The Indian Medical Association’s main opposition to a rural health providers’ course is that it is discriminatory and will create lesser-trained doctors for rural areas while the fully trained remain in urban areas. This assumption reflects an incomplete understanding of rural healthcare and of that very first level of need that health providers trained through this course can efficiently meet. The idea is not to develop a rural substitute for MBBS doctors but rather to fill a huge gap at the first level of care seeking in rural areas. A recent Public Health Foundation of India report correctly states that the “comparator is not the physician but the situation where no physician is present.”

Undeniably, this first level is critical because even the simplest decisions made here can have far reaching health consequences. Much of healthcare at this level has been, and is currently delivered, by a variety of providers who are not trained allopathic doctors. However, they fill a niche which the three-tier public delivery system has not been able to fulfill in 60 years1 . Even if most primary health centres (PHCs) and community health centres (CHCs) in India were fully staffed with doctors, this niche would still remain.

A paramedic in a remote PHC in Orissa attends to a patient's infected wrist abcess

To illustrate my point I describe scenarios from different states that I have come across in my own field research and personal encounters over the last 10-15 years. I began with the question “Where do people in villages go when they fall sick and need healthcare?”

Orissa, January 2009

Resettlement colony no. 2 (RSC 2) was a small hamlet of 30 Paraja tribal households on a hillside beyond the Machkund and Balimela dams in Malkangiri district in Orissa. These mega projects displaced the Parajas of RSC 2 twice but gave them no electricity, water or healthcare in return. The Balimela project hospital at Chitrakonda, five km on foot and 12 km by motorised transport, once a bustling hospital for project staff, closed down once construction got over. The local government converted it to an ‘area hospital’ but could only attract one MBBS doctor and one AYUSH (ayurveda, yoga & naturopathy, unani, siddha and homoeopathy) doctor. The hospital nevertheless continued to draw people from as far as 50-60 km as it was the only health facility with a doctor for 15 gram panchayats.

But people of RSC 2 did not go to the area hospital at first instance. Five km was a long way to walk when sick. When they suffered from malaria, diarrhea or body pains, their first port of call was either a disari in their own village, or an informal allopathic practitioner called Bhagbat Baral who came whenever called. Disari was a traditional healer who treated with herbs, roots and mantras; Baral gave allopathic tablets and sometimes an injection, all for Rs 10-15.  “Baral is like our father,” people told me. “If you have no money then that is not a problem. You can give money at any time. If you have no money, then he also lends you money.” They approached the area hospital only if the local cures did not work or if they felt their illness was more serious.

In Baliguda village people first called ‘patro doctor’ as the nearest ‘big’ doctor was at the government CHC, 12-15 km away. Patro was a pharmacist at a nearby additional PHC who managed that remote facility all by himself and also treated privately, for a fee. The distant CHC, which should have had five specialists, had only one MBBS doctor on OPD duty when I visited. The CHC’s sole specialist – a gynaecologist – had a history of depression and was on leave following a heart attack. On the outskirts of Malkangiri town, people usually first approached ‘Narayan doctor’, a private practitioner with a three-year rural medical practitioner’s diploma, and his own small clinic. In Lakurbhatta in Kalahandi, people first approached the village ‘kobiraj’ (who gave allopathic as well as herbal treatment) or a government nurse (ANM) who lived nearby. She dispensed and prescribed medicines for Rs 50.

Village Kobiraj with his medicine box in Malkangiri, Orissa

And so it was in village after village. More than 85% rural households first approached their nearest providers and these were not qualified doctors2. The only qualified doctors were at understaffed PHCs and CHCs. Here too, paramedics took on some of doctors’ conventional tasks – in one PHC I saw a health attendant performing surgical incision and drainage of an infected wrist abscess. Strikingly, except for a few government doctors in these districts who also consulted privately (as state policy allowed), there were almost no private doctors or private hospitals at the block or district level.

Andhra Pradesh, July 2008

Just across the border, Warangal and Karimnagar districts of Andhra Pradesh presented marked contrasts and similarities. Here too the majority of rural households did not approach a professional doctor at first contact. They approached their ‘village RMPs’ – informal allopathic practitioners who treated common illnesses like fevers, body pains, diarrhea, colds and cough with allopathic medicines. Compared to Orissa’s public-private mix, these were exclusively private practitioners and each catered to a few households. All had mobile phones, and practised mobile healthcare. “First I will attend emergency calls,” one RMP told me, “then I will go street by street and house by house…sounding the horn as I go.”

More households in rural AP approached professional doctors than in Orissa, but most of these were private doctors. Only 2-3% households approached public facilities. There was a very visible private sector in the AP districts, abundant at the district headquarters but also very visible in block and taluka level towns.

Bihar, April 2010

Two of the best PHCs I have seen in recent times were in Barachitti and Wazirganj blocks of Gaya district. Perhaps it is no coincidence that these were close to Gaya town and situated on good roads. Each had a roster of four-five doctors to ensure 24-hour emergency services. But even in villages within five-six km of these PHCs, households approached their “village doctors” first – the private informal allopathic practitioners. Almost every village had at least one such provider within residents’ easy access. People went to the PHC only if they did not get better here. They also had the option of consulting private doctors who commuted from Gaya town. But for people living in interior areas, the main source of healthcare were village doctors, or ‘bigger’ RMPs, and a few ayurvedic/unani/homeopathy doctors who practised in bazaar hubs. While the bigger PHCs in distant blocks had at least one doctor on duty, the smaller, remote ones were understaffed, and the two that I visited were locked. The (inequitable) staffing situation here probably reflected the (GoI’s) 2008 health facility data wherein out of 1,641 PHCs in Bihar, 1,243 were without a single doctor while majority of the staffed ones had more than four each.

A pharmacy-cum-clinic in rural Bihar

Notwithstanding the National Rural Health Mission’s (NRHM) successes including increased institutional deliveries, training of accredited social health activists (ASHAs), and improvements in the existing three-tiered public health delivery system, this national programme has failed to meet the everyday health needs of rural communities. During 2002-04 when I was doing my PhD field research in Uttarakhand and Uttar Pradesh, informal providers were the first port of call in every village I visited. They still are, even today, all over the country.

Even Tamil Nadu, with the best performing public health system in the country and good road connectivity, has several rural and tribal pockets where local populations rely on informal practitioners for first care. My friends Dr. Regi and Lalitha George in Sittilingi3 (Dharmapuri district) and Dr Nandkumar in Gudalur in the Nilgiris4 run secondary care rural hospitals that recruit and train their hospital staff locally. These doctors vouch for the importance of local health providers to meet local primary health needs and would also like to improve the skills of informal practitioners in their surrounding villages. Unfortunately our dominant medical establishment has labelled these practitioners as “illegal”.

Inter-state variations

At a macro level, different states may show variations in the mix and density of different types of public and private providers at the primary level: more mobile informal practitioners in AP, more clinic-based ones in UP, more public sector ones in Orissa. These differences are also repeated in the mix of qualified doctors available at level two in different states. Altogether these could reflect interstate differences in wealth (e.g. monthly per capita expenditure was Rs 704 in AP and 460 in Orissa – NSS 2005-06) and numbers of medical colleges (33 in AP, eight in Bihar and six in Orissa), among others. The important message is that even in high-income states like AP, with more private colleges and private doctors, the first port of call in villages is usually not a qualified allopathic doctor.

There are around 6,00,000 villages in India of which 60% are small and scattered with roughly 1,000 population. They represent a massive need for primary healthcare providers (almost one per village) who are within easy access, can be trusted by their local communities, and are trained to manage most common illnesses. For practical social and economic reasons doctors produced through the current model of medical education are unlikely to meet this first level of need substantially, at least not in the next several years. We need to consider mid-level clinical care providers as a competent alternative for the first level of health care. This is also the conclusion of a recent study5 by the Population Foundation of India on the 3½-year trained Rural Medical Assistants posted in remote PHCs in Chhattisgarh. The study found that medical officers and RMAs were equally competent to manage conditions commonly seen at the primary level. AYUSH doctors were less competent and paramedics the least.

The rural health providers’ course can develop competent primary care providers in the long term, but in the short term it must consider training, certifying, and regulating selected providers who already live and work in villages. These could include eligible and willing informal practitioners, public sector paramedics, nurses, and also AYUSH doctors. The planning of this course must be responsive to inter-state variations and avoid a one-size-fits-all formula.

Photos: Meenakshi Gautham

This piece first appeared in the April 16-30 issue of the Governance Now magazine (Vol.02, Issue 06).