{"id":47867,"date":"2020-06-24T19:46:19","date_gmt":"2020-06-24T18:46:19","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=47867"},"modified":"2020-06-24T19:46:42","modified_gmt":"2020-06-24T18:46:42","slug":"mobilising-informal-healthcare-providers-in-india-may-help-its-response-to-covid-19","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/06\/24\/mobilising-informal-healthcare-providers-in-india-may-help-its-response-to-covid-19\/","title":{"rendered":"Mobilising informal healthcare providers in India may help its response to covid-19"},"content":{"rendered":"

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.\u00a0\u00a0<\/span><\/p>\n

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\u2019s 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].<\/span><\/p>\n

Globally, informal providers <\/span>(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\u2019 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].\u00a0<\/span><\/p>\n

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.<\/span><\/p>\n

Following the corona lockdown, many small and medium formal private health facilities have closed in urban and peri-urban areas, due to fears of\u00a0 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\u2019 chambers are open, nursing homes and hospital OPDs are closed\u2026so villagers are turning to rural medical practitioners (IPs).”\u00a0<\/span><\/p>\n

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.\u00a0<\/span><\/p>\n

IPs have had little support in dealing with the corona virus outbreak. \u2018This is flu season\u2019, our key informant explained, \u2018and the number of flu patients is creating panic\u2019. 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.\u00a0<\/span><\/p>\n

How can informal providers be engaged?<\/b><\/p>\n

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:\u00a0<\/span><\/p>\n