Two Indias: The structure of primary health care markets in rural Indian villages with implications for policy

Financial barriers and inequity in medical education in India: challenges to training a diverse and representative healthcare workforce

India has been historically challenged by an insufficient and heterogeneously clustered distribution of healthcare infrastructure. While resource-limited healthcare settings, such as major parts of India, require multidisciplinary approaches for improvement, one key approach is the recruitment and training of a healthcare workforce representative of its population. This requires overcoming barriers to equity and representation in Indian medical education that are multi-faceted, historical, and rooted in inequality. However, literature is lacking regarding the financial or economic barriers, and their implications on equity and representation in the Indian allopathic physician workforce, which this review sought to describe. Keyword-based searches were carried out in PubMed, Google Scholar, and Scopus in order to identify relevant literature published till November 2023. This state-of-the-art narrative review describes the existing multi-pronged economic barriers, recent and forthcoming changes deepening these barriers, and how these may limit opportunities for having a diverse workforce. Three sets of major economic barriers exist to becoming a specialized medical practitioner in India - resources required to get selected into an Indian medical school, resources required to pursue medical school, and resources required to get a residency position. The resources in this endeavor have historically included substantial efforts, finances, and privilege, but rising barriers in the medical education system have worsened the state of inequity. Preparation costs for medical school and residency entrance tests have risen steadily, which may be further exacerbated by recent major policy changes regarding licensing and residency selection. Additionally, considerable increases in direct and indirect costs of medical education have recently occurred. Urgent action in these areas may help the Indian population get access to a diverse and representative healthcare workforce and also help alleviate the shortage of primary care physicians in the country. Discussed are the reasons for rural healthcare disparities in India and potential solutions related to medical education.

Exploring the preferences of traditional versus Western medicine in the Spiti Valley region of India: A qualitative approach

Background

Traditional healing practices are prevalent in rural and mountainous areas of India where Western medicine is not accessible. WHO guidelines recommend integration of traditional and Western medicine to meet rural primary care needs. We explored three dimensions of rural patients' decision-making and satisfaction with their medical care: pregnancy-related concerns, pediatric care for children under five, and acute injuries.

Methods

We conducted a qualitative study using a phenomenological approach in India's Spiti Valley between August and October 2023. Sixteen individuals, age 18 years and older, participated in one-on-one interviews. The interviews were transcribed from Hindi into English, reviewed for accuracy by a native speaker, and imported into Dedoose software. Data were analyzed using inductive coding.

Findings

Multiparous women aged 35-44 were concerned about pregnancy complications, leading them to choose Western medicine despite access and cost barriers. Pediatric illness requiring urgent care at night was a concern for women with children under five. Those in the injuries group reported having to travel for care beyond basic first aid. Overall, concerns were about limited access to some services locally, as well as costs of travel, medical procedures, and medications when services were obtained beyond the local area.

Interpretation

All participants considered their traditional healer their first point of contact for medical care. A number of Western medical services were not available locally. These findings suggest a need to strengthen access to and integration of Western and traditional medical care in rural settings in India.

Exploring the risks of fragmentation in health care markets - An analysis of inpatient care in Georgia

Private providers play an important role in health systems in low-and middle-income countries. In many such contexts, markets are characterized by a high number of relatively small private facilities. The potential risks from highly concentrated healthcare markets are well-researched, and feature in the "Theories of Harm" investigated by competition regulators. However, there is limited evidence on markets that exhibit substantial harms as a result of very low concentration. This paper explores the risks associated with such market fragmentation, drawing on the example of Georgia, which has a largely privatized provider network. We used a mixed-method study design to analyze the inpatient market in Georgia. Market structure was described using administrative data on bed capacity and discharge numbers and geo-location data on travel time between facilities. The implications of the market structure were explored through in-depth interviews (n = 35) with policymakers, healthcare managers, and local experts and an anonymous online survey of similar groups (n = 97). Georgia's inpatient sector is characterized by a high number of small hospitals in terms of bed numbers and inpatient volumes, mitigated to a limited degree by the presence of provider networks. Travel time to the 3rd nearest competitor was extremely short, ranging from 3 to 5 min in big cities to 10 min in small towns and 33 min in remote locations. The fragmented nature of the market, together with inadequate regulatory and purchasing mechanisms, was argued to exacerbate challenges in the availability and competence of clinical staff, while the financial challenges caused by intense competition encouraged wasteful marketing, harmful cost-cutting measures, and demand inducement. We present "Theories of Harm" from market fragmentation, and argue that an effective policy response requires market-shaping activities using regulatory, financing, and purchasing mechanisms to encourage appropriate levels of market consolidation and so enhance quality, efficiency, and effective governance.

Influences on use of antibiotics without prescription by the public in low- and middle-income countries: a systematic review and synthesis of qualitative evidence

Objectives

Self-medication with antibiotics is common practice in many low- and middle-income countries (LMIC). This review synthesizes the qualitative evidence on influences on perceptions and practices in relation to self-medication by the public with antibiotics in LMIC.

Methods

A systematic search was conducted of relevant medical, international and social science databases. Searching, screening, data extraction and quality appraisal followed standard methods. A meta-ethnographic approach was used for synthesis, starting with translation of studies and using a line-of-argument approach to develop the final themes.

Results

The search identified 78 eligible studies. Antibiotics were understood as a powerful, potentially dangerous but effective medicine for treating infections. This perception was strongly influenced by the common experience of being prescribed antibiotics for infections, both individually and collectively. This contributed to an understanding of antibiotics as a rational treatment for infection symptoms that was sanctioned by medical authorities. Accessing antibiotics from medical professionals was often difficult logistically and financially. In contrast, antibiotics were readily available over the counter from local outlets. People viewed treating infection symptoms with antibiotics as rational practice, although they were concerned about the risks to the individual and only took them when they believed they were needed.

Conclusions

A new model to explain self-medication with antibiotics is presented. This uses the socio-ecological model to integrate influences that operate at individual, community and wider socioeconomic levels, drawing on theories of medical authority and the medicalization and commercialization of health. Interventions to reduce overuse of antibiotics in LMIC need to address both clinical practice and community self-medication practices together.

The state of primary health care in south Asia

The south Asian region (SAR) is home to 1·74 billion people, corresponding to 22% of the global population. The region faces several challenges pertaining to changing epidemiology, rapid urbanisation, and social and economic concerns, which affect health outcomes. Primary health care (PHC) is a cost-effective strategy to respond to these challenges through integrated service delivery, multi-sectoral action, and empowered communities. The PHC approach has historically been an important cornerstone of health policy in SAR countries. However, the region is yet to fully reap the benefits of PHC-oriented health systems. Our introductory paper in this Lancet Series on PHC in the SAR describes the existing PHC delivery structure in five SAR nations (ie, Bangladesh, India, Nepal, Pakistan, and Sri Lanka) and critically appraises PHC performance to identify its enablers and barriers. The paper proposes investing in a shared culture of innovation and collaboration for revitalisation of PHC in the region.

Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

Challenges and opportunities in strengthening primary mental healthcare for older people in India: a qualitative stakeholder analysis

BACKGROUND

Primary mental healthcare (PMHC) allows for complex mental health issues in old age to be addressed. India has sought to improve PMHC through legislation, strategies and programmes. This study analyses the challenges and opportunities involved in strengthening PMHC for older persons in India from the perspectives of key stakeholders.

METHODS

Semistructured interviews were conducted with 14 stakeholders selected from the PMHC system in India and analysed using thematic analysis. First, the analysis was organizationally structured in accordance with the six WHO mental health system domains: (1) policy and legislative framework, (2) mental health services, (3) mental health in primary care, (4) human resources, (5) public information and links to other sectors, and (6) monitoring and research. Second, for each building block, challenges and opportunities were derived using inductive coding.

RESULTS

This study highlights the numerous challenges that may be encountered when attempting to strengthen age-inclusive PMHC. Among these challenges are poor public governance, a lack of awareness and knowledge among policy-makers and other stakeholders, and existing policies that make unrealistic promises to weak primary healthcare (PHC) structures with an excessive focus on medicalizing mental health problems. Thus, the mental health system often fails to reach vulnerable older people through PHC. Established approaches to comprehensive, family- and community-oriented PHC support attempts to strengthen intersectoral approaches to PMHC that emphasize mental health promotion in old age. Targeting the PHC workforce through age-inclusive mental health education is considered particularly necessary. Experts further argue that adequate monitoring structures and public spending for mental health must be improved.

CONCLUSIONS

In this study, we aim to elaborate on the mental healthcare developments that may serve to achieve equity in access to mental healthcare in India. Coordinated and collaborative efforts by public and private stakeholders involved in the care of older persons, both with and without lived mental health experiences, as well as their families and communities, are necessary to bring the vision of those policies for PMHC to fruition. The findings presented in this study can also inform future research, policies and practice in other low- and middle-income countries.

Health practitioner regulation and national health goals

The role of health practitioner regulation in ensuring patient safety is well recognized. Less recognized is the role of regulation in addressing broader health system priorities. These goals include managing the costs, capacities and distribution of health professional education institutions; ensuring the competence and equitable distribution of health workers; informing workforce planning and mobilization; enabling the use of digital technologies; and addressing challenges related to the international mobility of health workers. Even where health practitioner regulation is designed to advance these goals, important gaps exist between the potential of regulatory systems and their performance. The response to the coronavirus disease 2019 (COVID-19) pandemic led many countries to introduce regulatory changes to allow more flexibility and innovations in the mobilization of health practitioners. Building on this experience, we need to critically re-examine health practitioner regulatory systems to ensure that these systems support rather than impede progress towards national health goals. We discuss the role of health practitioner regulation in contemporary health systems, highlighting recent regulatory reforms in selected countries, including during the COVID-19 pandemic. We identify the importance of dynamic, effective and flexible health practitioner regulatory systems in progress towards universal health coverage and health security.

The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan

Incentivisation of general practitioners (GPs) by pharmaceutical companies is thought to affect prescribing practices, often not in patients' interest. Using a Bourdieusian lens, we examine the socially structured conditions that underpin exchanges between pharmaceutical companies and GPs in Pakistan. The analysis of qualitative interviews with 28 GPs and 13 pharmaceutical sales representatives (PSRs) shows that GPs, through prescribing medicines, met pharmaceutical sales targets in exchange for various incentives. We argue that these practices can be given meaning through the concept of 'field' - a social space in which GPs, PSRs, and pharmacists were hierarchically positioned, with their unique capacities, to enable healthcare provision. However, structural forces like the intense competition between pharmaceutical companies, the presence of unqualified healthcare providers in the healthcare market, and a lack of regulation by the state institutions produced a context that enabled pharmaceutical companies and GPs to use the healthcare field, also, as space to maximise profits. GPs believed the effort to maximise incomes and meet socially desired standards were two key factors that encouraged profit-led prescribing. We conclude that understanding the healthcare field is an important step toward developing governance practices that can address profit-led prescribing.

Of informal practitioners of biomedicine. The interplay of medicine, economy and society in India

Instead of diminishing with the spectacular advancement of medical expertise in the country , unqualified biomedical practice in India has been strengthened by the growth of the pharmaceutical production in the twenty first century. In public health discourse, the view that the informal health practitioners have to be punished and abolished has been countered by the recommendation that they could be trained and incorporated in primary health care where public health amenities are inadequate. The quality of care provided by the informal health care practitioners has also been subject to clinical assessment based on standardized patient vignettes. Based on a sociological approach, this paper examines the time line of chronically ill patients under lived conditions to arrive at an understanding of the role of informal health practitioners in long term treatment and highlights the setbacks. METHODS: This paper draws on 253 household surveys from two villages in Madhya Pradesh, in depth interviews with four unqualified practitioners in the area, twenty five unstructured interviews of chronic patients, twenty five structured interviews on the cases of untimely death and FGDs with health workers in 2021. CONCLUSION: Informal health care practitioners offer consultation cum dispensing of medicines and are the primary source of biomedical care in the remote study area without any public transport. But they are 'for profit' economic actors who are ill-equipped to handle chronic diseases. What sets them aside from the qualified private doctors in the town is their social obligation to balance their profit motive with the ethics of proximity and neighborly ties with the villagers amidst whom they reside. These features of the market and community place the informal health care practitioners at the cusp of economy and society and defy simple binaries that they are either crooks or assets.

Tuberculosis diagnosis and management in the public versus private sector: a standardised patients study in Mumbai, India

BACKGROUND

There are few rigorous studies comparing quality of tuberculosis (TB) care in public versus private sectors.

METHODS

We used standardised patients (SPs) to measure technical quality and patient experience in a sample of private and public facilities in Mumbai.

RESULTS

SPs presented a 'classic, suspected TB' scenario and a 'recurrence or drug-resistance' scenario. In the private sector, SPs completed 643 interactions. In the public sector, 164 interactions. Outcomes included indicators of correct management, medication use and client experience. Public providers used microbiological testing (typically, microscopy) more frequently, in 123 of 164 (75%; 95% CI 68% to 81%) vs 223 of 644 interactions (35%; 95% CI 31% to 38%) in the private sector. Private providers were more likely to order chest X-rays, in 556 of 639 interactions (86%; 95% CI 84% to 89%). According to national TB guidelines, we found higher proportions of correct management in the public sector (75% vs 35%; (adjusted) difference 35 percentage points (pp); 95% CI 25 to 46). If X-rays were considered acceptable for the first case but drug-susceptibility testing was required for the second case, the private sector correctly managed a slightly higher proportion of interactions (67% vs 51%; adjusted difference 16 pp; 95% CI 7 to 25). Broad-spectrum antibiotics were used in 76% (95% CI 66% to 84%) of the interactions in public hospitals, and 61% (95% CI 58% to 65%) in private facilities. Costs in the private clinics averaged rupees INR 512 (95% CI 485 to 539); public facilities charged INR 10. Private providers spent more time with patients (4.4 min vs 2.4 min; adjusted difference 2.0 min; 95% CI 1.2 to 2.9) and asked a greater share of relevant questions (29% vs 43%; adjusted difference 13.7 pp; 95% CI 8.2 to 19.3).

CONCLUSIONS

While the public providers did a better job of adhering to national TB guidelines (especially microbiological testing) and offered less expensive care, private sector providers did better on client experience.

Informal Providers-Ground Realities in South Asian Association for Regional Cooperation Nations: Toward Better Cancer Primary Care: A Narrative Review

PURPOSE

South Asian Association for Regional Cooperation (SAARC) nations are a group of eight countries with low to medium Human Development Index values. They lack trained human resources in primary health care to achieve the WHO-stated goal of Universal Health Coverage. An unregulated service sector of informal health care providers (IPs) has been serving these underserved communities. The aim is to summarize the role of IPs in primary cancer care, compare quality with formal providers, quantify distribution in urban and rural settings, and present the socioeconomic milieu that sustains their existence.

METHODS

A narrative review of the published literature in English from January 2000 to December 2021 was performed using MeSH Terms Informal Health Care Provider/Informal Provider and Primary Health Care across databases such as Medline (PubMed), Google Scholar, and Cochrane database of systematic reviews, as well as World Bank, Center for Global Development, American Economic Review, Journal Storage, and Web of Science. In addition, citation lists from the primary articles, gray literature in English, and policy blogs were included. We present a descriptive overview of our findings as applicable to SAARC.

RESULTS

IPs across the rural landscape often comprise more than 75% of primary caregivers. They provide accessible and affordable, but often substandard quality of care. However, their network would be suitable for prompt cancer referrals. Care delivery and accountability correlate with prevalent standards of formal health care.

CONCLUSION

Acknowledgment and upskilling of IPs could be a cost-effective bridge toward universal health coverage and early cancer diagnosis in SAARC nations, whereas state capacity for training formal health care providers is ramped up simultaneously. This must be achieved without compromising investment in the critical resource of qualified doctors and allied health professionals who form the core of the rural public primary health care system.

Can Self-Administered Rapid Antigen Tests (RATs) Help Rural India? An Evaluation of the CoviSelf Kit as a Response to the 2019–2022 COVID-19 Pandemic

This paper evaluates India’s first officially approved self-administered rapid antigen test kit against COVID-19, a device called CoviSelf. The context is rural India. Rapid antigen tests (RATs) are currently popular in situations where vaccination rates are low, where sections of the community remain unvaccinated, where the COVID-19 pandemic continues to grow and where easy or timely access to RTPCR (reverse transcription-polymerase chain reaction) testing is not an option. Given that rural residents make up 66% of the Indian population, our evaluation focuses on the question of whether this self-administered RAT could help protect villagers and contain the Indian pandemic. CoviSelf has two components: the test and IT (information technology) parts. Using discourse analysis, a qualitative methodology, we evaluate the practicality of the kit on the basis of data in its instructional leaflet, reports about India’s ‘digital divide’ and our published research on the constraints of daily life in Indian villages. This paper does not provide a scientific assessment of the effectiveness of CoviSelf in detecting infection. As social scientists, our contribution sits within the field of qualitative studies of medical and health problems. Self-administered RATs are cheap, quick and reasonably reliable. Hence, point-of-care testing at the doorsteps of villagers has much potential, but realising the benefits of innovative, diagnostic medical technologies requires a realistic understanding of the conditions in Indian villages and designing devices that work in rural situations. This paper forms part of a larger project regarding the COVID-19 pandemic in rural India. A follow-up study based on fieldwork is planned for 2022–2023.

Does high workload reduce the quality of healthcare? Evidence from rural Senegal

There is a widely held perception that staff shortages in low and middle-income countries (LMICs) lead to excessive workloads, which in turn worsen the quality of healthcare. Yet there is little evidence supporting these claims. We use data from standardised patient visits in Senegal and determine the effect of workload on the quality of primary care by exploiting quasi-random variation in workload. We find that despite a lack of staff, average levels of workload are low. Even at times when workload is high, there is no evidence that provider effort or quality of care are significantly reduced. Our data indicate that providers operate below their production possibility frontier and have sufficient capacity to attend more patients without compromising quality. This contradicts the prevailing discourse that staff shortages are a key reason for poor quality primary care in LMICs and suggests that the origins likely lie elsewhere.

Measuring catastrophe in paying for healthcare: A comparative methodological approach by using National Sample Survey, India

Healthcare expenditure significantly varies among various segments of the population. The appropriate measures of catastrophic health expenditure (CHE) will help to unravel the real burden of spending among households. Present study provides a link between the theoretical insights from Grossman's model and various methodological approaches for the estimation of CHE by using data from the three rounds of nationally representative Consumer Expenditure Surveys, India. Statistical analysis has been carried out by using multivariate logistic regression to identify the major determinants of CHE. Findings indicate that the occurrence of CHE has increased during 1993-2012. Rural residents and households with varying age composition such as with higher numbers of children and elderly were at higher risk. Economic status is significantly associated with CHE and increased demand for healthcare. The measurements differ as per the methodological approaches of CHE and definition of household's capacity to pay. Approach-based variations in the results can be of key importance in determining trends and magnitude in CHE. Despite these variations in measurements, study finds a limited incidence of CHE among the disadvantaged segment of the population though a greater share was devoted to health expenditure in recent years. Better risk pooling mechanism is required to address the healthcare needs of the disadvantaged segment such as elderly, children, poor and rural population in India.

Pandemic response in pluralistic health systems: a cross-sectional study of COVID-19 knowledge and practices among informal and formal primary care providers in Bihar, India

OBJECTIVES

Responding to pandemics is challenging in pluralistic health systems. This study assesses COVID-19 knowledge and case management of informal providers (IPs), trained practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) and Bachelor of Medicine, Bachelor of Surgery (MBBS) medical doctors providing primary care services in rural Bihar, India.

DESIGN

This was a cross-sectional study of primary care providers conducted via telephone between 1 and 15 July 2020.

SETTING

Primary care providers from 224 villages in 34 districts across Bihar, India.

PARTICIPANTS

452 IPs, 57 AYUSH practitioners and 38 doctors (including 23 government doctors) were interviewed from a census of 1138 primary care providers used by community members that could be reached by telephone.

PRIMARY OUTCOME MEASURES

Providers were interviewed using a structured questionnaire with choice-based answers to gather information on (1) change in patient care seeking, (2) source of COVID-19 information, (3) knowledge on COVID-19 spread, symptoms and methods for prevention and (4) clinical management of COVID-19.

RESULTS

During the early days of the COVID-19 pandemic, 72% of providers reported a decrease in patient visits. Most IPs and other private primary care providers reported receiving no COVID-19 related engagement with government or civil society agencies. For them, the principal source of COVID-19 information was television and newspapers. IPs had reasonably good knowledge of typical COVID-19 symptoms and prevention, and at levels similar to doctors. However, there was low stated compliance among IPs (16%) and qualified primary care providers (15% of MBBS doctors and 12% of AYUSH practitioners) with all WHO recommended management practices for suspect COVID-19 cases. Nearly half of IPs and other providers intended to treat COVID-19 suspects without referral.

CONCLUSIONS

Poor management practices of COVID-19 suspects by rural primary care providers weakens government pandemic control efforts. Government action of providing information to IPs, as well as engaging them in contact tracing or public health messaging can strengthen pandemic control efforts.

What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India

In many low- and middle-income countries, providers without formal training are an important source of antibiotics, but may provide these inappropriately, contributing to the rising burden of drug resistant infections. Informal providers (IPs) who practise allopathic medicine are part of India's pluralistic health system legacy. They outnumber formal providers but operate in a policy environment of unclear legitimacy, creating unique challenges for antibiotic stewardship. Using a systems approach we analysed the multiple intrinsic (provider specific) and extrinsic (community, health and regulatory system and pharmaceutical industry) drivers of antibiotic provision by IPs in rural West Bengal, to inform the design of community stewardship interventions. We surveyed 291 IPs in randomly selected village clusters in two contrasting districts and conducted in-depth interviews with 30 IPs and 17 key informants including pharmaceutical sales representatives, managers and wholesalers/retailers; medically qualified private and public doctors and health and regulatory officials. Eight focus group discussions were conducted with community members. We found a mosaic or bricolage of informal practices conducted by IPs, qualified doctors and industry stakeholders that sustained private enterprise and supplemented the weak public health sector. IPs' intrinsic drivers included misconceptions about the therapeutic necessity of antibiotics, and direct and indirect economic benefits, though antibiotics were not the most profitable category of drug sales. Private doctors were a key source of IPs' learning, often in exchange for referrals. IPs constituted a substantial market for local and global pharmaceutical companies that adopted aggressive business strategies to exploit less-saturated rural markets. Paradoxically, the top-down nature of regulations produced a regulatory impasse wherein regulators were reluctant to enforce heavy sanctions for illegal sales, fearing an adverse impact on rural healthcare, but could not implement enabling strategies to improve antibiotic provision due to legal barriers. We discuss the implications for a multi-stakeholder antibiotic stewardship strategy in this setting.