The impact of training informal health care providers in India: A randomized controlled trial
Delivering health care to mystery patients Many families in developing countries do not have access to medical doctors and instead receive health care from informal providers. Das et al. used "mystery" patients (trained actors) to test whether a 9 month training program improved the quality of care delivered by informal providers in West Bengal (see the Perspective by Powell Jackson) The patients did not identify themselves to the providers and were not told which providers had participated in the training program. The results of this blinded assessment showed that medical doctors delivered better care than informal providers but that the training program closed much of the gap. Science, this issue p. 80; see also p. 34 Training helped informal providers deliver better care for angina, diarrhea, and asthma. [Also see Perspective by Powell Jackson] INTRODUCTION In rural India, health care providers without formal medical training and self declared "doctors" are sought for up to 75% of primary care visits. The frequent use of such informal providers, despite legal prohibitions on their practices, in part reflects the absence of trained medical professionals in rural locations. For example, in the majority of villages in the Indian states of Rajasthan, Madhya Pradesh, and West Bengal, informal providers are the only proximate source of health care. RATIONALE The status of informal providers in the complex Indian health system is the subject of a highly charged debate among policy makers and the medical establishment. The official view of the establishment is that fully trained providers are the only legitimate source of health care, and training informal providers legitimizes an illegal activity and worsens population health outcomes. In contrast, given the lack of availability of trained providers and the fact that informal providers are tightly linked with the communities that they serve, others believe that training can serve as a stopgap measure to improve health care in tandem with better regulation and reform of the public health care system. However, despite the policy interest and important ramifications for the country, there is little evidence regarding the benefits (or lack thereof) of training informal providers. We report on the impact of a multitopic training program for informal providers in the Indian state of West Bengal that provided 72 sessions of training over 9 months. We used a randomized controlled trial design, together with visits by unannounced standardized patients "mystery clients" to measure the extent to which training could improve the clinical practice of informal providers over the range of conditions that they face. The conditions presented by standardized patients were blinded from program implementers. Therefore, we view the evaluation of this multitopic training program as a measure of impact on primary care in general. Standardized patient data are accompanied by data from day long clinical observations, providing a comprehensive picture of provider practice. Our study also benchmarks the impact of training against the performance of doctors in public primary health centers serving the same region. Lastly, it explores whether the training affected patient demand for informal providers. RESULTS Mean attendance at each training session was 56% [95% confidence interval (CI) 51, 62% with no contamination from the control group. Using standardized patient data, we find that providers allocated to the training group were 4.1 (1.7, 6.5) percentage points, or 15.2% more likely to adhere to condition specific checklists than those in the control group. The training increased rates of correct case management by 7.9 (0.4, 15.5) percentage points, or 14.2% and patient caseload by 0.8 to 1.8 (0.13, 3.57) patients per day, or 7.6 to 17.0% Data from clinical observations show similar patterns. Although correct case management among doctors in public clinics was 14.7 0.1, 30.4) percentage points, or 28.3% higher than among untrained informal providers, the training program reduced this gap by half for providers with mean attendance and reduced the gap almost entirely for providers who completed the full course. However, the training had no effect on the use of unnecessary medicines and antibiotics, although both training and control group informal providers prescribed 18.8 (7.7, 28.9) percentage points, or 28.2% fewer unnecessary antibiotics than public sector providers. CONCLUSION Training informal providers increased correct case management rates but did not reduce the use of unnecessary medicines or antibiotics. At the same time, training did not lead informal providers to violate rules with greater frequency or worsen their clinical practice, both of which are concerns that have been raised by representatives of the Indian Medical Association. Our findings thus suggest that multitopic medical training may offer an effective short run strategy to improved health care provision and complement critical investments in the quality of public care. Informal health care providers are the backbone of India's primary health care system. In rural India, up to 75% of primary care visits are to informal providers. We evaluated a training program for these informal providers by using a randomized controlled design. In our sample of 200 villages in West Bengal, there are 30 informal providers for every public sector doctor. Health care providers without formal medical qualifications provide more than 70% of all primary care in rural India. Training these informal providers may be one way to improve the quality of care where few alternatives exist. We report on a randomized controlled trial assessing a program that provided 72 sessions of training over 9 months to 152 informal providers (out of 304) Using standardized patients "mystery clients" we assessed clinical practice for three different conditions to which both providers and trainers were blinded during the intervention, representative of the range of conditions that these providers normally diagnose and treat. Training increased correct case management by 7.9 percentage points (14.2% but did not affect the use of unnecessary medicines and antibiotics. At a program cost of $175 per trainee, our results suggest that multitopic medical training offers an effective short run strategy to improve health care.
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