London School of Hygiene & Tropical Medicine

India faces a ticking-time bomb when it comes to public health. In 2015 it reported 27% of all neonatal deaths and 21% of all child deaths in the world, and the country accounted for 20% of the global burden of disease in 2013. More than 70% of ailing persons sought (PDF) care in the private health sector in 2014 and it is well known that a large proportion of this private sector is informal and unrecognised.

A chronic lack of primary care facilities and medical professionals in rural areas means some of the country’s poorest people face the greatest health risks. How can India develop a primary healthcare system that is fit for purpose?

Informal providers are the first choice of outpatient care for more than half the population in India, but they exist outside the boundaries of the formal health system. They possess no formal medical qualifications and are not licensed to practise medicine. Most have learned their skills by working as assistants with doctors in clinics or hospitals. This army of small entrepreneurs provide outpatient care for common ailments across rural India.

Relying on unqualified medical assistance may seem unthinkable to many of us. However, in rural India the nearest qualified doctor may be a day’s walk in the sweltering sun or beating rain – informal providers are available in or near almost every village. For the community whom they serve they are regarded as nothing less than gods, always there when needed. The Indian medical establishment sees things differently.

In their eyes, informal providers are quacks with no useful role to play in the health system. The Indian Medical Association has lobbied against any attempt to provide meaningful programmes of training, arguing that they legitimise an illegal activity and dilute standards. Not surprisingly, these divergent views and an absence of hard evidence have led to an impasse, almost as old as India’s independence.

A recent article in Science promises to move the debate on. Jishnu Das and colleagues meticulously evaluated a programme in the state of West Bengal that gave 150 hours of training on a wide range of topics over a nine-month period. The training was the brainchild of Abhijit Chowdhury, a medical doctor passionate about public health.

The researchers used a randomised controlled trial and measured clinical practice with ‘mystery clients’ – actors who present themselves with a carefully scripted set of symptoms – taking care to make sure the trainers did not know what conditions the providers would be assessed on.

The training increased informal providers’ correct case management by eight percentage points (52% control versus 60% intervention). Attendance at the training sessions was reasonably high (56%) and the cost of the programme was low ($175 per trainee). Had all the providers attended training, the programme would have closed the quality gap between them and primary care providers in the public sector.

Disappointingly the use of unnecessary and inappropriate medicines, including antibiotics, remained staggeringly high at 70%, albeit lower than the 88% found in the public sector doctors in the study. That formally trained doctors are perhaps even more guilty of inappropriate drug use than their informal counterparts is astounding but nonetheless consistent with a growing body of research on the generally low levels of quality of health care in India.

Since the study was conducted, the state government of West Bengal has made plans to scale-up the training programme to 100,000 informal providers in the state. In a companion piece in Science, Timothy Powell-Jackson argues that engaging with informal providers might offer a practical route to better primary health care in India. In the immediate future there is little prospect of the public sector expanding quality primary care while governance problems persist. Health workers remain poorly motivated and medical education remains tertiary-care centric.

At the same time, successfully scaling-up training of informal providers will require more understanding of how the programme worked – in particular why it improved case management but failed to change antibiotic prescribing behaviour. Ongoing research by Meenakshi Gautham in the same region aims to inform policymakers on how to address the problem of providers overprescribing antibiotics.

Every citizen in India has the right to a basic level of healthcare. Harnessing the informal sector and integrating it with its formal counterpart could be a pragmatic way forward to achieving this in the short-term.

Image: An informal provider’s clinic in north India. Credit : Meenakshi Gautham/London School of Hygiene & Tropical Medicine