Private rural practitioners, or "quacks," deliver the vast majority of healthcare in many countries around the world; there is a real opportunity to improve the health and well-being of millions of poor families if we can figure out how to best engage with these providers to improve their practice.
I was in India last month and had the opportunity to meet Mr. Nagendra in Jamsaut village - a small village in a rural part of the state of Bihar, in Northern India. Mr. Nagendra is a private healthcare provider who runs a private practice for villagers. He utilizes a mix of practices along with good "bedside manner" that engenders the trust of the people.
Mr. Nagendra's story is an important one because all across India, particularly in the northern states, there are millions of entrepreneurs just like him - about one per village - who are providing the majority of healthcare in the country. In rural India, about 80-90 percent of healthcare is provided by these private local providers with no formal training, often called Rural Medical Practitioners (RMPs).
Rural Medical Practitioners learn medical knowledge either passed down in their family or from apprenticeships with a pharmacy or medical practice. They often memorize the prescribing practices from doctors and then copy them in their practice. RMPs may not know why they are prescribing certain things, but they learn to recognize certain remedies for specific illnesses.
These "quack" doctors provide a range of basic family health services, such as treating pneumonia, diarrhea, or a variety of ailments in adults, such as hypertension and diabetes, as well as newborn conditions such as sepsis. They combine different approaches to medicine, using allopathic (western, evidence-based medicine), aruvedic (Indian traditional healing arts) and herbal treatments. When RMPs recognize that a patient's case is beyond their ability to help, they may refer these difficult cases to more qualified doctors, with whom they often have some sort of reciprocal relationship - "you train me and I'll refer you the cases I can't handle." However, the range of their services is impressive; RMPs often provide antibiotics, intravenous fluids, and contraceptives, and even deliver babies.
For example, Mr. Nagendra learned to be an RMP from a young age from his father, and set off on his own. He established a reciprocal relationship with a local medical doctor who passes along tips about medical practice, and to whom he refers the most difficult cases in return. He also visits regularly with pharmaceutical representatives who provide samples and information about the latest medications.
These doctors may not have the level of qualification that you or I are used to, and they aren't officially recognized as medical professionals, but when someone is sick, they have to go where care is provided and where they feel safe and cared for. And in rural India, that generally means going to a quack.
Unfortunately, the service level provided by RMPs is highly variable - some are better than others. In some cases, they can unintentionally hurt rather than help a patient, due to their lack of deep medical knowledge. And while there are restrictions on their practice - for example, they are not allowed by law to give antibiotics by injection - regulation of their practice is impractical and thus, they are in effect, "above the law." But we cannot ignore the fact that they exist and deliver a substantial portion of the healthcare to these communities. We have to leverage all the resources that are available in order to improve health and save lives, and this means trying to engage with quacks.
Bihar's current government has recognized local providers and is trying to improve their practices. We're working with them to engage RMPs and improve the quality of care, in part by linking them electronically to a network of qualified providers who are available 24/7 to provide advice and facilitate referral when necessary.
The reality is that these providers are entrepreneurs who, whether we like it or not, play an important role in the community. In many cases, if those providers weren't there, people suffering from illness or disease wouldn't go to a doctor at all.