India faces a historical burden of unqualified, self styled healthcare practitioners with little or no formal training. A study in Madhya Pradesh revealed that 60% of the healthcare providers were either untrained or traditional birth attendants. They go by several names such as RMPs, jhola chaps, hakims, vaidyas, dais, Bangali doctors etc. They treat variety of ailments including conditions of upper respiratory tract, fever, gastroenteritis, diarrhea, pregnancy related care, abortions and at times are involved in surgical management too. Such practitioners, whom we refer to informal providers (IP) henceforth, typically operate from a one room clinic situated in their houses. These clinics are stocked well with medicines from over the counter drugs to antibiotics and steroids.
The IP are more prominent in rural areas than urban since they are always available and are flexible in terms of payment. They are the first point of contact for any kind of ailment for the poor. In the charts below illustrating why IPs are so popular, we have categorized them as community influencing factors and health system-related factors.
Community Related Factors:
- Always available – they live close to the community and also make house calls
- Belongs to the community
- Flexible payment – most often the socio-economic condition is considered while charging a fee for service rendered
- Patient confidentiality – the IP never betrays the confidence of the patient to a third party
- Protected by the community – even if the community knows the IP is illegal they will never betray the fact to an outsider
Health System Related factors
- Shortage of human resources
- Mal distribution of human resources – concentration of health workers are more in the urban than the rural
- Poor infrastructure and inconvenient location of the public health centres
- Formal private providers are expensive – fixed payment and also the travel expenses are to be considered
- Dearth of social marketing initiatives except in localized settings
Many civil society organizations have recognized the strengths of the informal providers and employed them to enhance their service delivery. Organizations such as AED have educated nearly 20,000 informal providers to promote the use of Oral Rehydration Salt solution (Low-osmolarity ORS) and Zinc dispersible tablets/liquids as the first line of treatment of childhood diarrhea. The Hindustan Latex Family Planning Promotion Trust has created and nurtured a network of IPs in Andhra Pradesh known as ‘Tarang Network’ whose members are called ‘Tarang Partners’ for social marketing initiatives in family planning. Operation ASHA, in Delhi, implements the Directly Observed Treatment, Short-course (DOTS) program through the informal provider run clinics. Recognizing them as the primary source of health care services in the rural—often offering dubious treatment--Health Management And Research Institute, Hyderabad, in partnership with the state government of Andhra Pradesh has initiated a one-year training course for the IPs. The program is currently training 13,700 informal providers, of which 9000 will take exams at the end of this year.
The debate on whether to integrate them into the system or not is still an on-going one. Health managers vouch for their integration, whereas the Medical Council of India and the Drugs and Cosmetics Act consider them illegal. Adding to the chaos is the limited knowledge of the quality of the services and their relationships with various stakeholders of health. Considerable inconsistency and uncertainty surround the definition of an informal provider, the quality of the services rendered, the policies governing them and the overall impact they have in the healthcare services. The only thing certain is that they are more prominent in the rural areas and are the main providers of primary healthcare. States such as Assam and Chattisgarh have initiated diploma courses for people willing to become healthcare providers for the villages. Will such initiatives such change the market environment is left to be seen.