Published in The Hindu on December 6, 2012
Suffering from unstable angina, asthma or dysentery? The chances of correct diagnosis and treatment in both rural and urban areas by private and public care providers are dismal.
The shocking state of primary healthcare services in both private and public clinics in urban (Delhi) and rural (villages in Madhya Pradesh) areas has been highlighted in a scientifically carried out study published a few days ago in Health Affairs .
What is all the more appalling is that the 305 healthcare providers tested in urban and rural India were presented with nearly uncomplicated conditions — unstable angina, asthma or dysentery — and for which there exist well established medical protocols with clear triage, management and treatment checklists developed by the government’s National Rural Health Mission. These conditions are also common in both urban and rural areas.
In rural Madhya Pradesh, correct treatment protocol was followed only about 30 per cent of the time, and unnecessary or even “harmful” treatment was prescribed about 42 per cent of the time.
That only 14 per cent of care providers “asked about pain radiation” in the case of unstable angina is indeed a cause for grave concern. Pain radiation is a typical and clear indication of unstable angina. Little wonder that some of the incorrect diagnosis for unstable angina included “gastrointestinal or weather-related problems.” Less than a third of other vital sign checks were completed in these “patients.” The results are almost similar in the case of asthma and dysentery.
Of the care providers who accounted for “80 per cent of all primary care visits from households,” only 11 per cent of rural care providers had any medical education and 67 per cent had no medical qualification whatsoever.
But it is no different in the case of Delhi. The rate of correct diagnosis was as low as 22 per cent, and at nearly 46 per cent, the rate of correct treatment was lower than the halfway mark. Even the adherence to the standard and essential care checklist was just about 34 per cent. Although private sector care providers followed the essential care checklist, the likelihood of their prescribing the correct treatment was “significantly lower.”
Dispel the notion that care providers in the private sector in Delhi are better qualified. Only 52 per cent of care providers studied in both private and public sectors had any medical degrees. 41 private providers and 23 public providers were studied.
The wrong diagnosis or failure to follow the essential care checklist does not come as a surprise as care providers in the 58 villages in Madhya Pradesh spent just about 3.6 minutes, while it was 5.4 minutes in the case of Delhi.
“In both the rural and urban setting, we found only small differences between trained and untrained doctors in adherence to the checklist and no differences in the likelihood of providers’ making a correct diagnosis or providing the correct treatment,” the paper states. “In fact, the evidence suggests that untrained private-sector providers were better in adhering to the checklist, and no worse in their treatment protocols, than their public-sector counterparts.”
What makes the study unique is that it used 22 standardised patients (recruited from local community) who interacted with 305 healthcare providers in urban and rural India.
These “patients” were trained for 150 hours to present their illness consistently to multiple care providers and to accurately recall interactions with the care providers.
The use of adult standardised patients is considered as the “gold standard in quality measurement.” The use of such “patients” avoids recall bias and does not in any way change the behaviour of doctors “treating” them. It also helps the authors to estimate the case detection rate and make comparisons between doctors.
In all likelihood, the results from the study may hold true for many other common conditions in most parts of the country — both urban and rural areas and private and public care providers.