Indian healthcare’s inconvenient truth

Unqualified medical practice is big business in India. I had a unique opportunity to research the phenomenon through a field study. The major beneficiaries, apart from those that rely on the services of unqualified health providers (UMPs), were, quite unexpectedly, qualified doctors.

The revolving door opens when a qualified doctor employs a medically unqualified worker as an apprentice. Over 18 months to five years the assistant learns the tricks of the trade — prescribing drugs for practically all outpatient conditions — vomiting, diarrhoea, fever, crashes, joint pains, respiratory distress, abdominal pain, flu, typhoid, dengue besides children’s illnesses. The door closes when the UMP sets up his own practice but re-opens when the UMP starts referring his patients to the doctor for earning commissions.

Across every district in the country and in every village, slum and the unorganised areas in all cities these quacks known as RMP’s, jhola chaap doctors, Bangali doctors or just quacks, thrive. WHO (2016) reports that as many as 57 per cent allopathic doctors in India do not have a medical qualification. Even when free facilities are available in the vicinity as is the case with urban slums and nearby public sector dispensaries, the poor go to quacks as the first port of call.

For the daily wage earner the incapacity to report for work means a loss of wages which must be circumvented at any cost. He has no capacity or willingness to ponder on obscure things like side effects or drug resistance. For him the nearby UMP’s treatment is a one stop transaction, cheap and available 24x7. There is security and comfort in knowing that the neighbouring community also relies on the UMP whose treatment generally works.

Besides, attempting to go to a Primary Health Centre (PHC) where the nearest Government doctor is located is beset with problems. According to Census data most PHCs are located five, 10 or more kilometres away from the surrounding villages.

Getting there would necessitate taking the patient on a cycle, a two wheeler or by bus only to find that the doctor is absent or medicine unavailable. The second alternative is to go to a private practitioner and pay a minimum of ₹200 over and above outgoings on transport and incidentals.

Considering the generally “effective” and inexpensive treatment that a village or slum based UMP provides going to him in the first instance is a no-brainer. And given the time, cost and convenience factors this trend is unlikely to change.

How did the UMPs acquire skills to treat medical conditions? They learnt what they know from qualified doctors who engaged them as helpers. Once they leave the relationship grows into a marriage of convenience when the UMP provides a regular supply of patients and receives commissions (up to 30 per cent of the fees charged) for this service.

Women UMPs too are in high demand. Trained under qualified doctors who hired them as cheap help during deliveries, these skilled birthing attendants eventually move on and open their own maternity businesses. The ones I met were smartly turned out and articulate.

They describe every detail of how labour is induced; including the use of oxytocin injections after the dilation is sufficiently advanced. They could recognise pregnancy complications and were astute enough to refer cases to qualified doctors in time. The cost of delivering a baby here remains less than one quarter of going to a doctor’s clinic.

Pseudo pharmacists form another large and ubiquitous category. They readily sell antibiotics and steroids over the counter based on stated symptoms and by recalling AIIMS and other senior doctors’ prescriptions for given conditions. In addition the medical representatives of pharmaceutical companies were their trusted allies as they gifted them a bagful of free samples on every visit along with a tutorial on medical conditions and drug dosage.

Often such dawai (medicine) shops were owned by doctors but the front face was a qualified pharmacist who was but a proxy.

A fourth category of UMPs were found dabbling in a mixture of allopathy, Ayurveda, homoeopathy — even electro-homoeopathy. From signboards and the display of a wide variety of medicine it was apparent that they were in demand for treating gupt rog (secret diseases) aka sexually transmitted diseases, reproductive tract infections, sexual problems and piles.

Taken together the number of such practitioners is enormous. Few have anything more than a school education and even those who are graduates have not studied medicine. Their framed certificates and diplomas generally hark back to medical sounding titles which are all unrecognised.

In a 2015 working paper by Shailender Kumar Hooda an economist working with the Indian School of Industrial Development he has decoded NSSO data to show that there are 10.7 lakh medical establishments in the country.

Of these only 8 per cent are hospitals and the overwhelming majority are single practitioner enterprises run by unqualified practitioners.

One might well ask what different regulatory agencies are doing, knowing full well that this phenomena is entrenched in the lives of the poor. Apart from the side effects of using steroids and antibiotics irrationally, the greater risk is the probability of spreading multi-drug resistance in the wider population.

Under law the Medical Council of India and its state chapters are responsible for taking action against those who practice medicine without a medical qualification. Responses given by the Health Ministry to Parliament have invariably stated that it is for the State Medical Councils to take action. The Indian Medical Association castigates quackery but does not deregister its members from training and then paying commissions to UMPs to garner patients.

Other law enforcers too have safe alibis. Police officers and district magistrates even when they see what is tantamount to cheating and impersonation do nothing because the offences are not “cognizable”.

In other words arrests cannot be made without a complaint — something no member of the public is willing to give. The State Drug Controllers have a responsibility to ensure that prescription drugs (of which there are nearly six hundred listed in the Regulations,) are only sold under a doctor’s written advice. In fact there is virtually no checking.

While most State health departments prefer to look away, West Bengal began training the RMPs some seven years ago with the stated aim of preventing harm. Regular training classes have been organised using funds provided under the National Rural Health Mission.

It is another matter that unsupervised use of antibiotics, steroids and fourth generation drugs has serious costs for society and ought to give nightmares to all authorities. To ignore an inconvenient truth any longer would be iniquitous, unprincipled and dangerous.

The writer is former secretary, Department of AYUSH

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