India is a priority country (a) because of its size, (b) because knowledge of headache burden is not good and (c) because headache disorders appear to be highly prevalent there.
Indonesia is important because it is a populous country where nothing is known of the burden of headache there. However, there are no known contacts.
India is very large and diverse. State-based initiatives offer the best prospects of success. An epidemiological study has been completed in Karnataka.
Extrapolation to all India (population 1.2 billion) from an enumerated population of about 12,000 within one State may not be appropriate; another study with similar results from the north (eg, Delhi) would be reassuring but still not representative. However, if results from methodologically sound studies in India are within the worldwide range, no good reason will exist for believing they over-estimate the problem for health-care planning purposes. Therefore, Global Campaign resources may be better committed elsewhere in South-East Asia, where nothing is known.
The next stage is to propose a model for organisation of headache services in India.
There are multiple problems:
- 80% of care is out-of-pocket (in a poor country);
- the population is 72% urban, but there is a large urban/rural divide: health-care practitioners (HCPs) are 3.4 versus 0.6 per 1,000 population; hospital beds are 3.0 versus 0.2;
- overall there is 1 neurologist per 1.25 million people;
- patients may choose at what point they enter the health system, or be referred upwards within the system (there is no formal gatekeeper role);
- HCPs are unskilled in headache care;
- large variations occur across the country (climate, culture, literacy);
- population growth rate is 9%, not accompanied by proportionate increase in social spending.
The National Rural Health Mission provides a good opportunity for change. Its mission is: "to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children." Its goals include "access to integrated comprehensive primary healthcare".
In this context, a proposal for organization on three levels is realistic (although capacity may be inadequate):
- level one delivered by doctors and, in rural areas, by the new generation of non-medical health-care providers from primary health centres (PHCs) (one per 30,000 population)
(there is no tradition of nurse-led services, and pharmacists sell drugs whilst neither giving advice nor diagnosing);
- level two delivered from community health centres (one per 100,000 population) and/or Taluk hospitals (one per 5-600,000), the former having some and the latter all specialties;
- level three in District hospitals (one per 2-2.5 million), which have all specialties and admission facilities; there is a national policy to create academic medical colleges in all District hospitals.
In urban areas there are modifications (urban health centres) and this structure is supplemented by other specialist institutions (such as NIMHANS) and by private centres. Thus an alternative for level three may be community satellite clinics from these specialist institutions.
The way forward is probably through State-based demonstrational projects, supported by State governments, providing for defined populations.
Capacity-building of doctors, especially in PHCs, is a priority: essentially this is a training issue. Public education is a necessary adjunct, but likely to have limited efficacy alone.