By Joshua Kenyon
According to the WHO, 57.3% of “doctors” in India do not have any medical qualifications. Known as “quack” doctors, this problem has led to severe health outcomes in the country, as untrained healthcare providers are susceptible to making serious mistakes when undertaking medical procedures. The high number of unqualified doctors has been propagated not only by a lack of government funding but also by the perception that trained doctors are apathetic about their patient’s health. Despite some fierce opposition, it has been argued that training informal providers may provide short-term relief in the country’s underfunded healthcare system, especially in rural areas.
The problems in India’s healthcare system
Training to become a doctor takes years of study and practice. For an informal provider, however, it only takes a stethoscope and a bag of medicine. In their book Poor Economics, Abhijit Banerjee and Esther Duflo argue that it is very easy to set up as an informal healthcare provider in India. As one man explained to them, “I graduated from high school and couldn’t find a job, which is when I decided to set up as a [private] doctor”. There have been grave consequences of unqualified doctors practising medicine. In one instance, an informal provider was suspected of infecting people in his village with HIV after reusing an unclean syringe. More examples include illegal organ harvesting, death caused by a minor tongue surgery, and, more recently, fake Covid-19 cures. Not only does this damage the health of citizens, but it also damages the finances of poor families by charging them for ineffective treatments.
The ubiquity of unqualified doctors in India can be partly attributed to the lack of government investment in the health sector. India spends only 1.28% of its GDP on healthcare, compared to the UK which spends an equivalent of 10%. This has resulted in India only having one doctor per 10,926 people, one hospital bed per 2046 people, and one hospital for every 90,343 people – far below the WHO’s recommendations. Further still, 8% of primary public health centres do not have a doctor present. It follows, therefore, that patients may not see a qualified doctor even when they seek treatment in a public clinic, despite being more likely to receive better treatment when a qualified doctor is present.
Private doctors in India are mostly unqualified, whereas all public-sector doctors are qualified. Besides high levels of absenteeism in public health clinics throughout India, public doctors are sometimes characterised by putting less effort into their practices compared to private doctors. Studies have shown that public-sector doctors, on average, spend less time with their patients and are less likely to adhere to a checklist. When dealing with minor ailments, studies show that there is not much difference in the correct prescription rates between public and private clinics, and there is little evidence to suggest that patients are more likely to damage their health by getting treated at private clinics. And surprisingly, evidence shows that public sector doctors are more likely to unnecessarily prescribe antibiotics in some parts of India, a problem that has caused an increase in antibiotic resistance throughout the country.
Should India offer training to informal providers?
The Indian population needs to have some form of healthcare provision. With a lack of investment from the government, informal healthcare providers have tried to fill the gap. And, on occasion, they have proven useful. In Mumbai, local hospitals allow informal providers in the slums to help identify tuberculosis patients. There have also been cases of informal providers not only dissuading villagers from mass gatherings during the COVID-19 pandemic but also going door-to-door providing masks and sanitation. India has a shortfall of almost 2 million doctors, and this shortage is disproportionately felt in rural regions. Many graduate doctors prefer to work in the UK, US, or burgeoning Indian cities such as Delhi and Mumbai. Sanghamitra Ghosh, secretary at West Bengal’s state health and family welfare department, has admitted that informal providers were “filling a gap” in an “overburdened healthcare system”.
Given the shortage of qualified doctors and the ubiquity of informal healthcare providers, some argue that it is beneficial to provide medical training to help informal providers treat minor ailments. The Liver Foundation in West Bengal provides training courses to informal providers on the conditions that they no longer call themselves doctors and stop distributing certain types of antibiotics. Evidence shows that the training has a significant impact, with correct case management increasing by 14.2%. However, it has not reduced the over-prescription of antibiotics. Abhijit Chowdhury, the founder of the Liver Foundation, admits that this is not a doctor-producing endeavour, but rather a health-worker-producing endeavour. Despite some achievements with this training, there has been fierce pushback from medical professionals. And many believe that the government needs to do more to encourage doctor expansion into rural regions instead.
Some organisations are concerned that training informal providers may have the effect of legitimizing this otherwise illegal service. The President of the Indian Medical Association expressed this concern by stating “If those ‘doctors’ make mistakes and people pay with their lives, who is going to be held accountable?”. Moreover, medical professionals have argued that patients should be treated by qualified doctors. However, with such an underfunded health service, this seems unachievable in the short-term. Thus far, the government has introduced some measures to encourage graduate doctors to work in rural regions, such as compulsory rural postings and monetary incentives, but more must be done. Studies suggest that the government should incentivise working in rural areas by improving infrastructure and providing better salaries for graduates who practice medicine in these regions. It is clear, however, that there is no short-term solution to this drastic problem, and though unideal, informal healthcare providers may be providing an essential service in an overburdened healthcare system.
Joshua is an undergraduate at the University of Sheffield studying Economics, and has interests in economic development.
The views expressed in this article are those of the author and do not necessarily represent the views of Development in Action.
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