Abstract
In India, rural medical practitioners (RMPs) practice allopathic, homeopathic, and other modern systems of medicine without formal medical training. However, the quality of treatment offered remains questionable. The present study systematically examines the knowledge, practices, and competencies of the RMPs. While about 80% of RMPs can diagnose common diseases and treat them, 25% are involved in inappropriate practices like unsafe abortion and unsafe childbirth. Hence, there is an urgent need for appropriate intervention to reduce potential harm and improve care provided.
Introduction
In India, many programs have been implemented to enhance access to health care in rural areas. However, despite this, over 67% of people in need of medical care visit rural medical practitioners (RMPs) (Das et al., 2012) who have no formal medical training but serve as the first point of contact for health care services, especially for outpatient care (Kanjilal et al., 2013). Countries like Uganda, Bangladesh, and South Africa have been fairly successful in implementing the directly observed treatment (DOTS) program through such practitioners. RMPs have treated 58% of TB patients in Malawi and South Africa (Barker et al., 2006; Brouwer, Boeree, Kager, Varkevisser, & Harries, 1998; Pronyk, Makhubele, Hargreaves, Tollman, & Hausler, 2001); 45% of TB patients in Bangladesh, with a 90% success rate (Salim et al., 2006); and 64% of malaria patients in Senegal (Tine et al., 2013). However, the quality of treatment remains a concern because RMPs are not medically trained. The competency of RMPs has not been assessed or researched extensively, only a few studies mention their existence. In this “note from the field,” we try to assess the competency of RMPs using field survey data collected by the Indian Institute of Health Management Research in 2009.
Material and Method
The survey data on RMPs was collected from six subdistricts, which were selected from two districts of West Bengal, India. A two-stage sampling procedure was used to select RMPs from both remote villages and semiurban areas (SUAs). In the first stage, villages and SUAs were systematically selected, and in the second stage, RMPs’ clinics from each village and SUA were selected. A total of 185 RMPs, comprising 90 village-based and 95 semiurban-based and covering 34% of all existing RMPs practicing in the area, were interviewed using a structured questionnaire that provides a representative sample for estimating their characteristics.
Empirical Results
About 75% of RMPs have studied up to a higher secondary level. Many have received medical training from private, unrecognized institutes and also worked with private qualified doctors as assistants. They normally offer curative care services in outpatient settings. Usually, RMPs treat minor health problems like cold, cough, and fever; diarrhea and enteric diseases; common weakness, pain, and ache; high or low blood pressure; gynecological problems; and so on with drugs and medicines. They also offer medical support to pregnant women and assist during childbirth and abortion.
Knowledge and Practices of the RMPs
The quality of treatment provided by RMPs was evaluated through a review of their knowledge of symptoms for common illnesses like pneumonia and diarrhea, apart from gynecology, childbirth and health care, and even accident and injury. About 96% of RMPs can diagnose pneumonia on the basis of fever and other symptoms. More than 40% are able to differentiate between common and severe pneumonia based on changes in eye or skin color, loss of appetite, and so on. Medication and choice of treatment are consistent with the usual practice for common pneumonia. However, 10% of RMPs do not refer patients to qualified doctors for better treatment—one of the inappropriate practices identified. They prescribe steroids for managing severe pneumonia and continue the treatment based on their own conviction in the possibility of finding a cure, which not only amounts to inappropriate prescription of drugs but also a risky practice. Clinical results suggest that steroid use has proved ineffective in reducing mortality rate related to pneumonia (Pascale, Bello, & Antonelli, 2011).
In case of diarrhea, RMPs had confidence in their abilities and usually did not refer patients to qualified doctors. They described diarrhea as an illness during which patients have frequent loose or watery stools, vomiting, abdominal cramps, fever, lightheadedness, or dizziness from dehydration. For treatment, 90% of RMPs prescribed oral rehydration salt for common diarrhea, while 70% prescribed saline along with antibiotics like metronidazole, ciproxin, and ciprofloxacin, which is the appropriate treatment for patients suffering from severe diarrhea.
In India, many people die every year from alcohol poisoning and suicide attempts by ingesting toxic chemicals; in fact, RMPs treat 10–12 cases of self-poisoning in any given month. Despite limited knowledge about the treatment of chemical poisoning, they usually provide primary treatment in the form of gastric lavage and then refer the patient to a hospital.
Further, it is seen that about 80% of RMPs provided treatment for gynecological problems and a spectrum of women’s health issues, and about 28% also provided medical assistance during childbirth. They claimed that they were aware of the possible risks and complications associated with pregnancy like anemia, edema, eclampsia, and high blood pressure and generally administered saline, oxytocin, and ergometrine injections during labor. About 71% of RMPs continued treatment even when faced with a severe crisis like excessive bleeding (during or after childbirth) or other serious complications—which can be dangerous. Another harmful practice followed by RMPs is unsafe abortion. Since RMPs have no medical training, they lack the appropriate skills for performing abortions. Also, they do not even follow the minimum medical standard, that is, procedures are performed in unhygienic conditions which put the patients at greater risk of exposure to infections. Most of the RMPs perform an abortion by conventional dilatation and evacuation method, while some still follow primitive methods like using sticks, inserting catheters and herbal medicines, and so on. Resorting to such unsafe abortion procedures is one of the predominant causes of high maternal mortality and morbidity in India and other developing countries (World Health Organization, 2010).
Conclusion and Policy Implications
The study concludes that most RMPs can diagnose common diseases and treat them properly. Although they have a good nexus with the qualified doctors and mostly use these contacts to facilitate follow-up treatment of their patients, in some cases they use drugs and medicines inappropriately and in ways that could cause harm to the patients. This creates a policy dilemma for the health department: Whether to allow RMPs to continue practicing because they are popular among the rural people or stop such unqualified, self-styled practitioners from practicing since they may be doing more harm. As there is no concerted drive against RMPs, the health department would benefit from examining the approaches taken by other countries in supporting RMPs. For example, China has adopted the Chinese village doctors’ (formerly “barefoot doctors”) policy to strengthen health care facilities by ensuring that qualified health professionals provide the necessary medical assistance to all. In such a case, government-sponsored competitors will “crowd out” RMPs. Alternatively, the government can offer short-term medical training courses to RMPs (as in Bangladesh, where RMPs have been successfully used to deliver health care services), thereby redefining their role as rural “health care gatekeepers” who can provide basic health care services as well as refer patients to formal providers for follow-up treatment.
Footnotes
Acknowledgments
The author expresses his appreciation for the data support provided by the Future Health Systems research programme consortium, supported by the UK Department for International Development (DFID). Also author would like to thank to Ms. Puja Mehta for editorial support during revision of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.