Are India’s quacks the answer to its shortage of doctors?

Unqualified practitioners who pose as qualified doctors and administer potentially dangerous treatments to patients—so called quacks—are numerous throughout India.

But, owing to a lack of political will state governments and police aren’t taking action, say officials from state medical councils, who are grappling with complaints against these practitioners. “There is no political will” to deal with quacks, because they are popular among the electorate, Anil Bansal, former chairman of the anti-quackery cell of Delhi Medical Council, told The BMJ.

The Indian Medical Council Act of 1956 punishes this with up to a year in prison and a fine of Rs1000 (£10; €14; $15)—a weak penalty, argues Bansal. Quacks can also be tried under provisions of the Indian Penal Code, which punishes impersonation and cheating with up to seven years in prison. Several studies of unqualified practitioners have found that drug companies supply drug samples to quacks, leading to indiscriminate prescriptions.

How many unqualified doctors?

According to regional surveys, 70% of healthcare providers in rural India have no formal medical training. “Suppose one qualified doctor has a private practice. He has someone called a compounder or a helper. When the helper masters a few medicines, he starts working in an area where there is no other doctor,” GS Grewal, president of the Punjab Medical Council, told The BMJ.

quacks 2

The indian government has repeatedly shown its inability to raid illegal clinics citing dearth of government vehicles (http://bit.ly/1VmJxAR)

Quacks proliferate for two main reasons. Firstly, India simply does not have enough physicians, at 0.7 doctors for every 1000 people. India’s doctors do not wish to practise in rural areas because of the lack of critical infrastructure, Bansal says.

Secondly, they enjoy the patronage of local political leaders in rural areas because they are the only medical workers available, and they cultivate strong relationships with their clients. Such popularity and political support make it difficult to take action against them.

Government inaction and public support

In May 2014, reacting to this inaction, the High Court of Delhi approved an order requiring local police officers to conduct monthly raids in each of Delhi’s 13 districts to bring unqualified doctors to the notice of the Delhi Medical Council. “Until today, more than one year and two months later, hardly any raids have been conducted. Police are not cooperating at all,” Bansal told The BMJ in July 2015. Of about 250 doctors that the council flagged to the police in response to public complaints last year, very few have had cases lodged against them, Bansal said.

The damage caused by quacks is serious, say the members of state medical councils. Quacks frequently overuse I.V drugs because these fetch them higher fees from patients. The poor state of Indian public hospitals and the high cost of private hospitals forces poor patients to see quacks. They enjoy close relationships with people, providing them with emergency care and house calls for low fees, while government doctors don’t have the time or resources to do the same. As a result, complaints against unqualified practitioners are rarely registered.

Can quacks be trained?

A study led by Jishnu Das, lead economist in the development research group at the World Bank, found that qualified doctors were only about 30.9 percentage points more likely than unqualified healthcare providers to treat three diseases correctly. Das and colleagues sent 22 coached patients to present symptoms of unstable angina, asthma, and dysentery to a cross section of unqualified and qualified doctors in six villages of Madhya Pradesh.

The researchers found that although qualified doctors were more likely than unqualified doctors to treat diseases correctly, they were also more likely to prescribe unnecessary antibiotics—public and private doctors with MBBS qualifications prescribed antibiotics for unstable angina and asthma 48% and 45% of the time, respectively, whereas informal providers did so only about 28% of the time. This finding challenges the common perception that only quacks overtreat patients and shows that “bad practices are more likely to come from an MBBS doctor,” says Das.

Das and Chowdhury advocate a system of training unqualified doctors to administer basic care to patients and to refer patients with more difficult problems to qualified doctors. “People living in rural areas cannot reach out to big doctors in the city when they need them. [Unqualified healthcare providers] with virtually no training and some exposure to doctors, have been at the side of people in time of need.”

Multiple cadres of healthcare

Experiments in such training are already taking place in India. The Liver Foundation and the Foundation for Health Action, non-profit organisations based in West Bengal, and the World Health Partners, based in Delhi, train unqualified practitioners to treat uncomplicated diseases such as urinary tract infections and diarrhoea.

A few state governments are considering training unqualified healthcare workers to improve rural healthcare. These training programmes require students to stop misrepresenting themselves as doctors and to stop prescribing schedule H and X drugs, which only qualified doctors, can prescribe.

“For serious conditions like unstable angina and respiratory distress, we tell them to send the patient to the nearest hospital or healthcare provider after they are stabilised. The idea is that nobody dies in a village,” says Chowdhury, who runs the Liver Foundation’s programme.

Yet such programmes have met stiff resistance from medical councils, with doctors arguing that short training courses will only produce more quacks. Kishor Taori, president of the Maharashtra Medical Council adds that although such ideas seem good in theory, it would be difficult in practice to ensure that unqualified medical practitioners stick to their job description. “They will push the boundaries and start treating themselves as primary physicians,” he says.

Proponents of this theory, however, say that such opposition from doctors ignores the reality that there aren’t enough qualified practitioners in rural India. “What is the other option?” Das asks. “If you shut down informal providers, you will shut down 80% of our medical workforce.”

Modified from here.

Categories: Asia, Healthcare, India, News

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