More than 100 countries endorsed the declaration made last year at the Global Conference on Primary Health Care in Astana, Kazakhstan that primary healthcare was the cornerstone of achieving universal health coverage. Primary care goes beyond treating illnesses and conditions, it helps people prevent illnesses from recurring and promotes good health by addressing underlying social and environmental determinants of poor health, including safeguards to ensure access to water, sanitation, nutrition, and education. Importantly it focuses on the individual, family and community while providing guidance and acting as a channel to other parts of the health system as required. So, who better than to lead the way than the health professionals who are often closest to the community – nurses.
Despite the high quality of training and education available, the first challenge is that the role of the nurses have been largely limited to facilities and regulation, their impact often suppressed by requiring to work under the strict instruction and guidance of doctors. While nurses have been in the shadows serving patients, they have not been able to serve people, in their communities and have been kept away from leadership roles. This is the case not just in India but in many countries across the world, that it is only now when there is an acute shortage of doctors globally that there is recognition for the significant contribution nurses make both as clinicians and as healthcare leaders. Paradoxically it is now the medical profession who have recognised the global situation and are championing nursing as vital to be providing frontline autonomous healthcare.
Lord Nigel Crisp, co-Chair of Nursing Now, the global campaign aiming to raise the status and profile of nursing states “It is essential we recognise the key leadership role that nurses have to play in achieving universal health coverage. To do this their value needs to be recognised and amplified, they need the correct support and training, and the systems around them also need to change.”
The Invest4Wellness (I4We) model by Swasti (originating in India, and now working across 10 sites including in Lesotho) is a nurse-led, integrated and community health and well-being model working with poor communities (urban and rural), garment factories and sex workers (men and women). While the nurses supporting the model were some of the most competent in their field, it took almost a year for the communities to accept them.
“Even the poor want the highest standards of care, and not getting a doctor at the wellness center was a sign of sub-standard care, they were disappointed that only I was available and insisted I called my referral doctor” says Pankaja, an i4We nurse.
The second challenge is about the perceived standards of care. Even when the nurses are trained in the highest standards of care, they were not used to delivering the care themselves or prescribing medication but only serving as a doctor’s assistant. In response to this, Swasti (an Indian not for profit) and PCI partnered to develop simple evidence based protocols and training so that the nurses used simple tools for delivering standard and quality care and adequate risk protection.
The third challenge is that in several countries, including India, nurses are not allowed to prescribe medication. Now not only does this regulatory hurdle add to the negative public perception of the capacity of nurses to deliver care but also limits the nurses in being able to provide comprehensive care.
Resistance to nurses having an increased leadership role is understandable given the older model of delivering care was doctor-centric. However, today’s approach to primary care is a team-based one.
“Primary care needs a multidisciplinary team to be effective: to get quality healthcare to all and to improve wellbeing. Like doctors, nurses have a key role to play, and the I4WE nurse-led model is an example of how – with the right kind of support and tools – this kind of approach can work”. (Dr Adam Sandell, Clinical Associate at PCIl and Family Medicine Physician/GP)
This week, Heads of State and Government are meeting in New York to discuss Universal Health Coverage (UHC) at the highest political level. This century poses the world with unique challenges of ageing, strife, climate change, economic difficulties, all leading to needing newer and innovative services that are more holistic and people centered, with an increased focus on health promotion and prevention, using technology as an enabler. Nurses have a key role to play in this, in providing “meaningful care”. But for this to happen we need a shift in mindset and in countries’ regulatory framework, as well as an investment in training and support, to allow the nursing professionals to deliver the best value of care they are qualified to provide.
Dr Angela Chaudhuri is a Public Health Leader, Strategist and Journalist who has spent 19 years helping strengthen health systems across the globe to make wellbeing a reality for poor and vulnerable people. She currently serves as a Partner in Swasti, a global non profit headquartered in India.
Jane Lennon is Communications Manager at Primary Care International (PCI)