In 2009, one Indian state took a chance on quacks to help solve its healthcare crisis. What happened?
There remains considerable resistance in India to the idea of training the country’s abundant ‘quacks’ to provide proper medical care. But the state of Andhra Pradesh has been there and done that.
In 2009, around 56,000 ‘rural medical providers’ (more than half of the total number in the state) signed up for a six-month training programme in medical skills run by the state’s paramedical board. They received three months of classroom lectures, and were also put to work in hospital wards, accompanying doctors on their daily rounds. A number of the students also assisted doctors in the state’s 104 rural ambulance services.
Although the programme was aborted in 2012, it’s an interesting case study for what such training can achieve. It is impossible to assess this objectively without a randomised trial, but training has certainly made informal providers more aware of the damage their negligence can cause.
Choppari Shankar Mudiraj, a rural medical practitioner from Khammam, a city in Telangana, now uses disposable syringes instead of disinfecting reusable ones with Dettol. He also provides newly prepared intravenous equipment for each patient, even if this takes an extra half an hour. Most importantly, Mudiraj says, he refers patients to doctors sooner when his own treatment isn’t working. “We used to treat patients for up to one week. But now, we don’t treat them for more than three days.” S Venkat Reddy manages a hospital manned by several qualified doctors in a slum occupied mostly by construction workers. He says the programme taught him how to give correct first aid to a patient with a spinal fracture: “We learnt how to make that person lie down; turn him, shift him etc. I learnt that you cannot make him sit anywhere.” And Choleti Balabrahmachari, an informal provider from the Rangareddy district, has eschewed the use of metamizole, a drug he formerly prescribed frequently for stomach aches and headaches, because of the risk of severe side effects.
The programme didn’t change all students’ practices completely though. Although it required all participants to stop using the prefix ‘Dr’, several practitioners, including Reddy, still have it on their business cards. (The Andhra Pradesh paramedical board that ran the course has not been able to enforce this rule because the programme ended prematurely. Besides which, the participants were never officially registered with the board as paramedics.)
But a much bigger worry is that rural medical practitioners may attempt complicated surgical procedures or prescribe strong antibiotics and steroids, practices they are known to indulge in. The chairman of the Andhra Pradesh Medical Council, E Ravinder Reddy, opposed the Andhra programme – and argues that it’s highly unlikely informal providers will alter their behaviour after a matter of months receiving similar training. “They are already violating rules. [After the training] they will violate them even more,” he says.
The practitioners I spoke to vociferously disagreed. They say such malpractices are the work of a minority – and that senior organising bodies in the community view them sternly. Yet everybody is punished by overzealous government officials looking for scapegoats.
Balabrahmachari says it is easy to harass rural medical practitioners without taking into account the circumstances in each patient’s case. “Sometimes, when a person has a heart attack, his family brings him to us and demands that we give him intravenous glucose. He may not even have a pulse or may have very low blood pressure already. But the family forces us.”
I asked Balabrahmachari and others about another popular accusation: commission – or rural practitioners taking a cut from qualified doctors for referring patients to them. He had seen no evidence of this, but did say some circumstances could be misinterpreted. “Suppose I take a patient to an excellent hospital,” he says. “They give me bus-fare because I have closed my shop and haven’t even eaten food the entire day to get him there. He may give me 50 rupees to eat food.” P Hanumantha Rao, a provider from the Nalgonda district of Telangana, has a contrasting view. “There are nameless rural medical practitioners in tribal areas who may take more money and give unnecessary injections. There are 10 per cent such people definitely. But awareness programmes and training have made a lot of difference.” G Balraj, a graduate in biotechnology from the Armed Forces Medical College in Pune, worked at an Indian army blood bank for seventeen years before starting a medical practice. He explains that associations of informal providers fine their members for taking such ‘kickbacks’ – and expel them if it continues. “Nobody is taking [commission]. If I send my patient to a doctor, I tell him on phone: sir, whatever commission you want to give me, please deduct from [the patient’s] bill.”
According to these practitioners, patients rarely complain about them, because they know a doctor wouldn’t attend to them in the same way. Says Balabrahmachari, “Yesterday, while a man was washing crops in water, he got bitten by a snake. The village sarpanch [elected head of a village government] called me to attend to him. I tied a bandage and brought him to Osmania hospital. Would an MBBS [degree-level] doctor do this? By the time the patient would have reached Hyderabad, he would be dead already.”
S Venkat Reddy adds, “The people of Tanda [a region in Telangana where Reddy practises] have never told us to shut down, because they don’t even have access to buses for 13 km. I have to ride a cycle, wade across two streams after bundling my clothes on my head, borrow another cycle at the other end and ride again to reach the patient and give medicine.” That is why the families in Tanda respect and trust him, he says. “The government harasses us, but the people never do.”