based care for those requiring hospice services such as management of pain and physical symptoms, care during bowel and bladder dysfunction through tube feeding, urinary catheterization, and colostomy care.
| Strength and Limitations|| |
The numbers of students residing in the rural areas who are graduating in nursing are quite higher than medical graduates and they will prefer to work in a rural area if job opportunities are created in their nearby villages. Moreover, integration of middle-level health-care provider courses in the curriculum of BSc Nursing final year and post basic BSc Nursing 2nd year are already recommended and enacted by the Indian Nursing Council and the index model can act as a catalyst for the extension of nursing services in the community setting. However, the optimal outcome of this model purely depends on the quality of training as per the desired accountability.
| Conclusion|| |
There is an epidemiological transition in the primary health-care system in rural India with many public health priorities. The existing lacuna in the rural health system suggests the need to move from quantity to quality. Even though the flagship programs announced by the Government of India such as the “Ayushman Bharat and Prime Minister Jan Arogya Yojana” can strengthen the rural primary health care, universal health coverage depends on a fully functional model – “the community-based nurse-led clinic model.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]