The discreet charm of the private practitionerAccess, utilization & quality of healthcare

in a Delhi slum

Nupur BaruaH.S.R.E. Project

University of Aarhus (Denmark),& ICCIDD (AIIMS, New Delhi)

Delhi: at a glance

Capital city, one of the richest regions in the country

Population: Over 14 million

20 % of total population (approx. 3 mill) in registered slums (large nos. ‘unrecorded’)

34 hospitals (11 - govt., 23 – private)

Dispensaries & health centres: 166

No. of registered medical practitioners (’05-’06): 31,124

DMC estimates 40,000 ‘quacks’ practising in Delhi

The study in Delhi

Study siteJhuggi-jhopdi cluster in S. DelhiPopulation size: 12-15000

majority migrants, wage earners

Selection of respondents25 private practitioners 25 households as in-depth case studies (226 interviews)

Methodology

Unstructured, & later semi-structured interviewsObservations: practitioner-patient interactions in clinicsExit interviews of patients, when possible

ConstraintsRaids on nonqualified PPsMedia reportsDemolition of slums across Delhi

Midan Puri: Living on the edge

Among observed households, at least 1 member from a HH visits a practitioner once every 5 days

>4/5 visit individual private practitioners in jhuggi

Of 471 observed clinical interactions:Majority: Fever, cold, diarrhea, injury, asthma, cough, body pain, weakness, TB, skin problems, mental problems, BP, sexually-transmitted diseasesAbortions, mental health problems, HIV/AIDSRepeated surgery after abortions

Avg. expenditure on healthcare

0

10

20

30

40

50

60

70

80

90

Type of provider

Amou

nt (I

ndia

n Ru

pees

)

Govt facility Qual PP Non-qual PP

Average expenditure of visiting private clinic

< visiting public hospital

Preferred point of treatment

Govt. hospitals 2nd preferred facility after pvt. clinics

In 2/3 of 92 illness episodes practitioner was changed > 4 times

Selection informed by contacts, previous experience

Level of certification – not a deterrent

Overwhelming preference for biomedical treatment medicines/ injections

The private practitioner

Avg. age: 42; predominantly maleLocation: NQPPs – inside, QPPs – outside > 3/4th of NQPPs undergraduate

Avg. 8 years spent in current practice

80 % ‘trained’ outside Delhi

Similar prescriptive behaviour of QPP & NQPP on 1st

consultation

The practice

Proliferation of clinics: Increase in numbers despite raids

Type of practice88% dispensing practitioners, allopathic medicines3/4th do not possess formal degrees

Associations & networksPatient load: 10-35Consultation time: avg. 4 minPayment systemDisplay of certification

The dispensation of cure

Case 1: Antibiotic for infant diarrhea?

4 women carrying infants, all suffering from diarrheaPP takes a thermometer dipped in a small bowl of murky water &

inserts into the mouth of the infant for 1 min, & places it back in the bowl. He gives the same drugs to all: 6 tablets of Norflox TZ informing tablets be ground, mixed with water & fed to the infant twice a day.

When researcher questions him about soiled water & infection, the PP says ‘there is no such concept [of infection] among children’.

He does not possess any degrees, says that his knowledge of ‘ill health and treatment’ (bimari aur illaj) is ‘inherited’

When questioned that Norfloxacin is not recommended for children, the PP asks the researcher to leave his clinic.

Case 2: Injection use

21 cases of fever observed in consecutive sessionsIn all cases, PP uses a disposable injection, & reuses the same on the next patientThe hype over disposable injections is being generated by the media & the ‘english company’ (manufacturers) to increase sales…Was there AIDS when they had no plastic injections? In the olden days nobody died of using the same injection…so it is a myth….11 patients present in the clinic agree with the PP: Angrezi doctors use these tools to excuse them from charging more fees1 case: 13 antibiotic injections for recurrent fever!

Case 3: Why private?Sohanlal, 52 yrs, load-picker in a chemical factoryDiagnosed with TB 3 yr ago, stopped DOTS after 1 monthRA: But why didn’t you continue the free govt. medicines?Sohan: They were bad medicines. I became so sick after I took them, nauseous all the time…I had to stop working...but do they listen to you when you say that? Tablets..big big tablets…that’s all…they shout if you repeat that you can’t take them because you feel more sick…so what if they were free…they treat you like street dogs anyway…I prefer to come herePP: Just because they are poor doesn’t mean they should be treated like thatSohan: When I come here, doctor sahib treats me like a human being, he talks to me with respect…he tells me what food to eat…and these injections are good…I have been working for the past 6 months…I feel ok now

Behind the green curtainThe practitioner

Focus: ‘What the patient wants’Medicines

Approx. 40% cases medicines given sans examinationMostly: Antibiotics, injections with corticosteroids, tranquilizers Explained in detail

Loose medicines: according to colour, size, shapeMedicines in foil: pudiyas according to dosesDescriptions: “for heart”, “for bones”, “for tension”, “for sadness”, “for B.P.”

Doses given according to the amount of money in handDietary prescriptions offered with most medicines

Home visits

How do they diagnose?

Experience: chemists, helpers in doctors’ clinics & hospitals/nursing homes

Press releases: current public health issues

Short-term diplomas in ISM: basic information on human physiology

Raids: before…and after

BeforeSignboards pulled downFake registration numbers hidden

After…People want to assign blame, and it is better to target doctors like us… even big doctors make mistakes…how many times is that reported in the media?There is no point holding a knife….having great degrees….the main thing is are they here?

Knowledge of regulations…

These people lead such hectic, gruelling lives….they should be allowed all medicines, why so many rules about needing prescriptions?

The govt. keeps saying…TB is curable…they give free cure…HIV/AIDS counselling…but when you have these problems, just go to a sarkari [govt.-run]facility, they are treated like keeda [insects]…at least we give them good treatment…it works…so what if the govt. says this is not right…

Aspirations

Very keen to ‘upgrade their skills’ to ‘become better doctors’

Eager to participate in workshops & national programmes

Research team constantly asked, towards the end of the project, whether they would assist in training them, acquiring higher skills

Behind the green curtainThe patient

Who are they?Patients requiring immediate ‘action’, basic careSome chronic patients

What do they want?Best treatment both cost & qualityWork status – main driver return to work as quickly as possibleMore medication = better treatment

‘Hierarchy of competencies’#

‘Big’ hospitals/

pvt. clinics

Bada daktar

Specific illness

Previous experience

Local hierarchies

Individual/ localcategorization

Collective categorization

- Clinics in slum

- Chemist shops

Chota daktar

Does being informed matter?

(Perceived) quality of care drives selection, use of facility health outcomes

Competence in public facilities considered higher BUT

‘We don’t get what we need [in public facilities]’

Long distances, waiting time, registration procedures, disrespect, loss of wages prefer “better care” by NQPPs than “no care” in pub facility

The REAL world…

Even where public system is available, flourishing pvt. sectorPatient demand increasing numbers2`quacks' for every registered practitioner (IMA)

Only ones ‘on the spot’ to provide basic primary care to unreached

Regressive financial burden on most vulnerable for poor quality health careNo legal accountability, few complaints registered

Robin Hoods of the mohallaSeem able to discern complicated cases, & refer when unable to manageAppear to treat patients with dignity, respectCredit, piecemeal medication options: boon for daily-wage earnersSeem highly aware of health epidemics & media campaigns Most important: Time lag?Police raids not the answer – local networks relay information, PPs helped to ‘close down’, continue practice from next day…

A context of shared exclusion

Survival in no-man’s landPractitioners:

Illegal, unauthorized landUnauthorized practice Marginal

Households:No security of tenure, chronic crisis

Why they go to these PPsBoth HHs & PPs:Liminal category – fraught existence, neither here nor there

Way forward?

But HOW…?

Outlawing has not made them, and will not make them go away

What then should we as a collective do?

Responsive public sector Responsible private sector