HEALTHCARE IN INDIA AND COVID-19
Access to healthcare is a very important component for nations' development, and the good health of individuals can help a nation build its economy. Although the healthcare system in India is universal, there is a great discrepancy in the quality and coverage of medical treatment. India is a huge country, and the healthcare between states and between rural and urban regions is very different. Hospitals are unevenly distributed across the country. With the recent surge of cases in the second wave (2021) of coronavirus disease 2019 (COVID-19), the healthcare system in India is facing challenges in simultaneous detection and care of patients with COVID-19 and providing care to patients with non-COVID conditions. Rural parts of the country often experience hardships and disparities between states. The public healthcare system is provided by federal and individual state governments. Unfortunately, many individuals in India do not have access to healthcare. There are multiple reasons for this, but the large population makes access to healthcare for everyone a difficult task. The public healthcare system is developed but cannot cater to the needs of all. The private healthcare system includes primary care clinics, secondary care hospitals, and tertiary and quaternary care hospitals; it helps to increase healthcare access to its citizens, but not everyone can afford it.[1,3] Patient care in India's healthcare system heavily depends on physicians as sole clinicians; however, there is a huge scarcity of medical doctors in the country, which adds to the problem of access to healthcare. Furthermore, COVID-19 has caused a major disruption in healthcare access. During the pandemic, many of the existing healthcare facilities were converted to COVID-19 care centers. This disrupted access led to a compromise in patient care and increased morbidity and mortality.[5–7] With the everyday surge of patients with COVID-19 to new heights and its management the priority, there were shortcomings in the regular follow-up of patients with other health conditions.
Individuals who are undergoing treatment for chronic diseases like diabetes do not usually develop any signs and symptoms. These patients must go for routine follow-up at regular intervals to make sure that their blood glucose is within normal limits and they do not develop complications. However, it is important to note that their follow-up during this period was not a priority and their visits to hospitals or clinics would increase the patient load, which could compromise healthcare to higher priority patients. Lack of follow-up could also result in acute complications from diabetes, like ketoacidosis, for which patients need to be hospitalized. These problems in access to healthcare can be addressed by increasing the expenditure on healthcare, but that is an exhaustive and time-consuming process.
The role of pharmacists as members of healthcare in India is quite different from developed countries. The pharmacy practice in India is mainly the industrial pharmacy practice followed by community pharmacy practice and hospital pharmacy practice. The industrial pharmacy practice is well established owing to the fact that India is self-reliant and, in turn, a major exporter of pharmaceuticals to the world. The hospital pharmacy practice primarily focuses on distribution, availability, inventory, and dispensing of medications. In the public sector, there is a position for pharmacists but the position for clinical pharmacists does not exist. Recently, the Pharmacy Council of India has amended the pharmacy practice regulations in India to include the post for clinical pharmacists and creation of drug information centers in hospitals. Though a commendable initiative, it awaits the approval by the Ministry of Health and Family Welfare, Government of India. There is no special clinical pharmacy licensure examination. The medication therapy management (MTM) services are nonexistent.
Innovative Model for Chronic Patients
In this article, the authors suggest an innovative model of healthcare delivery that can take care of the existing problem in healthcare access. The solution starts with India's greatest strength, which is the availability of pharmacies in every part of the country. Patients do visit the pharmacies to get over-the-counter medications for minor ailments. We are suggesting that MTM clinics can be launched at participating pharmacies. MTM is an idea of incorporating a pharmaceutical care and chronic care model. The components of MTM with an example are shown in Table 1.
These MTM clinics can provide care to patients with chronic disease conditions whose acute complications lead to hospitalizations. Table 2 lists the chronic disease conditions for the MTM program (adapted from the Centers for Medicare and Medicaid Services). A group of MTM clinics can be linked to one physician who can participate in collaborative care and provide supervision. This model can hence overcome the problem of scarcity of physicians by making use of existing pharmacists. The care process at the MTM clinic is a continuous cycle as presented in Figure 1.
MTM clinics have been shown to improve health outcomes by reducing costs in a number of chronic health conditions in the US.[14,15] A study conducted in Oklahoma evaluated a hypertension MTM program among diabetic patients, which resulted in a 7% increase in adherence rate and 32% increase in achieving the blood pressure target. Some of the interventions in this study were education on diet and lifestyle modification, regular exercise, comprehensive discussions on the role of medications, and individualized plans created for each patient. The study from Erku et al conducted in Ethiopia reported that pharmacist-led therapy improved adherence rate and reduced hospitalization for patients with type 2 diabetes in comparison to the usual care. One important fact highlighted was that proper MTM guidelines and policy should be set in place to have successful MTM program. Table 3 mentions the benefits and challenges in the incorporation of MTM clinics.[18,19]
Incorporation of the MTM model of healthcare delivery has some challenges. There can be questions on the existing competencies of the pharmacists for delivery of care. This issue can be overcome by training the pharmacists to provide MTM for patients with chronic diseases. This training program should be developed by experts in the field of diabetes, such as members of the Diabetic Association of India, in collaboration with relevant pharmacy associations. A certificate program can be administered to pharmacists through academic institutions in every district of the participating states.
There is evidence for the positive effect of MTM clinics on patients with diabetes, hypertension, heart failure, and those needing anticoagulation therapy.[20,21] MTM clinics could also be started in university medical center settings because they have been associated with good outcomes. A start must be made with one health condition like diabetes and, based on the success of the program, the model can then be extended to patients with other health conditions. Though there can be resistance in the implementation of this model, we strongly believe that an attempt must be made to start MTM clinics. These clinics can improve access to healthcare for all individuals, particularly in these times made more difficult by the pandemic. More research has to be done to study the organization, implementation, and management of MTM clinics in India. We need to use the guidance from the developed countries and consider the local factors to improve the healthcare system.[23,24] The MTM model was implemented effectively and is already in use in many other countries. India need not be behind and must use its existing resources effectively.
The authors thank Dr. Rifah Anwar Assadi, LAIQ Medical Center Ajman (SKMCA) and Dr. Anam Sohail, Thumbay University Hospital Ajman.
Source of support: None. Conflict of Interest: None.