Training Providers to Improve Rural Health in India
Government of West Bengal to scale up training of informal medical practitioners following study by the World Bank, Liver Foundation, and J-PAL South Asia
Informal health providers with no formal medical training are the mainstay of India’s primary care system, reportedly providing more than 70 percent of primary care. A rigorous evaluation of a training program for informal medical practitioners in West Bengal found that contrary to popular perception, the training led to substantial improvements in both knowledge and practice among informal providers. The results of this study have been published in the October 2016 issue of the journal Science.
The study, co-authored by J-PAL Director Abhijit Banerjee (MIT), Abhijit Chowdhury (Liver Foundation), Jishnu Das (World Bank), and Reshmaan Hussam (Yale), evaluated the benefits of a nine-month long training program on the quality of care provided by informal health providers.
Why is this important?
Informal practitioners, who operate without formal medical training, form a majority of India’s rural healthcare workforce, addressing patient healthcare needs where government sources may be less accessible. As the source of primary care, these providers offer a range of services. They treat patients with conditions that can be managed in a primary care setting, refer patients with serious conditions to higher level care, and diagnose and manage patients with chronic conditions. However, it is contentious whether these practitioners should be integrated with the health system, and if so, what might be the best way.
On the one hand, the Indian Medical Association argues that any kind of training legitimizes an illegal activity. On the other hand, it has been argued that training can improve their quality of medical attention and act as a stopgap solution to rural India’s acute shortage of trained healthcare personnel.
“This study provides robust evidence on this ongoing debate and shows that medical training can be an effective strategy for improving the quality of care provided by informal providers. This study is not only relevant for West Bengal but for other states too, such as Madhya Pradesh and Uttar Pradesh; as the structure of the informal provider market is often found to be similar – both in terms of their widespread presence in the community and the knowledge gaps they face.”
— Abhijit Banerjee
The nine-month training program for rural informal practitioners, designed and implemented by Liver Foundation in Birbhum, West Bengal, aimed to improve the practices of informal providers along the various dimensions of services offered by them. Over the 72 classroom sessions, taught by certified medical doctors, the structured curriculum covered topics such as physiology, drug use and abuse, emergency medical care, childcare and antenatal care, as well as public health programs.
Using a randomized evaluation methodology, researchers randomly selected 152 of the 304 informal providers from 203 villages in Birbhum to participate in the training program, while the remaining providers were offered the training program after the completion of the study. Using unannounced standardized patients (‘mystery’ patients) and clinical observations, researchers assessed the impact on the training on informal providers’ clinical practice. Further, researchers benchmarked these practices with those of public health providers in the same area.
The study found evidence that training informal providers did not worsen care, as has been argued by representatives of the Indian Medical Association. On the contrary, the study found that those offered the training were more likely to correctly manage a case, as well as complete recommended checklists of history questions and examinations. In fact, the training closed half the gap in correct case management relative to the public sector.
However, the training did not lead to a decline in the use of unnecessary medicines, antibiotics or injections among providers who were trained. Nonetheless, both trained and untrained informal providers were less likely to give unnecessary medicines and antibiotics relative to doctors in the public sector. Finally, the training increased the patient load of the provider, and it is estimated that the resultant increase in revenue would allow the informal practitioners to recover the cost of the training in anywhere between 66 to 210 days.
The low costs of training imply that permanently hiring 11 additional fully trained providers with medical degrees into the public sector would be as costly as training 360 informal providers every year through this program.
The Government of West Bengal issued an order last November to introduce a similar training program state-wide for informal practitioners, with the Liver Foundation acting as a resource and knowledge hub. A program to train the first batch of 2,000 practitioners over a six-month period is in the process of being rolled out across 35 centers. Rural healthcare providers will be trained in batches of 50 by nurses teaching at nursing-training centers across the state.
Abhijit Banerjee, Professor of Economics at MIT, co-founder J-PAL, and co-author lauded the decision by state and added “I hope that the West Bengal government serves as a role model for other governments in terms of funding research to determine whether a program works and then using the evidence generated to inform scale-up decisions.”