Quality of underground health care: A case study of Indian RMPs


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Barun Kanjilal of the Indian Institute of Health Management Research (IIHMR) presents on the role of rural medical practitioners (RMPs) in 'underground' health care in India. The presentation was given on 9 July 2011 to the Private Sector in Health pre-congress symposium at iHEA 2011 in Toronto.

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Quality of underground health care: A case study of Indian RMPs

  1. 1. Quality of underground health care: A case study of Indian RMPs Barun Kanjilal Indian Institute of Health Management Research July 9, 2011
  2. 2. Rural medical practitioners (RMPs)¡  RMPs: village doctors who practice modern (allopathic) medicines without any formal registration / approval or legal sanction¡  Dubious / unrecognized qualifications¡  Independent practitioners after a stint with other qualified / unqualified practitioners¡  Primarily treat common ailments but also treat major ailments¡  Unique market penetration strategy make them highly popular and a dominant player in outpatient care market 2
  3. 3. Problem  RMPs’ quality of care highly questionable but both market and government fail to address it.  Dilemma in policy making silence / neglect  What kind of regulatory framework would be appropriate for an underground but highly relevant market force?
  4. 4. Setting¡  Data collected from the Sundarban islands of India – a geo-climatically challenged area inhabited by 4 million people¡  A KBP survey on about 200 RMPs ¡ Knowledge on common diseases treatment procedure and medicines ¡ Comparing with a standard protocol prepared by a team of public health experts ¡ Qualitative study 4
  5. 5. Sources of treatment (% of ailing persons) NGO 2% Private formal 22% Govenrment 12% RMP 64%
  6. 6. Key findings¡  Knowledge on medicine reasonably high – up-to- date on latest drugs¡  Deliberate effort to keep treatment process indistinguishable from authorized practitioners¡  The distorted clinical quality is packaged with unique non-clinical strategies.¡  Bounded rationality of the clients and unique delivery strategy help build a trust element in the quality
  7. 7. Major Threats¡  Indiscriminate use of antibiotics¡  Minor / major surgeries¡  Gradual penetration to inpatient care market 7
  8. 8. Some evidences % of RMPs prescribing drugs in case of normal deliveryErgometrineNo medicine % of RMPs ReferOxytocin inj 0% 20% 40% 60% 80% 100% 8
  9. 9. Prescription Behavior by Disease Condition (% of RMPs) 90.00 80.00•  Rampant use of 70.00 Amoxicillin antibiotics for Percentage of RMPs 60.00 common diseases 50.00 Refer•  Use of steroid in 40.00 limited cases 30.00 20.00 Steroid 10.00 0.00 Common cold Pnemonia Severe Pneumonia Diagnosed disease condition
  10. 10. Treatment of child diarrhea¡  70% admitted administration of IV Fluids for diarrhea at the outset¡  Use of antibiotics irrespective of severity¡  54% recommend normal breast feeding while 37%, exclusive breast feeding during diarrhea.
  11. 11. Referral practice % of ailing children ¡  Dubious referral practice (17000) Rest 19.00% ¡  An underground nexus Referre 8.90% with local private Died hospitals / clinics3.10% ¡  Usually refer when situation completely goes Cured out of control 69.00%
  12. 12. Research / policy implications¡  From market-based to institution-based approach of understanding quality of care – application of institutional economics for analyzing underground market.¡  Focusing more on non-clinical aspects of quality – especially the neutralizing aspects of clinical quality¡  More evidences on integration of RMPs and contract monitoring at the local level in an unregulated market
  13. 13. Thank you