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.

1. Quality of underground health care: A
case study of Indian RMPs
Barun Kanjilal
Indian Institute of Health Management Research
July 9, 2011

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. 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. 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. Sources of treatment (% of ailing persons)
NGO
2%
Private
formal
22%
Govenrment
12%
RMP
64%

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. Major Threats
¡ Indiscriminate use of antibiotics
¡ Minor / major surgeries
¡ Gradual penetration to inpatient care
market
7

8. Some evidences
% of RMPs prescribing drugs in case of
normal delivery
Ergometrine
No medicine
% of RMPs
Refer
Oxytocin inj
0% 20% 40% 60% 80% 100%
8

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. 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. Referral practice
% of ailing children ¡ Dubious referral practice
(17000)
Rest
19.00%
¡ An underground nexus
Referre
8.90% with local private
Died hospitals / clinics
3.10%
¡ Usually refer when
situation completely goes
Cured
out of control
69.00%

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. Thank you