The Circle of Care: A Proposed Multichannel Approach to Integrated Community-Based Primary Care

Introduction: While definitions of community-based primary care include the community health worker (CHW) as a representative of the formal system in its remit, they tend to ignore three other critical providers of healthcare and public health services: the family, the community pharmacy or medicine shop, and faith-based healers. Even the Alma Ata Declaration of 1978 failed to recognize the essentially plural nature of health systems at the primary care level when the reality is that even when well-equipped and free primary care clinics are made available, they receive fewer than half the patient’s visits. And, even for these visits, the clinics and CHWs are unable to fully address the challenges of poor health-seeking and adherence to treatment recommendations. In this chapter we explore what an updated CBPHC approach might look like if it gave due consideration to people’s preferences and constraints. Methods: The chapter, benefitting from the authors’ experience, carries out a rapid evidence synthesis and then examines conceptual frameworks which can help develop an approach toward integrating multiple primary care providers at the community level. Results: We find that people use all four categories of healthcare providers to meet their healthcare needs. These include community health workers, pharmacists, family members, and faith-based healers, each of whom provides a distinct set of services with its own unique mechanism of impact. Many health systems have used one or more of these providers. We also find four frameworks from which insights can be drawn to integrate the services offered by these providers. Discussion: While each channel adds value, no one channel can provide all the services needed to deliver comprehensive primary care, and there are also risks of harm associated with some of the approaches taken by these providers. It is important to preserve the unique contribution of each channel and to resist the temptation of training them all to provide the same set of biomedical services and to find a way to integrate their services so that the patient can have the best possible experience of primary care. We suggest that making the community health worker the point of integration, supported by a digital layer, which is also linked to payments, may offer the best way to ensure this.