Lack of access to public health care is not the only reason why quacks — informal private health-care providers without any formal medical education — continue to flourish in rural India. Most private providers, the bulk of whom lack formal medical qualifications, “exerted significantly higher effort than public providers” and “recommend correct treatments equally often.”
These are the findings of an audit conducted in rural Madhya Pradesh, and published in the American Economic Review (December 2016).
Metrics and findings
For the study, Standardised Patients (SP) or highly trained “fake patients”, were coached to accurately present symptoms like “normal patients” for three different conditions: unstable angina, asthma, and dysentery in a child. They made 1,100 unannounced visits to a representative sample of public and private health facilities in rural Madhya Pradesh to collect data on various metrics. Four major findings were reported.
First, private providers — 70 per cent of whom didn’t have any formal training — spent 1.5 minutes more with patients when compared to public providers. Further, while public providers completed around 15.3 per cent of the checklist which comprised questions and examinations which are considered essential for reaching a correct diagnosis, private counterparts completed 22.30 per cent of the list (7.4 percentage points more), which indicated a higher effort. Note that 30 per cent of the private providers did have formal training. Of the rest who were unqualified and who would be classified as quacks as per norms of the Medical Council of India, a majority reported having received some training, the most common form being an assistant in another doctor’s practice.
Second, both were equally likely to pronounce a correct diagnosis. Data show that 26 per cent of public providers gave a diagnosis, of which 15 per cent was correct. In the private sector, 43 per cent gave a diagnosis of which 13.5 per cent was correct.
The third finding raises concerns: doctors who serve in public facilities as well as in their private clinics, perform better in the latter. The study found that the “same doctors spent more time with SPs, completed more items on the checklist, and were also more likely to offer a correct treatment in their private practices, relative to their public practices”.
Patient cost
Fourth, the per-patient cost of the public health-care system was found to be at least four times when compared to a private system. According to estimates by the study’s authors, the cost per patient interaction in the public sector is around Rs.240 — billed not to the patient but to the exchequer — whereas the per consultation fee was Rs.51 in the private sector. However, as the findings indicate, the higher cost does not translate into better outcomes.
These results may not generalise beyond primary care to tertiary care or for more critical illnesses, but it is still quite crucial as primary care serves as the first step in identifying the need to go to a hospital. For instance, in the case of angina — one of the three conditions for which SPs were coached — it is difficult for patients to know by themselves, without proper medical advice, if there was a need to go to the hospital.
The results suggest that the quality of the public system of health-care delivery is constrained by a lack of enforcement of administrative accountability and inadequate incentives. For instance, doctors are often reported to be missing from the primary health-care centres. These limitations should be taken into consideration as the policy debate focusses on increasing spending and improving access to publicly provided health care. Plus, while there is a resistance to train and provide legitimacy to unqualified private providers, the study notes that “the marginal returns to better training and credentialing may be higher for private health-care providers who have stronger incentives for exerting effort.”
Irrespective of the sector, the study says, “patients in our setting have few good options for health care”.
