Indian 'quacks' being trained in primary medical care

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Unqualified medics, popularly known as quacks, are routinely arrested in India for posing as doctors. But, BBC News reports, a charity is now trying to train them in primary medical care.

Sanjoy Mondal opened his small clinic with just a desk and a few plastic chairs in eastern India 15 years ago, after a short stint assisting a doctor working at a government hospital. Although he has not studied medicine, Mondal says he has conducted countless minor surgeries and prescribed drugs to hundreds of patients in a village of mud-walled homes in West Bengal state. Now, the report says, the 40-year-old is one of thousands who have been taught the basics of front-line care by a non-governmental organisation which wants to ensure patients aren't harmed by self-taught medics. "I now understand what safe drugs and what unsafe drugs are,” Mondal says, boxes of pills piled up behind him on shelves hammered into the sky-blue walls of his dark, dingy clinic.

The report says Liver Foundation, the Kolkata-based charity offering the training, says most of India's medical establishment will criticise such a programme because they think unqualified practitioners are the bane of the country's healthcare system.

In recent weeks, in southern Tamil Nadu state, authorities launched a crackdown after several children died reportedly after seeking treatment from unqualified medics.

Anil Bansal, a former head of the anti-quackery section of the Delhi Medical Council, which registers and oversees the Indian capital's doctors, says "they are cheating the general public" and breaking the law.

According to the report, however, the Liver Foundation's founder, Abhijit Chowdhury, believes they should be utilised because India faces a chronic shortage of qualified doctors and medical staff. And a new study has assessed the effectiveness of the foundation's training programme.

The Healthcare Federation of India says the country has a shortfall of nearly 2m doctors and 4m nurses. It is most prominent in rural swathes where it is estimated that more than 60% of primary care visits made by villagers are to fee-charging unqualified practitioners like Mondal.

Sanghamitra Ghosh, secretary at West Bengal's state health and family welfare department, admitted it was difficult to retain doctors in remote areas and says unqualified medics are "filling a gap" in an "overburdened healthcare system". More than 100,000 unregistered freelancers practice self-taught medicine in West Bengal, home to some 90m people. Across India, there's an estimated 1m – meaning there are more fake doctors than real ones.

"I'm more confident in my job,” Mondal said about the training he received, which lasted nine months with two classes each week. But has it reduced the risk of medical errors? The report says the new study out recently showed mixed results.

It used so-called "mystery clients" trained to pose as patients suffering from three conditions – chest pain, asthma and child diarrhoea. How to detect these ailments were among the things taught to those who had undergone training.
To compare care, the mystery clients were sent to trained and untrained informal providers, as well as doctors working in government clinics. The study found that although those who had taken the Liver Foundation course were more likely to adhere to checklists after training and made big improvements in providing correct treatments, it did not affect the unnecessary doling out of antibiotics and other drugs.

This is worrying and "one of our goals – harm reduction – in that sense, was not achieved," said Chowdhury, who co-authored the paper along with World Bank economist Jishnu Das, Abhijit Banerjee from Massachusetts Institute of Technology and Yale University's Reshmaan Hussam.

But, the report notes, the team discovered the situation was worse among trained physicians. They found unqualified providers – trained or untrained – were less likely than doctors at public clinics to give out unnecessary antibiotics and medicine – reinforcing findings from earlier studies.

The report says in an attempt to explain this, the study's authors say, medical knowledge among trained doctors varies dramatically because of differences in the quality of training given at India's medical schools. Second, along with high levels of absenteeism, low effort among doctors working in rural India remains a problem.

A study published last year and conducted in the central state of Madhya Pradesh found that because untrained providers spent longer with patients than government doctors on average, they performed no worse on diagnoses and treatment. In other words, what untrained providers lack in terms of classroom time, they made up for in patient contact.

Giving incentives to government doctors is of course one approach to rectify this, but the report says the new study's authors point out that efforts in the past have proved difficult.

With this in mind, and the reality that rural public healthcare infrastructure is scarce (for example, West Bengal has 909 primary health centres in total, far short of the required 2,166, according to official statistics) training quacks – already with a large presence across India – could be more viable and cost-effective, the authors say. There is "some grounds for optimism", they said, because "training was sufficient to improve the clinical practice of the most regular attendees to the point where the performance of these informal providers matched that of better-trained, but presumably poorly motivated, public sector doctors". They added that training fake doctors "offers an effective short-run strategy to improve health care".

The West Bengal state government has said it will make this model a reality. Since 2007, it has funded the Liver Foundation's classes in Birbhum – one of the districts in the state where training has been offered.

But, the report says, it's likely to face serious resistance. In the past, the Indian Medical Association, a membership organisation for registered doctors, has taken legal action and successfully stopped similar schemes. The same could happen in West Bengal.

Introduction: In rural India, health care providers without formal medical training and self-declared “doctors” are sought for up to 75% of primary care visits. The frequent use of such informal providers, despite legal prohibitions on their practices, in part reflects the absence of trained medical professionals in rural locations. For example, in the majority of villages in the Indian states of Rajasthan, Madhya Pradesh, and West Bengal, informal providers are the only proximate source of health care.
Rationale: The status of informal providers in the complex Indian health system is the subject of a highly charged debate among policy-makers and the medical establishment. The official view of the establishment is that fully trained providers are the only legitimate source of health care, and training informal providers legitimizes an illegal activity and worsens population health outcomes. In contrast, given the lack of availability of trained providers and the fact that informal providers are tightly linked with the communities that they serve, others believe that training can serve as a stopgap measure to improve health care in tandem with better regulation and reform of the public health care system. However, despite the policy interest and important ramifications for the country, there is little evidence regarding the benefits (or lack thereof) of training informal providers.
We report on the impact of a multitopic training program for informal providers in the Indian state of West Bengal that provided 72 sessions of training over 9 months. We used a randomized controlled trial design, together with visits by unannounced standardized patients (“mystery clients”), to measure the extent to which training could improve the clinical practice of informal providers over the range of conditions that they face. The conditions presented by standardized patients were blinded from program implementers. Therefore, we view the evaluation of this multitopic training program as a measure of impact on primary care in general. Standardized patient data are accompanied by data from day-long clinical observations, providing a comprehensive picture of provider practice. Our study also benchmarks the impact of training against the performance of doctors in public primary health centers serving the same region. Lastly, it explores whether the training affected patient demand for informal providers.
Results: Mean attendance at each training session was 56% [95% confidence interval (CI): 51, 62%], with no contamination from the control group. Using standardized patient data, we find that providers allocated to the training group were 4.1 (1.7, 6.5) percentage points, or 15.2%, more likely to adhere to condition-specific checklists than those in the control group. The training increased rates of correct case management by 7.9 (0.4, 15.5) percentage points, or 14.2%, and patient caseload by 0.8 to 1.8 (0.13, 3.57) patients per day, or 7.6 to 17.0%. Data from clinical observations show similar patterns. Although correct case management among doctors in public clinics was 14.7 (–0.1, 30.4) percentage points, or 28.3%, higher than among untrained informal providers, the training program reduced this gap by half for providers with mean attendance and reduced the gap almost entirely for providers who completed the full course. However, the training had no effect on the use of unnecessary medicines and antibiotics, although both training- and control-group informal providers prescribed 18.8 (7.7, 28.9) percentage points, or 28.2%, fewer unnecessary antibiotics than public-sector providers.
Conclusion: Training informal providers increased correct case management rates but did not reduce the use of unnecessary medicines or antibiotics. At the same time, training did not lead informal providers to violate rules with greater frequency or worsen their clinical practice, both of which are concerns that have been raised by representatives of the Indian Medical Association. Our findings thus suggest that multitopic medical training may offer an effective short-run strategy to improved health care provision and complement critical investments in the quality of public care.

Jishnu Das, Abhijit Chowdhury, Reshmaan Hussam, Abhijit V Banerjee

Full BBC News report Science Mag abstract Science Mag perspective World Bank study

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