Abstract
This case revitalizes the policy debate about mainstreaming informal providers (IPs) in India’s rural healthcare delivery system. Using a narrative case method, this case highlights the poor state of public healthcare delivery in rural areas and the resulting dependence of the rural population on IPs. It begins with the narration of an incident wherein the Union Health Minister visits Jawanpore District Hospital and, after taking a round of hospital premises, he addresses a gathering. Soon, Mr. Das from an NGO rushes to the podium and appeals to the minister to address the issues of access in rural areas. The minister lends his ears to the critical issue and calls for a policy roundtable to find a solution. The first roundtable discussion ends without any clear way forward. The second roundtable is due with an expectation of finalizing a strategy to resolve access issues in rural India. Ms. Shyama, the case protagonist, has researched the inequities in healthcare access and, based on her groundwork, proposes a strategic solution to deal with the dilapidated state of healthcare delivery in rural India. Her proposition is supplemented with facts about the poor state of rural health infrastructure (especially in Madhya Pradesh, Bihar, Rajasthan, and West Bengal), with research evidence supporting the effectiveness of training programmes for IPs, and evidence on the healthcare quality equivalence between registered medical practitioners and IPs, thus making a strong case for mainstreaming IPs. The major proposition of the case is to mainstream IPs via digital training programmes and ensure healthcare access to rural people. This proposition warrants a deep analysis given the challenges posed by limited digital literacy, the digital divide, the limited efficacy of training programmes, arguments of the medical community, and ensuring quality care to the rural population.
HEALTH CARE IN RURAL INDIA
The healthcare infrastructure in rural areas has been developed as a three-tier system.
Sub Centre (SC): The most peripheral contact point between the primary healthcare system and community operated by one female health worker/auxiliary nurse midwife and one male health worker.
Primary Health Centre (PHC): A referral unit for 6 SCs with 4–6 beds manned by a medical officer in charge and 14 subordinate paramedical staff.
Community Health Centre (CHC): A 30-bed hospital/referral unit for 4 PHCs with specialized services.
Population norms for rural healthcare infrastructure:
The three-tier infrastructure is based on the following population norms.
One SC serves a population of 5000
One PHC is for a population of 30,000
One CHC is for a population of 1,20,000
As per Rural Health Survey (2019), the average population covered by SC, PHC, and CHCs is 5616, 35567, and 165702, respectively, as of 31st March 2019. There is a shortfall of SCs, PHCs, and CHCs, especially in remote and tribal areas. Furthermore, the average number hides the real picture in the backward states such as Madhya Pradesh, Uttar Pradesh, Bihar, and Rajasthan. Moreover, the lack of a skilled workforce is an issue as primary healthcare centres continue to face, as there is a severe shortage of doctors and other personnel. Data from CHCs show an even greater mismatch, with 79.9% fewer specialists available than needed. Furthermore, 68% of the specialist positions sanctioned at CHCs are unfilled. People frequently complain that a lack of medical personnel hampers government health functionaries. Thus, rural healthcare in India must be re-evaluated and reforms and concrete steps must be implemented immediately (Singh & Badaya, 2014).
For every nation in the world, improving access to healthcare is one of the main objectives of health policy. The shortage of skilled workforce in rural areas (Saikia, 2017) needs policy attention to achieve the goal of universal health coverage. Because of the lack of skilled workforce in rural areas, several Indian states have implemented regulations requiring medical graduates, post-graduates, and super-specialists to enrol in all public and private (50% of total seats) institutions to serve the state for a period ranging from 1 year to 10 years after completing these courses. This ensures the availability of doctors in resource-limited settings. Though the National Medical Commission recommends a uniform rural service bond for medical undergraduates, there is no consistency in bond duration after medical postgraduation (Chatterjee et al., 2022).
Given the failure of this policy to ensure healthcare access to the rural population, alternative solutions need to be deliberated to solve access issues in rural India. Patients living in remote rural locations may find it expensive and challenging to go to a primary care provider, and specialized care is frequently located at even greater distances. These patients may choose to forgo treatment altogether or switch from local primary care doctors to subspecialists. In such a scenario, IPs fill the gap and ensure access to primary care for the rural population.
It is well accepted that IPs are the ones who fill significant gaps in formal healthcare provision, particularly in states with a shortage of health workers and where the majority of qualified health professionals are concentrated in urban areas. As per estimates from some studies, 1.6 million IPs provide essential doorstep healthcare services to rural Indian households. IPs remain the dominant providers of care in most settings, accounting for 74% of all visits, even when there is a public provider in the same market, and 60% of all visits, even when there is a public MBBS doctor in the same market. The MBBS doctors account for only 4% of all patient interactions.
THE POLICY ISSUE
The underprivileged population of developing countries rely on IPs for their first line of treatment. The lack of private health facilities, along with the issues of absenteeism, poor maintenance, and stock-out issues in public health facilities, has allowed IPs to flourish. Informal healthcare workers provide more than 70% of primary care in rural India. These IPs provide low-cost essential care to community people, but given that many IPs have no formal training, the quality of care and the resulting health outcomes are always a concern. Thus, mainstreaming IPs in the formal health system as the primary provider is highly contentious.
Recently, there has been a paradigm shift in policy response towards IPs. Earlier, the dominant discourse was the outright rejection of IPs. IPs, popularly termed as quacks, were considered to be responsible for poor health indicators, including infant mortality rate and maternal mortality rate in rural and remote areas. However, with increasing evidence of the supportive role of IPs, especially in most backward states in India, the policy debate is shifting towards a co-option strategy for IPs. Moreover, the people in the community trust them more than the allopathic doctors, who charge higher fees and are located far away from rural areas. The very high cost of treatment and travel costs add to the hesitation of the rural population in seeking care from private providers.
The role of IPs in the formal healthcare system remains equivocal, and the best policy response is yet to be identified. The existing evidence on IPs’ role in the formal healthcare system is divided. A recent study in the Indian context highlighted the knowledge gap among IPs for neonatal care (Mungai et al., 2020). At the same time, there are evidences from research studies and medical audits that the quality of care and correctness of diagnosis provided by IPs and public providers are not different. Instead, some audit studies suggest that the IPs put in more effort vis-à-vis public providers (Das et al., 2016).
DIGITAL TRAINING PROGRAMME: CHALLENGES
While there is no doubt that mainstreaming IPs in the healthcare system is the way forward in resolving issues of access and timely care, the best strategy to get them engaged is yet to emerge. This case study proposes a digital training programme for IPs that needs to be well-researched as a strategy in terms of efficiency and effectiveness. Besides this, the challenges of designing and implementing a successful digital training programme for IPs in rural and remote areas need attention. A few of the challenges are listed below:
Digital divide in India Time commitment by IPs for training programmes Accountability for the successful implementation of training programmes Designing these programmes as per needs assessment Long-term plan for IP integration in the system Training them as primary providers or support staff Resistance from the medical community
Furthermore, the existing evidence is divided on the efficacy of training programmes for IPs, especially online training programmes. There is a need to identify the best possible ways to train IPs and the areas which need attention. The existing literature suggests a critical role of IPs as supporting staff in healthcare provision, such as for directly observed therapies for tuberculosis treatment (Thapa et al., 2021). Still, their role as a primary provider remains questionable.
As a first step, training IPs is undoubtedly a good strategy, but we need a long-term plan to ensure quality care for the rural population.
Footnotes
DECLARATION OF CONFLICTING INTERESTS
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
FUNDING
The author received no financial support for the research, authorship, and/or publication of this article.