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Informal rural healthcare providers in North and South India

Meenakshi Gautham et al. Informal rural healthcare providers in North and South India. Health Policy Plan. (2014) 29 (suppl 1): i20-i29. doi: 10.1093/heapol/czt050
Abstract / Summary: 
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 yearss 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.    
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Selected extracts: 
- Informal providers (IPs) are an important source of primary health care for rural and poor households, but their roles have evolved differently in the two study sites.
- IPs in Tehri and Guntur differed with respect to years of education, modes of practice, relationships with the formal sector and levels of self organization.
- More than two-thirds of IPs at both sites knew how to manage common conditions, but they still prescribed/dispensed more drugs than necessary, especially in Guntur.
- Interventions with IPs need to take into account the specific aspects of the organization of health markets in different localities.
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Meenakshi Gautham et al.

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