As India battles the covid-19 pandemic, it also confronts the challenge of unavailability of formally trained healthcare practitioners, revealed a study published in ScienceDirect’s Social Science & Medicine journal. The study stated that 68% of healthcare providers in rural India have no formal training. They are, therefore, operating illegally, and outside the ambit of health policy. Primary healthcare in rural India is in the hands of providers who don’t legally exist, the study said.
The research titled Two Indias: The structure of primary health care markets in rural Indian villages with implications for policy was conducted by Georgetown University, Center for Innovation and Impact, Global Health Bureau, USAID, University of California US and Centre for Policy Research, New Delhi.
The researchers visited 1,519 villages across 19 Indian states to count all healthcare providers and elicit their quality as measured through tests of medical knowledge.
According to the study, the average Indian village had 3.2 primary healthcare providers. Of these, 86% were in the private sector and 68% had no formal medical training. In richer states, the share of informal providers did not decrease but quality improved and per-patient costs were lower.
“The medical knowledge of informal providers in Tamil Nadu and Karnataka is higher than that of fully trained doctors in Bihar and Uttar Pradesh. Surprisingly, the share of informal providers does not decline with socio-economic status. Instead, their quality, along with the quality of doctors in the private and public sector, increases sharply,” the study said.
According to the study findings, 74% of villages had at least one healthcare provider and 64% of care is sought in villages with three or more providers. Most providers (86%) are in the private sector. In terms of qualifications, of the 3,473 providers who were surveyed, 2,367 (68%) were informal providers (IPs) in the private sector, 842 were AYUSH providers (24%) and 264 (8%) had an MBBS degree.
The greater availability of knowledgeable public sector doctors is not associated with a reduction in the prevalence of informal unqualified providers, but rather an increase in their medical knowledge, the study highlighted. Northern states are stuck in a situation with low quality and high per-visit costs while Southern states enjoy higher quality at lower per-visit costs, it said.
The study said that the situation also has implications for the proposed National Exit Test, advanced by the central government through the National Medical Commission Act, 2019. According to the Act, the granting of medical degrees by individual institutions would be replaced by a centralized examination.
“If the cutoff is at the national level, in many states it may be that no MBBS doctor passes the test. An alternative is state-level cutoffs, but then it is not clear what problem the test will solve, as many healthcare providers in the informal sector might already meet state-level quality standards,” the study said.
“There are vast differences across states in the medical knowledge of doctors. We have conducted simple exercises to show that even a single national cutoff for exit test can choke the supply of all new doctors in many states,” said Jishnu Das, author of the study.
The study highlighted that in rural areas, there is a huge trade-off between access and cost. Most clinics in rural areas are massively underutilized and the per-patient cost can be very high.
“The covid-19 pandemic has brought the weaknesses in India’s health infrastructure out in sharp relief. These are not just about low investment (although that is a significant part of the problem) but also about challenges of quality of care, the complexity of rural health markets (the high prevalence of an unqualified, private sector alongside a unaccountable highly qualified government sector) and individuals’ own responses to health challenges,” said Yamini Iyer, President and Chief Executive, Centre for Policy Research. – Livemint