Members of the Future Health Systems consortium in India took the opportunity of a recent gathering in Kolkata, India on the role of Rural Health Care Providers (RHCPs) in India to launch its new book Health Markets in Asia and Africa: Improving quality and access for the poor. The learning and sharing meeting, which was convened by the Liver Foundation, West Bengal and the Bristol Myers Squibb Foundation from the USA, took place on Sunday, 18 November 2012 at the University of Calcutta.
Within the Indian context, RHCPs (also called RMPs, or rural medical practitioners) provide the majority of primary health care as compared to both formal private sector and public sector providers, especially in rural areas. However, this important part of the Indian health system has been ignored for too long. To begin to address this, the meeting convened over forty participants from diverse backgrounds, including: clinicians from both private and public health care institutions, organisations engaged in capacity building interventions for RMPs, research organisations, academic institutes, donor agencies and the media.
Various participants offered their perspectives on why RMPs remained a taboo topic in Indian politics and academia. For example, Swati Bhattacharya, Editor of Anandabazar Patrika, the local-language daily with the widest circulation, noted that the media’s take on RMP is more like society’s view on child labour: a necessary evil. As such, the media mostly remains non-committal on the topic, while paying lip service to the cause of capacity building for the RMPs. That RMPs do not constitute a voting block does not help either: they are a sort of political orphan. Finally, media coverage on health is more focussed on hospitals, in-patients and sudden deaths, which broadly ignores issues of access to most primary health services.
But working with RMPs is itself a challenge. As Arijita Dutta, a professor at Kolkata University, put it, working with RMPs ‘is essentially a trade off between quality and access’. In other words, it’s impossible to get the level of coverage that these RMPs provide through the formal health sector, but the care that they offer is not always of high quality.
Overall, most participants felt that it is necessary to get a complete understanding about the service delivery quality of the entire health system. Merely singling out RMPs and building their capacity while keeping all the rest the same would not help in sustaining the interventions. They stressed that future research should focus on demand-side dynamics related to what health care users perceive as quality and effective treatment.
Abhijit Vinayak Banerjee, Professor of Economics at MIT and Director of J-PAL in the US, and Gerry Bloom, Research Fellow at the Institute of Development Studies in the UK, launched of the FHS book, hoping that it could inform discussions of the future scope of research to find out what works and what does not in mainstreaming the RMPs to achieve universal coverage in health in the remote areas and for the vulnerable populations.
At the end, key questions raised at the meeting include:
- Training for RMPs was questioned as a way of improving care. This assumes that it is a lack of knowledge that prevents quality care – but there are other incentives (like selling unnecessary drugs) at work.
- As such, are there ways to shift incentives? In other words, is the profit earning potential compatible with desired health outcomes?
- RHCPs should not look more qualified than they are, or it risks legitimising sub-par practices.
- Instead of training, are schemes to increase coverage of formal health providers, like rural doctors schemes, a better alternative? What are the costs and benefits of each approach?