Abstract
Research on patients' choice of healthcare practitioners has focussed on countries with regulated and controlled healthcare markets. In contrast, low- and middle-income countries have a pluralistic landscape where untrained, unqualified and unlicensed informal healthcare providers (IHPs) provide significant share of services. Using qualitative data from 58 interviews in an Indian village, this paper explores how patients choose between IHPs and qualified practitioners in the public and formal private sectors. The study found that patients' choices were structurally constrained by accessibility and affordability of care and choosing a practitioner from any sector presented some risk. Negotiation and engagement with risks depended on perceived severity of the health condition and trust in practitioners. Patients had low institutional trust in public and formal private sectors, whereas IHPs operated outside any institutional framework. Consequently, people relied on relational or competence-derived interpersonal trust. Care was sought from formal private practitioners for severe issues due to high-competence-based interpersonal trust in them, whereas for other issues IHPs were preferred due to high relationship-based interpersonal trust. The research shows that patients develop a strategic approach to practitioner choice by using trust to negotiate risks, and crucially, in low- and middle-income countries IHPs bridge a gap by providing accessible and affordable care imbued with relational-interpersonal trust.
Highlights
Healthcare decisions require patients to make choices – they must choose when to seek care, where to seek care and, in most instances, how long to be under care
The goal of this research was to develop an understanding of how people choose between public practitioners, formal private practitioners, and informal healthcare providers (IHPs) that occupy the pluralistic healthcare markets of low- and middle-income countries
This research in rural India found that affordability, accessibility of care when needed and low institutional trust in public present barriers that prevent both poor and affluent rural patients in this research to consistently seek care from trained and qualified practitioners either in public or private sector
Summary
Healthcare decisions require patients to make choices – they must choose when to seek care, where to seek care and, in most instances, how long to be under care. Past research studies have noted that IHPs provide a large share of health services in both urban and rural areas of many developing countries (Ahmad et al, 2011, Cousins, 2019, Crabbe et al, 1996, Diamond-Smith et al 2016, Kruk et al 2011, Memon, 2006, Peltzer and Pengpid 2015, Saha and Hossain 2017, Thac et al, 2016) Interest in this third sector has largely been limited to exploring the quality of the care provided by IHPs (Das et al 2015, May et al 2014, Pulla, 2016). A key starting point in understanding how patients choose practitioners in pluralistic healthcare markets of low- and middle-income countries is in exploring how patients frame the risks associated with seeking care in each of the three sectors. Understanding how people negotiate healthcare risks requires a sociocultural approach that takes into account the local knowledge, culture and the overall social context within which people make decisions (Douglas, 1992)
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