India has one of the most privatized health systems in the world, but the public sector is leading its response to covid-19. [1] It has focused, so far, on the needs of the middle classes, but the virus is spreading to low-income neighbourhoods and rural districts. In Mumbai city, most epicentres of covid-19 containment zones are within or close to slums. [2] A rural outbreak could be looming, associated with the return of thousands of migrant workers to their villages, following a national lockdown.  

The public sector needs to be well prepared, as both infrastructure and human resources are inadequate in rural areas. More than 75% of the country’s qualified doctors and nurses work in the urban private sector. [3] The government plans to upgrade 150,000 rural health centres by 2022, for comprehensive primary care with newly trained mid-level providers. [4] However, only 38,549 are currently functioning, so huge inequities persist in access to qualified providers. Some reports suggest that in some areas, the first contact of more than 80% of care-seekers in slums and rural areas is with informal private providers [5, 6].

Globally, informal providers (IPs) do not have a formal medical qualification or registration [7]. They include western/biomedical as well as traditional practitioners and unregistered pharmacists and drug sellers. IPs in India function as private paramedics with small clinics, treating patients and dispensing drugs for a fee [6]. Most have higher secondary education followed by informal paramedical or allied health training and basic knowledge of managing common conditions. Health authorities are ambivalent about IPs’ semi-legal status and let them operate, since IPs address needs unmet by the formal health system, but a few states have tried to engage with them through training, and a pilot in West Bengal has shown good results [8,9]. 

IPs are several times more widespread and accessible than qualified doctors. For example, there are 30 IPs for each public doctor in rural West Bengal [9]. Being male, they can be more influential among men in rural communities than public sector ASHAs, a cadre of female community health workers who focus on maternal and new-born health.

Following the corona lockdown, many small and medium formal private health facilities have closed in urban and peri-urban areas, due to fears of  staff infections [10]. Anecdotal evidence would suggest that the number of consultations with IPs imay have increased, in person or through tele-consultations. An office bearer of an IP association with 12,000 members told one of the authors: “before the corona lockdown, 70% of local people would come to us for treatment, now 95% are coming. No doctors’ chambers are open, nursing homes and hospital OPDs are closed…so villagers are turning to rural medical practitioners (IPs).” 

As the corona virus spreads to rural areas, containment will be critical as health infrastructure is seriously limited. Prevention, detection and quarantining need to be stepped up and ignorance, stigma and fears countered. Maintenance of non-covid health services and supply of medicines need to be ensured; these are already facing severe disruptions in rural areas. 

IPs have had little support in dealing with the corona virus outbreak. ‘This is flu season’, our key informant explained, ‘and the number of flu patients is creating panic’. Ignoring IPs in these critical times would be detrimental to covid prevention and closing their practices without providing alternatives to people would risk creating an underground market for inappropriate treatments and drugs. 

How can informal providers be engaged?

An effective response to contain the impact of covid-19 on the rural population must include IPs. We suggest that clear guidelines be provided to IPs and peri-urban primary care physicians, with supportive communication to communities to: 

• encourage people with mild symptoms to stay at home or seek telephonic consultations. This would reduce the risk of providers becoming a locus of infection.
• triage symptomatic patients with travel or contact history and refer them for testing and manage no contact/travel history patients as per local protocols. 
• use correct information to counter rumours, decrease stigma and encourage people to comply with quarantining.
• maintain physical distance with patients, avoiding physical examinations, wearing face masks and washing hands.  
• strengthen tele-consultations between IPs and public/private physicians for IPs to seek advice on covid and non-covid patients. 

The public sector was unprepared to support millions of urban poor during the early lockdown [11], but it still has time to harness all health providers and minimise the impact of covid-19 among the rural population.

Meenakshi Gautham is a Research Fellow in health systems and policy analysis with the London School of Hygiene and Tropical Medicine. Twitter: @Gautham_meen

Gerald Bloom is a physician and health systems researcher with the Institute of Development Studies in Brighton, UK.

Priya Balasubramaniam is a Senior Public Health Scientist and Director at the Public Health Foundation of India and the Centre of Sustainable Health Innovations, Singapore. Twitter: @PriyaBeKay

Catherine Goodman is a Professor in Health Economics and Policy at the London School of Hygiene and Tropical Medicine. Twitter: @CatherineGoodm9

Birger C Forsberg is a public health physician and Associate Professor of International Health at Karolinska Institutet, Sweden.     

Amod Kumar is an Indian Administrative Service officer, currently working as Principal Secretary, Planning Department, Government of Uttar Pradesh, India. Twitter: @amodkumar

Competing interests: None declared

References:

1. Mackintosh, M., et al., What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries. Lancet, 2016. 388: 596–605.
2. Patranabis, S., S. Gandhi, and V. Tandel, Are slums more vulnerable to the COVID-19 pandemic: Evidence from Mumbai, in BROOKINGS. April 16 2020, https://www.brookings.edu/blog/up-front/2020/04/16/are-slums-more-vulnerable-to-the-covid-19-pandemic-evidence-from-mumbai/.
3. Rao, K., R. Shahrawat, and A. Bhatnagar, Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey. WHO South-East Asia Journal of Public Health, 2016. September 2016 | 5 (2): p. 133-140.
4. GOI. Ayushman Bharat – Health and Wellness Centres. April 2020, https://ab-hwc.nhp.gov.in/#about.
5. Priya, R., R. Singh, and S. Das, Health Implications of Diverse Visions of Urban Spaces: Bridging the Formal-Informal Divide. Front. Public Health, 2019. 7:239.
6. Gautham, M., et al., Informal rural healthcare providers in North and South India. Health Policy and Planning, 2013. 2013; 1–10 doi:10.1093/heapol/czt050.
7. Sudhinaraset, M., et al., What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review. PLoS ONE, 2013. 8(2): e54978. doi:10.1371/journal.pone.0054978.
8. Chandra, S. and S. Bhattacharya, Unqualified Medical Practitioners: Their Illegal but Indispensable Role in Primary Healthcare. Economic and Political Weekly, 2019. Vol LIV No. 5(Februray 2, 2019): p. 36-44.
9. Das, J., et al., The impact of training informal health care providers in India: A randomized controlled trial. Science, 2016. VOL 354 ISSUE 6308. doi: 10.1126/science.aaf7384.
10. KPMG, Potential Impact of COVID-19 on the Indian Economy: Healthcare. 2020: India. https://www.linkedin.com/feed/update/urn:li:activity:6652858853966823424.
11. Editorial, India under COVID-19 lockdown. The Lancet, April 25, 2020. Vol 395 

 

Authors: Meenakshi Gautham (LSHTM), Gerald Bloom (Institute of Development Studies, Brighton), Priya Balasubramaniam (Public Health Foundation of India), Catherine Goodman (LSHTM), Birger Forsberg (Karolinska Institute), Amod Kumar (Govt. of Uttar Pradesh, India)