Abstract
Rural households in India rely extensively on informal biomedical providers, who lack valid medical qualifications. Their numbers far exceed those of formal providers. Our study reports on the education, knowledge, practices and relationships of informal providers (IPs) in two very different districts: Tehri Garhwal in Uttarakhand (north) and Guntur in Andhra Pradesh (south). We mapped and interviewed IPs in all nine blocks of Tehri and in nine out of 57 blocks in Guntur, and then interviewed a smaller sample in depth (90 IPs in Tehri, 100 in Guntur) about market practices, relationships with the formal sector, and their knowledge of protocol-based management of fever, diarrhoea and respiratory conditions. We evaluated IPs’ performance by observing their interactions with three patients per condition; nine patients per provider. IPs in the two districts had very different educational backgrounds—more years of schooling followed by various informal diplomas in Tehri and more apprenticeships in Guntur, yet their knowledge of management of the three conditions was similar and reasonably high (71% Tehri and 73% Guntur). IPs in Tehri were mostly clinic-based and dispensed a blend of allopathic and indigenous drugs. IPs in Guntur mostly provided door-to-door services and prescribed and dispensed mainly allopathic drugs. In Guntur, formal private doctors were important referral providers (with commissions) and source of new knowledge for IPs. At both sites, IPs prescribed inappropriate drugs, but the use of injections and antibiotics was higher in Guntur. Guntur IPs were well organized in state and block level associations that had successfully lobbied for a state government registration and training for themselves. We find that IPs are firmly established in rural India but their role has grown and evolved differently in different market settings. Interventions need to be tailored differently keeping in view these unique features.
Highlights
In India, as in many other low and middle-income countries, informal providers (IPs) deliver a substantial proportion of health care to rural, poor and underserved populations (Bloom et al 2011; Sudhinaraset et al 2013)
We find that IPs are firmly established in rural India but their role has grown and evolved differently in different market settings
The public sector provides health services to India’s rural population of over 800 million people (GOI 2011b), living in 640 867 villages through a limited network of 23 887 primary health centres (PHCs) and 4809 community health centres (CHCs) staffed by doctors, and 148 124 sub-centres staffed by auxiliary nurse midwives (ANMs) (GOI 2011a)
Summary
In India, as in many other low and middle-income countries, informal providers (IPs) deliver a substantial proportion of health care to rural, poor and underserved populations (Bloom et al 2011; Sudhinaraset et al 2013). This is largely a response to the relative unavailability of trained public and private sector health workers. The staffing of many facilities with trained health workers does not even meet these norms (Satpathy 2005). The same applies to the new cadre of accredited social health activists (ASHAs), who are trained under the National Rural Health Mission to link women and children with the health system for immunizations, institutional deliveries and antenatal and post-natal care, but not to deliver clinical care
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