INDIA’S PUBLIC HEALTHCARE system is known to be abysmal in villages. Healthcare infrastructure is absent or an apology for one, and there is an enormous shortage of medical professionals. According to a paper published in the journal Lancet, as of March 31st, 2015, more than 8 per cent of 25,300 primary health centres in the country had no doctor, 38 per cent were without laboratory technicians, and 22 per cent had no pharmacist. In community health centres, the shortfall was starker. In all, there was an 83 per cent shortage of surgeons, 76 per cent of obstetricians and gynaecologists, 83 per cent shortage of physicians and 82 per cent of paediatricians. The report noted, ‘Even in health facilities where doctors, specialists, and paramedic staff have been posted, their availability remains in question because of high rates of absenteeism.’
At the other end of the spectrum is the high presence of unqualified medics or quacks: people who practice medicine without any formal training. According to a 2009 study, there are around 2.5 million quacks in the country. While the medical establishment believes they pose a danger to public health and the police often crack down on them, quacks still thrive in far-flung places.
In West Bengal, a curious experiment is now unfolding to use them as a network for mainstream healthcare services. Supported by the state government, a Kolkata-based NGO called Liver Foundation is imparting short-term courses in basic medicine to train informal medics in rural Bengal. Conducted via four-hour-long classes held twice a week for nine months, the programme aims to provide these rural medics theoretical and practical medical knowledge, training them in the basics of medicine, from lessons in human anatomy to the uses and adverse impact of drugs. According to Dr Abhijit Chowdhury, secretary, Liver Foundation, “We say these people (quacks) are harmful and illegal. But they have existed and will continue to do so. [Given] the path of development our country is taking, there is going to be an increasing rural-urban divide, and I presume these people will increase in underdeveloped rural areas. If we can’t [stop quacks], it is better to bring them into the fold and tell them what not to do and then what they can do.”
According to Chowdhury, there has been an outcry in the Indian Medical Association against the idea, which is being flayed as dangerous, akin to legalising quackery. But the Liver Foundation believes that not only will training reduce incorrect diagnoses and treatment, it will also aid the cause of better public healthcare. “India needs different categories of medical professionals. These trained rural healthcare providers won’t replace doctors. They will function like ancillary services.”
The training, carried out in some small rural centres in West Bengal since 2008, is now being scaled up by the state government. Since its inception, around 2,200 quacks have been trained to become rural healthcare providers. From December onwards, the state government, with the help of Chowdhury and Liver Foundation, will impart similar training at 33 centres across the state, each of which will churn out around 60 rural healthcare providers. The course will be shortened from nine to six months, and the training will be done by nurses. While the first batch will have around 2,000 informal workers, the following ones will probably have more. “The plan is to train all informal health providers across the state,” he says.
The journal Science recently published a detailed study on the effectiveness of the programme. The researchers got volunteers, so-called ‘mystery’ patients who feigned illnesses, to visit both untrained and trained informal medics as well as qualified doctors working at government facilities. The study found that informal medics who had been trained by Liver Foundation were more likely to adhere to checklists and their diagnosis and treatment was much better compared to those who hadn’t taken the training. Medical doctors were found to deliver better care than informal providers. ‘But the training program,’ the researchers wrote, ‘closed much of the gap’. “It’s a bit like freestyle wrestling. But with training, we have found they become disciplined. They adhere to checklists,” Chowdhury says. The study also found that both trained and untrained informal medics were less likely to prescribe unnecessary medicines and antibiotics in comparison to doctors. The researchers write, ‘...both training- and control-group informal providers prescribed... 28.2% fewer unnecessary antibiotics than public-sector providers.’
Claiming that the problem of medicines being overprescribed is worse in mainstream healthcare, Chowdhury says this happens because qualified doctors are often poorly motivated and overburdened. “Also, doctors can get away [with it], despite there being a medical council, because they have a licence.”
While the initiative remains controversial, Chowdhury argues that the human resources within the established medical system are far from perfect. “What we are doing is recycling [quacks] to service the system,” he says.