If everything works to plan, health care in rural West Bengal may soon see a change for the better. Nearly 3,000 quacks — informal health-care providers with no formal medical education — are to be trained for six months. The crash course in medicine, and to be conducted by 130 trained nurses, is to begin from December 1.
The objective is to provide these informal providers with a minimum scientific understanding of human health and the dos and don’ts when those who are sick approach them. (Listen to the podcast).
As part of medical ecosystem
“The aim is to turn the self-proclaimed, untrained village doctors into a group of skilled health workers who can deliver primary health care in villages and detect life-threatening conditions and refer patients to qualified doctors or medical facilities,” says Dr. Abhijit Chowdhury from the Institute of Post Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata. “Uttar Pradesh has shown interest in undertaking similar work and we are doing pilot studies in Bihar and Jharkhand.”
“The endeavour is not to produce doctors of sub-optimal quality for rural people. It is an attempt to use the available health-care human resources to become assistants to doctors by providing them with some understanding of life-saving measures,” he says. “They are not as good as qualified doctors and we will teach them not to call themselves doctors but as health-care workers.”
Fully trained informal providers were found to be on a par with qualified doctors in handling cases.
West Bengal has taken the lead in providing some essential and basic training to informal providers after a novel experiment that trained quacks to correctly handle cases and compile basic checklists. The results have put to rest the long-held concerns of the Indian Medical Association (IMA) that trained informal health-care providers would violate rules with greater impunity and frequency or worsen their clinical practice. The programme was undertaken in 2013 in 203 villages in the State’s Birbhum district by the Liver Foundation in West Bengal.
Spread over 150 hours over nine months, the programme for 152 randomly recruited informal providers led to 14.2 per cent improvement in their ability to correctly handle cases and compile basic checklists. Where the attendance was 56 per cent, it was found that the gap between qualified doctors and quacks to correctly manage cases was reduced by half. Those who had attended all the training sessions were found to be on a par with qualified doctors in handling cases. The results were published on October 7 in the journal Science; Dr. Chowdhury is one of the authors of the paper.
“We take two definitions of correct case management — did the patient get what was needed to make them better irrespective of anything else that they may or may not get. And, what was the overall rating (taking into account necessary and unnecessary care) by a panel of three physicians, blinded from the identity of the providers. We find improvements in both; because public sector MBBS doctors give more unnecessary medicines and antibiotics, we find slightly stronger effects for the latter,” says Dr. Jishnu Das from the Centre for Policy Research, New Delhi and the lead author of the paper.
The trained providers were able to correctly manage cases in 52 per cent of interactions, while the control group that did not undergo any training could offer only over 11 per cent of “average quality or higher” treatment. Though the training had little effect on the use of unnecessary medicines and antibiotics, quacks prescribed about 28 per cent fewer unnecessary antibiotics than qualified doctors.
The trained providers would have been able to correctly manage cases nearly 26 per cent better than the control group had all the 152 providers attended all the sessions, says Dr. Das. Standardised patients who posed as patients suffering from chest pain (angina), breathing problem (asthma) or dysentery were used to evaluate how well the providers handled cases. A day-long clinical observation to evaluate clinical practice of genuine patients was also conducted.
“These three conditions cover situations where the provider must refer (angina); diagnose and possibly manage (asthma) and treat in the primary care (diarrhea). We gave the simplest possible, non-complicated case without any co-morbidities. The reason for this is that even with this very simple depictions of the cases, there are significant deficits in the quality of care, even among MBBS providers. For instance, in the public sector, 35 per cent diagnose and treat such cases wrong,” says Dr. Das in an email.
Role in primary care
The training was not restricted to these three conditions but covered a range of topics to improve their diagnostic medical skills. Since the trainers were unaware of the conditions that would be used for evaluation, the authors say that there is “some evidence” that training increased the correct management of cases for more number of conditions that quacks encounter in their daily practice.
The increased case load of trained informal providers is again proof that overall quality of care offered by them had improved. The increase in quacks’ case loads was witnessed only in those villages where qualified doctors were not available. Since 90 per cent of patients said they would seek care only from informal providers, the increased case loads of trained quacks must have been from patients switching from untrained providers to trained providers than from qualified doctors to trained quacks, the authors say.
Nearly 75 per cent of primary care visits in rural areas, especially in States such as Rajasthan, Madhya Pradesh, Andhra Pradesh and Uttarakhand are to informal providers. Since all steps to increase the number of qualified doctors in rural areas and change the health-seeking behaviour of patients have not been successful, training informal providers might be an “effective short-term strategy to improve health care in rural areas”.
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