Role of primary care physicians in diabetes care in India

Sir,

Diabetes is a major worldwide epidemic and a public health challenge of 21^st century with >415 million individuals living with the disease and this number is expected to grow to staggering 642 million by 2040.¹ Of patients with this disease, 90% to 95% have type 2 DM.² Factors contributing to this increase mainly of type 2 diabetes include an aging population, improved survival rates, and the increasing prevalence of overweight or obesity.³

India is home to more than 69 million individuals with diabetes, and this figure is expected to rise to 123 million by 2040, accounting for one-fifth of world’s population of diabetes.^1,4 Patients with diabetes need to see providers regularly to obtain guidance on lifestyle modifications and assistance in managing their disease.⁵ It is practically impossible for the health system to provide care to the huge number of diabetes patients in India through specialist clinics. Number of diabetologists or endocrinologists available are also very limited which are concentrated in urban areas. As India has a sizeable population of diabetics in rural region, focus needs to be on moving care of diabetic patients from specialists’ hospitals into community or primary care settings. While India has a robust public health care system which caters to the vast majority of its citizens for providing preventive and curative services at primary, secondary, and tertiary levels, control of non-communicable diseases including diabetes is still in its infancy.⁶ Further, in view of the low doctor-to-population ratio (1:1800), uneven distribution of specialists (most of whom are in urban areas), and the fact that most initial diagnoses of diabetes (about 70%) are made by non-specialists, one key to effectively tackling the challenge of diabetes is to strengthen the primary health care.⁷

Primary care physicians or the family physicians, are first level of contact between community and health services and are usually acceptable, available and affordable to community as well. National list of essential medicines (NLEM), based upon World Health Organization (WHO) list of essential medicines, enlists a number of essential drugs which needs to be available universally at public health facilities.^5,8,9 The drugs listed in the NLEM are adequate for the management of the vast majority of people with diabetes particularly of type 2 diabetes or Non-insulin dependent diabetes mellitus (NIDDM). A primary care physician with appropriate training and expertise can thus become provider of diabetes care services to vast majority of people. Today most diabetes care in India is provided by the private sector, but given the need for early screening, large numbers of those with pre-diabetes and diabetes mellitus and significant out-of-pocket expenditure incurred by patients, there is a clear need for active involvement of public health system through primary care physicians. National program for prevention and control of cancer, diabetes, cardiovascular diseases and stroke (NPCDS), launched in 2010, provides detailed operational guidelines for management of these non-communicable diseases including diabetes.⁸ It also list responsibilities of staff at various levels of health care in which responsibility of screening, early diagnosis and management of diabetes is primarily assigned to the medical officer of the primary health center (PHC).⁸

In conclusion, primary care physicians can play a huge role to reverse the current epidemic of diabetes in India and to prevent the morbidities and complications associated with it.

REFERENCES

1. 1. International Diabetes Federation. Diabetes Atlas. 7th ed. Brussels, Belgium, International Diabetes Federation, 2015. Available at: http://www.diabetesatlas.org. Accessed on 16^th April 2019.
2. 2. National Diabetes Information Clearinghouse (NDIC) National diabetes statistics, 2007. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics. Last update on: June 2008. Accessed on 16^th April 2019.
3. 3. Olofsson EK, Cederholm J, Nilsson PM. Risk of cardiovascular disease and mortality in overweight and obese patients with type 2 diabetes: an observational study in 13,087 patients. Diabetologia. 2009;52(1):65-73.
4. 4. Mohan V, Vassy J, Pradeepa R, Deepa M, Subashini S. The Indian Type 2 diabetes risk score also helps identify those at risk of macrovasvular disease and neuropathy (CURES-77). JAPI. 2010;58:430-3.
5. 5. Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, et al. Patient and provider perceptions of care for diabetes: results of the cross-national DAWN Study. Diabetologia. 2006;49:279-88.
6. 6. Kalra S, Julka S, Joshi R. Strengthening diabetes management at primary health level. Indian J Endocrinol Metabol. 2015;19(4):443-7.
7. 7. Deo MG. Doctor population ratio for India - the reality. Indian J Med Res. 2013;137:632-5.
8. 8. National List of Essential Medicines of India. Available from: http://www.cdsco.nic.in. Accessed on 25^th August 2017.
9. 9. WHO Model List of Essential Medicines. Available at: http://www.apps.who.int/iris/bitstream/10665/93142/1/EML_18_eng.pdf?ua=1. Accessed on 25^th August 2017.