At least two of every three "doctors" in rural India are informal providers of care, with no qualifications in modern system of medicine, according to India's first comprehensive assessment of public and private health care availability and quality, as measured by their medical knowledge.
Although 75% of villages have at least one health care provider and a village on average has three primary health providers, 86% of them are private "doctors" and 68% have no formal medical training, found a survey of 1,519 villages across 19 states in 2009 by researchers from the Centre for Policy Research (CPR) in New Delhi. The study has been published in the Social Science and Medicine journal.
The study supports the World Health Organization's 2016 report on 'The Health Workforce in India', which had also found that 57.3% people practising allopathic medicine in India did not have a medical qualification, and 31.4% were educated only up to secondary school level.
The CPR study found that formal qualifications were not a predictor of quality, with the medical knowledge of informal providers in Tamil Nadu and Karnataka being higher than that of trained doctors in Bihar and Uttar Pradesh, the study found.
"For the vast majority of rural households, informal providers--usually called quacks-- are the only option that is locally available. Public health clinics and/or MBBS doctors are so few and far between that they are just not an option for most villagers. I knew that this was true of places that I had worked in (Madhya Pradesh and West Bengal), but had not realised that this generalised to almost every state, except Kerala. So the idea in health policy circles that as states get richer, informal providers will automatically vanish, is just not true in the data," said lead author Jishnu Das, professor at the McCourt School of Public Policy and the Walsh School of Foreign Service at Georgetown University in Washington, on email.
The share of informal providers did not decline with rising socioeconomic status, though the quality of doctors improved. "If informal providers are counted as primary care providers, there is really no "shortage" of human resources.. Any strategy that does not account for the fact that most of our primary care is delivered by these providers cannot work at this moment," said Das, who led the study called, 'Two Indias: The structure of primary health care markets in rural Indian villages with implications for policy'.
The study found no correlation between the average local availability of healthcare providers and state health indicators, such as child mortality, which indicates that though people in villages can choose among multiple providers, they still do not get quality health care.
The massive variation in medical knowledge was closely tied to training, the study found. "The variation across states in the quality of an MBBS degree is huge, with southern states doing much better than those in the north. Because informal providers typically spend a few years with a formal doctor, either as a compounder or in some attendant function, their knowledge also depends on who they worked with. So, the quality of informal providers and MBBS doctors moves together," said Das.
The paper estimated informal providers account for 68% of the total provider population in rural India, with 24% of them being Ayush doctors practising traditional and alternative stems of medicine and only 8% having an MBBS degree.
"The Covid-19 crisis has placed unprecedented demands on our health care, making it clear that we need to have an urgent discussion on how it needs to be structured moving forward. This crucial paper uncovers fundamental features of our rural health care system with key insights for regulation, training and capacity," said Yamini Aiyar, president and chief Executive, CPR.
India is divided into two nations not just by quality of health care providers, but also by costs, with better performing states provide higher quality at lower per-visit costs. This trend was consistent with significant variation in the availability and quality of medical education across state.
Not much has changed since 2009, according to professor Das . "In all likelihood, the availability and type of human resources has not changed since 2009. We base this on smaller surveys that have been carried out in several states in more recent years, which show a similar dominance of unqualified providers in the private sector," he said.
What has certainly changed is the cost of private healthcare. "Training community health officers to provide free primary health care with tele-medicine support at health & wellness centres under Ayushman Bharat is a way out, but for similar training of informal providers in the private sector to work, we need safeguards to ensure they don't further misuse the training and put the health and lives of patients at risk," said Dr Randeep Guleria, director, All India Institute of Medical Sciences, Delhi.