Training of informal health providers, a major component of primary care, can help fill the gap in the rural healthcare system due to huge shortage of medical professionals, a study has suggested.
The study was led by Abhijit Banerjee, professor of Economics at Massachusetts Institute of Technology (MIT) in the US and co-founder J-PAL (Abdul Latif Jameel Poverty Action Lab), along with partners from Liver Foundation, the World Bank and Yale University.
“A rigorous evaluation of a training programme for informal medical practitioners in West Bengal found that contrary to popular perception, the training led to substantial improvements in both knowledge and practice among informal providers,” the study says.
The nine-month programme for rural informal practitioners, designed and implemented by Liver Foundation in Birbhum, is aimed at improving the practices of informal providers along the various dimensions of services offered by them.
“Over the 72 classroom sessions, taught by certified medical doctors, the structured curriculum covered topics such as physiology, drug use and abuse, emergency medical care, childcare and antenatal care, as well as public health programmes,” a senior official at J-PAL South Asia said.
The researchers believe that training these informal providers can help fill the gap in the healthcare system due to shortage of medical professionals.
J-PAL said it was an intervention programme to analyse the impact of providing training to the informal health providers, and that the study found evidence that training them “did not worsen care, as has been argued by representatives of the Indian Medical Association.”
“On the contrary, it found that those offered the training were more likely to correctly manage a case, as well as complete recommended checklists of history questions and examinations. In fact, the training closed half the gap in correct case management relative to the public sector,” it said.
The Indian Medical Association’s stand has been that it is against any attempt to provide training to informal health providers or ‘quacks’, saying that they legitimise an illegal activity and dilute standards.
The senior official of the research centre also said that based on the outcome of the study, “the West Bengal government is now in the process of scaling up the training programming to other parts of the state”.
The results of this study have been published in the October, 2016, issue of the journal ‘Science’.
Informal health providers with no formal medical training are the mainstay of India’s primary care system, reportedly providing more than 70 per cent of primary care, the study says.
“The study provides robust evidence on this ongoing debate and shows that medical training can be an effective strategy for improving the quality of care provided by informal providers,” Banerjee said. Informal practitioners, who operate without formal .
medical training, form a majority of India’s rural healthcare workforce, addressing patients’ healthcare needs where government sources may be less accessible.
They treat patients with conditions that can be managed in a primary care setting, refer patients with serious conditions to higher level care, and diagnose and manage patients with chronic conditions.
However, it is contentious whether these practitioners should be integrated with the health system, and if so, what might be the best way.
The study, meanwhile, also suggests that training informal health providers can also help address the manpower shortage in the health sector.
“The low costs of training imply that permanently hiring 11 additional fully trained MBBS providers into the public sector would be as costly as training 360 informal providers every year through this programme,” it says.
The study used a randomised evaluation methodology, by selecting 152 of the 304 informal providers from 203 villages in Birbhum to participate in the training programme.
“Using unannounced standardised patients (‘mystery’ patients) and clinical observations, researchers assessed the impact of the training on informal providers’ clinical practice. Further, researchers benchmarked these practices with those of public health providers in the same area,” the J-PAL said.
The West Bengal government has issued an order to train the first batch of 2,000 practitioners over a six-month period, which is in the process of being rolled out across 35 centres. Rural healthcare providers will be trained in batches of 50 by nurses teaching at nursing training centres across the state, J-PAL South Asia said.
“This study is not only relevant for West Bengal but for other states too, such as Madhya Pradesh and Uttar Pradesh; as the structure of the informal provider market is often found to be similar — both in terms of their widespread presence in the community and the knowledge gaps they face,” Banerjee said.
However, the training “did not lead to a decline” in the use of unnecessary medicines, antibiotics or injections among providers who were trained. Nonetheless, both trained and untrained informal providers were less likely to give unnecessary medicines and antibiotics relative to doctors in the public sector, the study further said.
“Finally, the training increased the patient load of the provider, and it is estimated that the resultant increase in revenue would allow the informal practitioners to recover the cost of the training in anywhere between 66 and 210 days,” it added.