Should Informal Healthcare Providers be Trained or Barred from Practicing?
By Sandhya Mishra
Sandhya Mishra explores the course of an illicit informal healthcare provider to a certified Charlatan .
A compounder working with a doctor, after a few years of experience at handling medicines, starts his own ‘practice’ at his village in some remote area. A roadside or under the flyover ‘traditional healing booths’; traditional bonesetters; umpteen posters and flyers on railways claiming to cure cancer or other chronic ailments, or a doorstep medical treatment in rural areas are few examples of quackery in India. Basically, a person exercising medical practice without being trained in modern medicine is a quack which also includes AYUSH doctors as per the Indian Medical Association.
Quackery is a punishable offence under IPC 419, 420, 465, 467, 468 & 471 which punishes impersonation, cheating, forgery and fabrication of records with up to ten years’ imprisonment. Despite the legal refrain, quacks continue to flourish.
Melancholy descends over India’s public health mess with the stats saying quacks outnumber the real doctors in India. Around 80% of doctors in rural India are quacks. Almost 45% of the doctors practicing medicine in India have no formal training, as per IMA.
With this acute shortage of qualified doctors, comes the idea of leveraging the available self-proclaimed practitioners for some actual public health good. With unsubtle lack of political will to change the ‘quack’ scenario, well-known economists, healthcare NGO’s and some bureaucrats are of view that training the informal healthcare providers in real medical skills, providing them the grant for better primary care administration at rural level can be used as a stopgap to address the current non-existent healthcare infrastructure at rural India. Well the scoop is, some of the states have already adopted this ideology.
In West Bengal, a health NGO called Liver Foundation recruited local quacks for providing primary healthcare in the region by training them for 9 months on basic physiology and anatomy. In Madhya Pradesh, quacks are already given green flag to dispense some 70 medicines to the rural dwellers in need after a 3 months crash course in medicine. The ever willing AYUSH doctors were also speculated to be bridged with conventional medicine, however, with the strong opposition by doctors and IMA, Cabinet had to remove the bridge course.
When we talk about ‘quacks’ they just not include traditional healers or paramedicals but also total phony self-styled doctors who has not studied beyond class X. With lack of infrastructure, no available qualified doctors wanting to work in rural areas, the country is pushed to play it by ear and use the quacks for better public health than it has currently in rural areas. Having said that, India is predominantly a rural country. Also, ironically, India is the biggest exporter of doctors in the world.
The current dispute on recognizing, training and mainstreaming quacks is centered around one assumption— will they be able to identify and manage complications? What will happen if the course of the disease turns towards severe complications or the common presentations actually pertain to rare and serious diseases from the list of differential diagnosis? For example, headache can be the only presenting symptom of brain tumour, which such providers are likely to miss.
Dr Vikrant Prabhakar, Associate Professor, Dept. of Community Medicine, Adesh Medical College, Kurukshetra says, “All efforts since last many years to bar informal healthcare providers have remained futile, and are likely to remain so, in future too. Instead, the effort should be to bring them within a regulated system.
“My assumption will be that over half of the patients visiting research institutions like AIIMS and PGI can be managed in tertiary care institutions like medical colleges, provided they are appropriately strengthened. Similar (or even higher) proportion of cases visiting medical colleges can be managed in the District Hospitals. Large proportion of cases visiting district hospitals can be managed of CHC’s, PHC’s and so on. Why is this shift of care happening?
The reason lies at two levels: -
The current health care need in India requires medical education system to produce primary and tertiary care physicians in the proportion of 70:30. However, the current system of medical education prepares physician with pure curative perspective, and with no inclination to work and provide primordial prevention and primary care.
The structure of health care delivery system puts emphasis on providing tertiary care, on the expense of primary care. Does any health insurance scheme (whether in public or private sector) incentivise preventive services? Will corporates ever open a sub centre, that too with the same zeal or support as their tertiary care hospitals? The answer to both the questions is a no.
Existing informal care providers can strengthen the primary health care services and are also well accepted by the beneficiaries. If we can appropriately manage even 50% of our primary care need patients through them, imagine the decongestion it will bring to the system above. This will enable the secondary, tertiary and research institutions to provide services they are supposed to provide - with quality.
Train this sector of informal health care providers in rational decision-making process. Help them differentiate patients which they can manage from cases beyond their control.
Strengthen the referral system and referral transport, so that patient in need reach the appropriate level of care, timely.
Create a regulatory mechanism. Review and audit managed and referred cases from these providers. Retrain, or punish, as the need be. Make sure they do not trespass into the territory which is beyond their control.
In the meanwhile, strengthen medical education to create primary care physicians, to take over this job.
This will have multiple benefits. On one hand, people will have availability of quality care nearby, as almost all such providers live in the locality they serve. On the other hand, the most precious resource, the doctors, will be allowed to do what they like most – provide quality curative services in secondary and tertiary care institutions. Additionally, government will be saved of the trouble of ensuring availability of doctors and can focus on what it is supposed to do— govern. A win-win situation for everyone.”