Training the Informal Health Workforce in India

A program to train informal health workers in the Indian state of West Bengal has won the support of the government and is attracting the interest of other states with shortages of health sector personnel. Richard Downie traveled to rural West Bengal to find out more:

India’s chronic shortage of health workers is one of the biggest barriers to improving access to quality health services. The problem is particularly acute in rural areas, where more than 70 percent of Indians still live.  In Uttar Pradesh (UP), India’s largest state with a population of 200 million, primary health centers and community health centers—the bedrocks of the health delivery system—are only 50 percent staffed. No wonder, then, that UP has some of the worst health indicators in the nation, with the second highest maternal mortality ratio and the third worst infant mortality rate across India’s 36 states and union territories.

The government of Prime Minister Narendra Modi is trying to address this problem. The union budget, unveiled in February, included plans to fund 5,000 extra postgraduate medical seats across the country.  However, these extra slots have forced government medical colleges to relax teacher-student ratios, with potential implications for teaching quality. Besides, it will take several years for the new graduates to enter the workforce and does not alter the fact that health personnel are reluctant to serve in rural areas.

In the meantime, several innovative programs are under way that utilize resources from the informal sector.  One of the defining features of health care in India is the presence of a vast army of providers who—without any formal training—offer medical consultations and dispense medicines. It is estimated that these so-called ‘quacks’ comprise more than 70 percent of the health workforce in India.  The government and the Indian Medical Association—which represents doctors—loudly condemn their illegal activities but they are a fact of life and people continue to trust them and use their services, particularly in areas where the public system is weak or absent.

In West Bengal, a program that trained informal health care providers is attracting interest from other states. The project was designed by the Liver Foundation, a non-governmental organization based in Birbhum, a district of West Bengal about four hours’ drive from Kolkata. Over the course of nine months and more than 70 training sessions led by professional doctors, the informal health providers who volunteered for training learned the basics of human anatomy, physiology, maternal and child health, and public health programs, among other topics.  Those who completed the course—more than 2,500 in all—were renamed Rural Health Care Providers (RHCPs).  They received no certificate or qualification and were reminded that they were not doctors or in any way part of the formal system. But that did not seem to matter to the RHCPs we spoke to at a top-up training session in Suri, the capital of Birbhum district. They simply wanted to learn and were eager to improve the quality of the service they provide. 

The Liver Foundation’s program was subject to a rigorous analysis by a team of experts from MIT, Yale, and the World Bank. According to their findings, published in Science, those who underwent the training were 14 percent more likely to correctly diagnose a set of conditions than those who did not.  When evaluated on correct case management, they halved the performance gap between themselves and public sector doctors, compared with their untrained peers. Furthermore, the training was delivered at a cost of just $175 per person.

For Dr. Abhijit Chowdhury, the founder of the Liver Foundation, informal health care providers are “candles in the darkness,” providing services that would not otherwise be available.  He added, however, that it was incumbent to “reduce harm and increase benefits” to the population that relies on these providers.

In Hansra, a village an hour’s drive from Suri, the impact of the training was clear to see.  The RHCP we spoke to, Muzibur Rehman, told us that he was more confident than before, explaining that he previously made informed guesses based on the fragments of knowledge he had picked up while serving as a doctor’s assistant in Delhi more than 20 years before. He said that he was now more aware of his limits and knew when to refer patients to the formal health system.  Gesturing at the assortment of tablets on the desk in front of him, Mr. Rehman explained that he now prescribed fewer unnecessary medicines than before. More importantly, the patients valued his services even more.  We watched as a succession of people trailed into his cramped consulting room, paying 20 rupees (approximately 30 cents) for their visit; a boy suffering from sickness and diarrhea, two men with hypertension, a man who had come to have stitches removed from a head wound, and a pregnant woman coming for a routine checkup.  They all told us that they had noticed an improvement in the care they received.

The state government of West Bengal was so impressed by the Liver Foundation’s work that it is taking on the program and scaling it up across the state.  Dr. Chowdhury and his colleagues have worked with the government to draw up a curriculum, which will be taught by nurses in the public health system.  Training will get under way in the coming months.  Other states, including neighboring Jharkhand and UP, are considering similar schemes.

Meanwhile, in southern Karnataka state, a small nonprofit established by four Stanford University classmates has turned to another untapped source of healthcare support—the family of the patient.  Noora Health, based in Bangalore, delivers quick, simple training modules to families so that they can better care for their loved ones when they are discharged from hospital.  The training is delivered by nurses in the hospital with the aid of mobile apps and other visual tools, and includes basic information on administering medication, healthy eating, and physical therapy exercises.

The project has trained more than 75,000 people so far and appears to be leading to lower readmission rates.  So far, Noora Health has worked in individual hospitals, mainly in the private system, but recently started talks that could lead to its work being scaled up across public hospitals in two states, Karnataka and Punjab.

Innovations like these are not without risks—particularly during the scale-up phase—and it would be incorrect to view them as alternatives to the formal health system.  However, they offer practical solutions to the shortage of qualified health professionals. Noora Health uses a readymade support network that is eager to help and offers its services for free.  The RHCPs fill a gap in areas where there are few, if any, healthcare alternatives.  While the medical professions do not like this shadow workforce, the fact remains that millions of people use informal health providers and will continue to do so in the absence of a functional primary health care system.  Better to reduce the harm they inflict than simply hope in vain that they will disappear.