Is Training Informal Healthcare Providers The Solution to India’s Doctor Shortage?

India, like other developing countries, is struggling with a scarcity of formally trained medical professionals, especially in rural and isolated areas. This gap has fueled the proliferation of informal healthcare providers, known pejoratively as “medical quacks.” These untrained providers provide more than 70 percent of primary care in rural India. Across the country, there are an estimated 1.6 million rural informal providers compared to less than one million licensed MBBS doctors. Policymakers and the Indian medical establishment have resisted the integration of these providers into the formal medical system. However, recent research published in Science evaluates an alternative policy to meet India’s healthcare need: train the informal medical providers.

The Liver Foundation, a public health organization based in the Indian state of West Bengal, offered a nine-month training program to 152 randomly assigned informal practitioners. During 72 sessions, attendees were taught about a wide range of topics, emphasizing “basic medical conditions, triage, and avoidance of harmful practices.” A second group was randomly assigned to a control group, which would receive the training the following year. The program, which had an average of 56 percent attendance per session, measured the impact of training on primary patient care and compared any impact against public doctors.

Researchers used unannounced standardized patients, who were sent to all study participants and to 11 public primary health centers to measure the impact of the program. Standardized patients were coached to describe symptoms for one of three conditions: severe chest pain, asthma, or child diarrhea. Patients were unaware of the provider’s status in order to limit behavioral differences during visits. Additionally, researchers conducted clinical observations at least three months after training to assess overall care quality and potential short-term declines in instructed skills.

The standardized patient data shows significant improvements by those in the training group within the parameters of “history and exam checklist completion” and “correct case management,” by 15.2 and 14.2 percent, respectively. Correct case management is met when necessary condition-specific actions are taken, even if accompanied by unnecessary actions. Data from clinical observations revealed a similar trend, with those in the treatment group more likely to adhere to condition-specific checklists even months after graduation. However, training did not affect the prescription of unnecessary medications or antibiotics. Since many informal providers earn profits through both consultation and selling medication, training may not be able to overcome the propensity to dispense drugs for profit.

The study also found some significant but surprising differences between informal providers and MBBS doctors at primary health centers (PHCs). Informal providers, both trained and untrained, followed exam checklists more consistently and spent more time with patients than MBBS doctors in the same village. The authors surmise this is because medical education quality varies across India, and doctors put forth less effort when working in public clinics. Informal providers also offered fewer antibiotics, unnecessary medicines, and injections than trained PHC doctors. The reason for this outcome remains unclear and requires further investigation.

The authors suggest that with perfect program attendance, not only would correct case management increase by 25.6 percent versus the control group, but trained informal providers would also have correct case management numbers nearly identical to those of PHC doctors. Since distance to the training center was the biggest determinant of attendance, the authors believe training centers located within five kilometers of informal providers would increase attendance to 80 percent.

This study suggests that training centers are a possible policy solution to the physician shortage in rural India, particularly given the scarcity of PHCs (only 11 PHCs served the 203 villages in the study area) and the cost of maintaining them. Based on the training program cost and the yearly salary of MBBS doctors in West Bengal, the government can train 360 informal providers for the same cost of hiring 11 doctors. The data does not show increased violation of rules or deterioration in clinical practices, which are concerns of the Indian Medical Association. On the contrary, most aspects of patient care quality remained unchanged or significantly improved with training.

Article source: Das, Jishnu, Chowdhury, Abhijit, Hussam, Reshmaan, and Abhijit V. Banerjee.“The Impact of Training Informal Health Care Providers in India: A Randomized Controlled Trial.” Science 354 (2016).

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