Who Provides Care

Who Provides Care

By David Sobel, MD, MPH
Contributing Writer

While we tend to think of medical professionals as the providers of health care, in reality the vast majority of all care is provided by people for themselves and their families. Increasing our competence for and confidence in self-care may well be the most important function of any health care system.

When the health care system is described, patients are often viewed primarily as passive consumers of health care and health professionals as active providers of services to improve health. The usual image of the health care system is a pyramid with specialists (e.g. surgeons, oncologists, radiologists, etc.) at the top and primary care (e.g. family practice, internal medicine, pediatrics, etc.) at the bottom. This incomplete image of the health care system is, in reality, only the professional care segment. Professional care is just the tip of an iceberg with the much larger system of lay health care or self-care submerged beneath the surface and hidden from view.

The Hidden Health Care System
The Hidden Health Care System

Consider the fact that, in any month, 75% of the general population experiences some kind of physical discomfort or symptom. Between 70% and 90% of these symptoms are self-diagnosed and self-managed without the help of health professionals. If only 10% of these individuals were to forgo self-care and seek professional care, the demand for costly medical care would increase by nearly 50%, immediately swamping the health care system.

At the same time, it is estimated that at least 25% of physician office visits are for problems that patients could treat themselves. If self-care increased by even a small percentage of this amount, such as 5%, the demand for expensive professional services could be reduced by nearly 25%. This suggests that it may be possible to improve health while reducing health care costs simply by helping patients to care for themselves, i.e., knowing when to seek professional advice and when and how to use self-care.

The bottom line: The true primary health care providers are not doctors or nurses. Rather, the vast majority of all health care is provided by people for themselves and their families.

Once consumers are viewed in their role as providers of care, practical and safe methods of self-care could be developed and disseminated. A vital function of the health care system then becomes increasing self-care competence and empowering patients to become active partners in health care.

Many developing as well as developed countries are harnessing the power of lay people as providers of care. People are being trained to be health workers and health coaches to assist people in the communities with self-care, healthy lifestyle changes, and how to effectively access professional medical and social services when needed and appropriate. Increasingly, lay people are informally and formally providing health care with good health and economic results.

Where There Is No Doctor

Throughout the world millions of people lack access to quality professional medical care due to geographic, economic and cultural barriers. These people can often be helped to make better self-care decisions by village health workers equipped with carefully selected and curated health information. One group providing such resources, is the Hesperian Foundation, a nonprofit organization offering over 20 health guides, spanning women’s health, children, disabilities, dentistry, health education, HIV, and environmental health. Available in more than 80 languages with scores of clear illustrations, these materials are used in 221 countries and territories, from Afghanistan to Zimbabwe. Hesperian health guides are used by community health workers, Peace Corps volunteers, missionaries, teachers, health educators and community organizers to improve health around the world. Hundreds of government agencies and nonprofit organizations rely on these guides to provide practical and comprehensive information that moves communities to take action on a wide range of health issues – from disability rights to women’s health, from protecting local ecosystems to training the next generation of health workers.

Self-Care Credo

  • Health care is not only everyone’s right, but everyone’s responsibility.
  • Informed self-care should be the main goal of any health program or activity.
  • Ordinary people provided with clear, simple information can prevent and treat most common health problems in their own homes—earlier, cheaper, and often better than can doctors.
  • Medical knowledge should not be the guarded secret of a select few, but should be freely shared by everyone.
  • People with little formal education can be trusted as much as those with a lot. And they are just as smart.
  • Basic health care should not be delivered, but encouraged.

from Where There Is No Doctor: A Village Healthcare Handbook, David Werner and Carol Thuman

Lay Health Advisors and Community Health Workers

Even where there are doctors and other professional resources, lay people can help advance community health. From barbers to bartenders, farmers to shop keepers, teachers to ministers, every community has its natural helpers – people who are sought out for health or medical advice. In some cases these people may be more formally trained and utilized as community health workers. In China they are ‘barefoot doctors”. In Hispanic/Latino communities they are called “promotores”. While most of their work entails educating target audiences about health issues affecting their community they also provide guidance in accessing community resources associated with health care. Often community health workers are residents and identified leaders in their community who work for community-based health promotion projects or as part of a research group. Thus, the lay health advisors serve as liaisons between their community, health professionals, human and social service organizations. As liaisons, they often play the roles of an advocate, educator, mentor, outreach worker, role model, and interpreter.

Although they are not professional health workers, they are often tasked with projects similar to that of a professional health worker if the area where they work is significantly underserved (e.g., case management, referral source). Another highlight of the importance of lay health advisors is labor costs. Even though they are not required and in most instances do not hold academic credentials (e.g., bachelor or master’s level degrees) they perform well enough to, in general, have similar improved outcomes to that of professional health workers but as volunteers or at a lower salary rate.

Self Managing Chronic Disease

Four out of five people over the age of 65 have one or more chronic conditions. Chronic diseases such as heart disease, diabetes, arthritis, and chronic lung disease account for 90% of all illness, 80% of all deaths, and 70% of all health care dollars.

Patients can learn from other patients. Consider the Chronic Disease Self-Management Program developed at the Stanford Patient Education Research Center and now disseminated internationally. The educational groups are comprised of patients with one or more chronic diseases such as heart disease, lung disease, stroke and arthritis. The intervention consists of a patient self-management handbook and seven weekly two-hour small group sessions led by lay leaders most of whom themselves have chronic conditions. The focus of the group sessions is not on the specific diseases or conditions. Rather, it is on the shared determinants of functioning and living well with a chronic condition. The program content concentrates on patients’ perceived needs and self-management options for common problems and symptoms such as pain, fatigue, sleeping problems, anger and depression which cut across specific diagnoses. Patients learn skills to maximize their functioning and ability to carry out normal daily activities. Relaxation and imagery are taught and practiced within the group sessions. They also learn how to manage the emotional changes brought about by illness such as anger, depression, uncertainty about the future, changed expectations and goals, and isolation.

A significant part of learning and benefit comes from being able to share and help other patients, which reduces a sense of isolation and shifts the focus from one’s own problems to helping others. Even patients with high levels of social support may feel isolated within their life role as a person with a chronic disease. The group interaction also improves the participant’s sense of their own capabilities by putting their disabilities in perspective through the process of social comparison “Things could be worse, I could have. . .”. They develop a greater appreciation of what they can do, what’s working right or improving, rather than focus on their limitations and disabilities.

Rather than providing solutions for problems, the sessions are highly interactive involving practice and feedback in decision-making and problem-solving skills. Similarly, the focus is on increasing patients’ self-efficacy and confidence in their ability to manage their condition. Patients also develop skills to enhance physician/patient partnership by monitoring and accurately reporting changes in their condition and actively sharing concerns, questions, and treatment preferences. While health professionals are primarily responsible for medical management of the disease, the patient is primarily responsible for the day-to-day management of the illness. In the domain of living with a chronic disease the patient becomes the expert.

The desired outcomes of the intervention focus on quality of life, functional status, emotional well-being, and health care utilization rather than learning about their specific diseases. The goal is to get people to focus on healthy living while minimizing the time, attention, and disability associated with their diseases. Several research studies have shown those participating in the course experienced significant improvements in confidence (self-efficacy), health behaviors (such as exercise), better symptom management, and less health-related distress, fatigue, disability, and social/role limitations. They also had fewer days in the hospital and visits to emergency departments resulting in reduced health care costs per person in the range of $400 to $1000 per year. This equates to a potential net national savings of $3.3 billion if only 5% of adults with one or more chronic conditions are reached with this type of self-management education and support.

People are not just consumers of health care, they are the true primary care providers in the health care system. Increasing the confidence and skills of these primary care providers can make health and economic sense.