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Understanding informal markets: The roles and perspectives of RMPs in West Bengal and Karnataka, India


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Dr Asha George of JHSPH presents work on the role of informal health care providers in India. She compares West Bengal and Karnataka -- two states with very different health profiles -- providing both qualitative and quantitative insights into how and why the poor use poorly trained rural medical practitioners as their first port of call when accessing health services.

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Understanding informal markets: The roles and perspectives of RMPs in West Bengal and Karnataka, India

  1. 1. Understanding informal markets: the roles and perspectives of RMPs in West Bengal and Karnataka, IndiaAsha George, Barun Kanjilal, Aditi Iyer
  2. 2. Who are RMPs?• ‘Registered / Rural Medical Practitioners’: – ‘a person who has permission to practice’ – no longer true but regulations not enforced• Practice allopathic medicine with no formal training – (1) with no formal training in any system of medicine – (2) with degrees from institutions unrecognized by government medical education boards – (3) with Indian Systems of Medicine medical degrees from institutions recognised by government medical education boards (AYUSH: Ayurveda, Yoga, Unani, Siddha, Homeopathy) (also understood as cross-practice)
  3. 3. West BengalKarnataka
  4. 4. Data Sources• West Bengal (Malda, Bankura, and North 24 Parganas districts) – household survey, n= 3152 • two stage sampling, first 35 primary sampling units (PSUs) based on PPS (probability proportion to size), then 30 households from each sampling unit based on a systematic random process – provider survey, n= 71 RMPs • random selection of rural PSUs from household survey, then lists of RMPs in selected PSUs developed and at least one selected• Karnataka (Koppal district) – provider census, n= 91 RMPs • from 60 villages in project site and surrounding towns and market villages • 49 no degrees vs. 42 unofficial degrees – Observation and interaction over approximately 9 months continuously & 4 years intermittently
  5. 5. Karnataka: Census of private providers in project area, 60 villages with approximately 82,000 people• 35 spiritual healers• 133 traditional healers• 178 traditional birth attendants• 152 provision stores selling tablets• 2 medical shops• 47 RMPs• 1 Ayurvedic doctor• No private qualified allopathic doctors (except for government doctors moonlighting)
  6. 6. Table 1: Percentage of households usuallyseeking treatment for minor ailments, bysources of care West Bengal:% of households Total Rural Urban How important areusually seekingtreatment forminor ailments RMPs as a source offrom care for rural andNumber of 3152 2404 748householdsinterviewed urban households?RMP 68.3 80.1 30.5Local chemist shop 26.8 18.3 54.1Traditional healers 2.5 2.9 1.2Government 53.8 56.8 44.3facilitiesPrivate qualified 41.2 32.2 70.1doctorGovernment doctor 11.2 8.6 19.7doing privatepracticeOthers 6.9 6.4 8.3* Total is more than 100% due to multiple responses
  7. 7. Table 2: Percentage of affected personsactually sought treatment from RMPs, byper capita expenditure quintiles West Bengal:% of Rural Urban Which householdspersonssought No. of % of No. of % of use RMPs?treatment persons them persons themfor minor treated treated treated treatedailments by byfrom RMPs RMPs RMPsPoorestquintile 1,056 53.69 295 33.90Next 20% 1,083 52.26 309 26.86Next 20% 1,075 53.67 296 15.20Next 20% 1,079 59.50 284 10.92Least poorquintile 991 48.94 266 4.89Total 5,284 53.69 1,450 18.76
  8. 8. West Bengal: How much do households spend out of pocket per provider?Figure 1. Average out-of-pocket payments for treatment of minor ailments, by sources of treatment (in Rs.) 350 339 300 250 231.9 200 RMP KM Public 150 137.5 Private qualified 100 73.574.6 67.8 50 0 Rural Urban
  9. 9. West Bengal: How far do households go to access each provider?Figure 2. Average distance to sources of treatment for minor ailments, (in Kilometers) 6 6 5 4 RMP KM 3 PHC Private clinic 2 1.48 1.34 1 0.68 0.66 0.37 0 Rural Urban
  10. 10. West BengalHousehold reported RMP reported practicespreferences for RMPs1. close location • 90% of RMPs reported2. always available working around the3. cheap clock,….. • 80% provided4. availability of medicines medicines • 85% negotiated delayed5. scope to pay later or payment by installments
  11. 11. Karnataka: RMPs No fixed location or timings…the RMP method. This means going from door to door to give treatment. People will not come to the clinic. (Upper caste RMP with unofficial degree)If we fix timings for our clinic, it’s an insult to the patient. One cannot know when one is going to fall sick. Only if we are ready to give treatment whenever it is needed, we will be known as good doctors. If I sleep for two nights in a week, I am lucky. (Upper caste RMP with no degree)
  12. 12. Karnataka: Setting up practice Main motivations• People contactKnown people were here. They used to come to my uncle for treatment. They told me that there was no doctor here. That is why I came. (Muslim RMP with no degree)• Main reason: good earningsI came here for the sake of filling my stomach as the income is good. (Lower caste RMP with no degree)• No RMP listed helping people as a motivation
  13. 13. Karnataka: RMP CredibilityAlthough not bound by treatment protocols or regulatory standards, RMPs are still answerable to patient demands• Do not collect payments until cure is tangibleWhen I give treatment, in case the patient doesn’t get immediate relief, they behave badly…they trouble me without giving me any money, so I have to keep quiet. (Upper caste RMP with unofficial degree)• Scare tactics when complaints ariseI told him that without my treatment, he had chances of getting typhoid. All doctors do like this because people don’t believe us. (Upper caste RMP with unofficial degree)• Cross-practice & curative commoditiesIf we ask a patient with high fever to drink cumin and ginger solution, they won’t bother to return to us for health. We have to give them injections and tablets. (Upper caste RMP without any degree)
  14. 14. Karnataka: RMP self-restraint• I do not treat serious patients…I can fight with disease, but not with the God of Death (Yama). In case the patient dies, the community will blame us. (RMP with unofficial degree)• Even if I am not confident that I can give treatment, I send serious patients elsewhere. If something goes wrong, we are the ones who will get a bad name. (RMP with unofficial degree)• Reputation matters• RMPs clinical periphery of formal providers• Complimentary vs. competitive
  15. 15. Karnataka: RMP referral• Those less qualified more likely to refer to government vs. private• If it’s a major ailment involving more syringes or expenses, I send them to the government hospital. (RMP with unofficial degree)• Strategic co-production: provider networks share information as well as patients• Financial: RMPs also received kickbacks from Govt & more formal private providers
  16. 16. West Bengal: Do RMPs facilitate timely access to care?• 60 % rural hospitalized persons initiated their treatment with RMPs• And prior to hospitalization they on average undertook treatment for 33 days and spent on average Rs. 1400
  17. 17. Karnataka: RMP fees• Balance of power assumed to be with providers• But ‘free’ care for the poor = delayed payment• Not concession but fait accompliWe cannot demand any fixed amount from the people in the villages. If we insist on a fixed amount, from the next day onwards people will stop coming. Then we will have to sit swatting flies. Our practice will end and we will have to leave. (Muslim RMP without any degree)
  18. 18. Karnataka: RMP fees• Delayed payments ensures continuity of care. Reflects not a one time exchange, but series of interactionsHere many people go for daily wages. When they get earnings they will pay…They treat us like their own family members and we also look after them with the same love. (Muslim RMP without any degree)• Patients inability to pay: daily wage & seasonal employment• Entails financial riskNo doctor will stay for a long time because people are very rough. After taking treatment, they will ask for credit. I have yet to recover Rs. 8,000. From where can I raise this money? (RMP with an unofficial degree)
  19. 19. Karnataka: RMP fees• Securing clients through fee structureFor house visits to regular patients I charge Rs.10, but for others I charge Rs.20. (upper caste RMP without any degree)• Inability to charge known peopleMy earning is not so good after coming here, because here people are well known to me. But I don’t want to practice in other places, as here I am closer to my native place. Therefore I am running transportation now and have lost interest in my RMP practice. (RMP with no degree)
  20. 20. Reciprocity & Fragile Dependency• ‘People contact’: relocation & protection• Communities have few alternativesOnce there was a police complaint against me and the police came. But the village people told the police to leave me alone, because if there is any problem at night, there is no one in this place to help them. (upper caste RMP with an unofficial degree)• But communities can retaliate through rumor and mob violenceOne person had a heart attack and despite my pumping on his chest, he expired. The villagers started spreading rumours that I had done something to kill the patient (upper caste RMP with unofficial degree)Once an RMP doctor handled a delivery case, but the baby could not be saved. As the baby died, people beat the RMP (RMP without any degree)
  21. 21. Conclusions: Informal markets as negotiated socialinstitutions mixing economic and social interests Within these negotiations, trust, reciprocity, reputation emerge, both as a function of familiarity and rapport, as well as a function of vulnerability and a lack of alternatives. This calls for a more nuanced understanding of agency, trust and reciprocity, as not just mythic behaviors or aspirational ideals, but also as fragile and negotiated relationships within the political-economies they inhabit. Quality of market and service provision overall: networks, incentives, vulnerabilities vs. narrow focus on individual provider quality of care in isolation from their social and political economy contexts
  22. 22. Acknowledgements• Families and providers as respondents• Field investigators, NGO and government collaborators• Donors: – West Bengal FHS 1 & 2: DfID – Karnataka Gender and Health Equity Project: SIDA, MacArthur Foundation, Rockefeller Foundation, Ford Foundation• Mentors: Gita Sen, Amar Jesani, Hilary Standing