Excerpts from “Symptoms and medical conditions in 204,912 patients visiting primary health-care practitioners in India: a 1-day point prevalence study (the POSEIDON study)” by Salvi S, Apte K, Madas S, et al, published in the Lancet Global Health (Volume 3, No 12, December 2015, e776–84):
Of the world’s 7·5 billion population in 2015, 1·2 billion people live in India. Around 18% of all global deaths and 20% of loss of global disability-adjusted life years (DALYs) occur in India, making it a country with one of the highest disease burdens in the world. Non-communicable diseases have recently overtaken communicable diseases as the leading causes of mortality and morbidity in India.
A vast and populous country such as India that has a significant health burden faces many challenges in the provision of health services. India needs to build appropriate health-care infrastructure, allocate appropriate health-care resources, and train medical and paramedical personnel in diseases that are most commonly encountered in clinical practice. Further, the country needs to develop preventive and public health programmes for diseases that have high morbidity and mortality, and prioritise research funds for diseases with an important health burden. These objectives can only be met by interventions based on reliable, nationwide data on what ails India.
Health care in India is provided by 1·5 million practitioners registered with the Medical Council of India. Of these, 0·7 million are trained in modern medicine and 0·8 million are trained in alternative forms of medicine. Primary health-care providers in India include general practitioners (trained in modern as well as alternative forms of medicine), general physicians (internists trained in modern medicine), and paediatricians (trained in modern medicine). About 80% of patients visit a private practitioner, which they do at their own expense.
However, most health-related data in India are obtained from public hospitals and public health-care service units and because public facilities provide only 20% of all outpatient care in India, they, therefore, do not necessarily provide a true picture of the whole morbidity profile in India. The National Family Health Survey (NFHS) is the largest nationwide health-related survey in India that has been conducted in three rounds so far (1992–93, 1998–99, and 2005–06). However, these data are collected via self-reports and the focus has been on information related to fertility, infant and child mortality, contraception and family planning, maternal and child health, reproductive health, nutrition, and anaemia. Little information about disease patterns has been collected. Moreover, self-reports could result in under-reporting of disease patterns.
The POSEIDON study, across 880 cities and towns in India, identified the main conditions that lead a patient to visit a primary health-care practitioner. Analyses of the 554,146 ailments reported in 204,912 patients visits have provided an insight into what ails India. The results of this study have implications for planning of health-care services and infrastructure development, design of medical education curricula, and identification of health research priorities in India.
Practice-based morbidity surveys such as the POSEIDON study provide data that are different from those of population-based health surveys because they have the unique advantage of added inputs of physician interpretation. They provide population-level sickness patterns that are valuable for deploying often limited resources available for health-care services. Several countries have used the results of such surveys to drive public health policies. This is the first attempt at such a large nationwide study from India and sets an example of how large, meaningful, and good quality data can be generated in resource-poor settings by partnership between academia and the pharmaceutical industry.
In contrast to studies from Singapore, Sri Lanka, Malaysia, and South Africa, where more female patients visited a primary care physician, our study showed that primary practitioners received a greater proportion of visits from male patients (54·1%). This gender bias remained throughout all age groups, including children, adults in the reproductive years, and older people, and was constant across all regions of the country. In an equitable society, one would intuitively expect the child-bearing related needs of women to lead to greater use of ambulatory health care in women. Although non-inclusion of women’s-health specialists might have led to an underestimate of the number of female patients, the gender difference was even larger in patients younger than 18 years (57% males). Such gender inequality is similar to that seen in other recent population-based studies and probably reflects social values surrounding male preference in India.
Furthermore, only 7·9% of patients who visited a primary health-care provider in our study were older than 60 years. The proportion of people older than 60 years is 8% in India. Since older people will suffer from age-related ailments, our findings probably reflect a reduced opportunity to seek health care compared with that for younger people. Other than infirmity, we speculate that economic reasons prevent older people from seeking health care, since 80% of health care in India is paid for by the individual, rather than the state. Supporting this observation is a finding from Agrawal and colleagues that when health-care delivery is provided free of charge and delivered near patients’ homes, older people are the largest users of such care. Since women and older people have greater health needs than the rest of the population, our findings might be describing a widespread social inequality in India.
Respiratory symptoms were the leading cause of a visit to a health-care provider across India, accounting for about half of all patients and 65% of all child patients. Although infections of the upper and lower respiratory tract were among the leading causes of respiratory symptoms, asthma and COPD together captured under the category of obstructive airways diseases was the second most common diagnosis reported by primary health-care practitioners in India. Previous work by Duong and colleagues showed that Indians had the lowest lung function of the 17 countries that were studied, with a mean difference in spirometric indices of about 30–35% lower than white people matched for age, sex, and height. COPD was reported as the second leading cause of death in India in the 2013 Global Burden of Disease Report. These previous studies and the results from the POSEIDON study highlight the huge burden of both acute and chronic respiratory diseases in India and should serve as a call for urgent public health measures to reduce the burden of chronic, non-communicable respiratory diseases in India.
Although circulatory symptoms accounted for the third most common cause of a visit to a health-care provider in India, hypertension was the most common diagnosis reported by the primary health-care practitioners. More importantly, a fifth of patients with hypertension in the POSEIDON study were younger than 40 years, indicating a high burden of young patients with hypertension in India and suggesting that blood pressures be routinely measured in young adults. The diagnosis of hypertension was more commonly reported from cities and towns with a population greater than 1 million people than from those with a population less than 1 million, suggesting that hypertension is more common in overcrowded and urban places in India. The results of the POSEIDON study support the World Health Statistics Report, which showed that in India between 1980 and 2008, there was an increase in age-standardised prevalence of hypertension. This finding is in contrast with other regions of the world where there has, in fact, been a downward trend.
Health care in India is not organised in accordance with societal needs, and it faces several challenges, such as socioeconomic inequality, inappropriate distribution of government subsidies, low emphasis on preventive services at all levels, and a lack of effective national programmes or policies for many common illnesses. The results of the POSEIDON study should not only help organise health-care delivery in accordance with societal needs, but also set the path for future studies in other developing countries. Resultant data could help to establish disease patterns and patient profiles, which could then influence and drive health-care services, medical research and medical education, as well as fuel innovation in health epidemiology.