Disparate Quality: In rural India, degrees don’t make doctors

Published: June 29, 2020 5:20 AM

Bulk of the healthcare providers in India's villages lack formal medical degrees, finds a new study

Non-MBBS healthcare providers are in a minority only in two states, Assam and Kerala, while there is wide variation in terms of quality of knowledge of the healthcare providers across states.Non-MBBS healthcare providers are in a minority only in two states, Assam and Kerala, while there is wide variation in terms of quality of knowledge of the healthcare providers across states.

By Arjun Mukherjee

Nearly 75% of villages in India have at least one healthcare provider, as per a study. However, the bulk of the healthcare providers in the villages — 68% — don’t have formal medical education degrees, while 24% are qualified Ayush practitioners, and only 8% are MBBS degree-holders.

The study led by researchers at the Delhi-based Centre for Policy Research, Georgetown University, and University of California-San Diego — covering 1,519 villages in India’s 19 most populous states — found that private sector healthcare providers, including those who don’t hold formal qualifications, dominate rural healthcare marketplace, making up 86% of the provider population.

Non-MBBS healthcare providers are in a minority only in two states, Assam and Kerala, while there is wide variation in terms of quality of knowledge of the healthcare providers across states.

The researchers measure quality of knowledge against the mean MBBS performance within the sample, on accuracy of diagnosis and treatment of four health conditions —TB in young adult male, pre-eclampsia in pregnancy, diarrhoea and dysentery in children.

As per the study, informal healthcare providers from Tamil Nadu and Kerala had better knowledge than the average MBBS in Uttar Pradesh and Bihar. Indeed, no healthcare provider across segments in terms of qualification in UP and Bihar was above the national standard for quality of medical knowledge. All states, barring Kerala, Himachal Pradesh and Assam, reported a higher proportion of informal healthcare providers above the mean-MBBS knowledge level for the state than MBBS doctors below this level.

The study also found that the dominance of non-MBBS healthcare providers doesn’t fall significantly with higher socioeconomic status (SES) of the household sample in each state. These healthcare providers make up for more than half of all providers in all states other than Assam and Kerala.

“While higher state SES predicts a smaller presence for non-MBBS providers, the association is weak and driven primarily by the inclusion of Kerala,” say researchers Jishnu Das, et al, in the study published in the journal Social Science & Medicine. Kerala, as per the study, reported the highest proportion of villages with at least one MBBS doctor available (both public and private sector) — 56.1%, compared with West Bengal’s 22%, which was the next highest. While the southern states (undivided Andhra Pradesh considered for the study) recorded double-digit figures for this, only two from the rest of the states, Punjab and Assam, had a similar showing. This seems borne out by Union health ministry data that shows, upon a back of the envelope calculation, 1 allopathic doctor at a PHC for every 21,800 people in Kerala versus every 62,300 people in Uttar Pradesh (as on March 31, 2019). With similar gaps in terms of healthcare personnel, there have been attempts to regularise informal healthcare providers – Chhattisgarh had rolled out a 3-year diploma for rural medical practice, which was later junked, while West Bengal had started a training programme; even the Centre had talked of a bridge course. But these have met stiff opposition from interest groups like the Indian Medical Association.

The study also finds that better-performing states in terms of quality of healthcare provider were doing this at lower costs per patient. In these states, a public sector MBBS saw more patients over a month at a much lower per visit cost vis-a-vis her peers in states that didn’t have as high-quality healthcare providers.

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