Indian Express, 4 April 2005
In fact, even quacks are better than doctors in public dispensaries
If you live in a poor locality in Delhi, are you better off going to a quack or to the public dispensary? A disturbing study on the quality of healthcare in Delhi by health economists Jeffery Hammer and Jishnu Das shows that in many cases, you may actually be better off going to the quack. And, this is not merely because he gets to spend more time with you, but because he might actually ask you more of the relevant questions and diagnose your disease better, even though on paper, he is less qualified than the MBBS doctor at the government dispensary.
A patient has four choices: A non-MBBS doctor, a private MBBS doctor, a public dispensary or a public hospital. The study is based on independent tests of the knowledge and effort levels of the doctors in a detailed survey of seven localities of Delhi by the think-tank ISERDD. While evidence suggests that doctors at public hospitals are the most competent, evidence about the others is mixed. Private doctors are usually better than the doctors at the public dispensaries, but often end up overdosing patients.
Given the limited resources in developing countries, it was thought that one way to improve health services for the public may be to provide informal health practitioners, who are easily accessible and may help in curing minor diseases, while referring more complicated cases to hospitals and specialists. This idea was influential in framing both the WHO policy (the Alma-Ata declaration), and consistent with it, Indian health policy. In this system, primary healthcare is expected to rely on trained health workers, as well as traditional practitioners, who may not be MBBS. Following this route, India has created a large mass of RMPs (Registered Medical Practitioners) who are expected to diagnose and treat minor illnesses effectively.
The strategy does not seem to have worked. The less competent a medical practitioner is, the more likely he is to treat, rather than refer, most illnesses. A non-MBBS practitioner, who may have done a five-year course in Ayurvedic medicine is least likely to send you to a specialist and most likely to overdose you heavily. Most prescribe, and even dispense, allopathic medicines. So, for example, instead of prescribing water with salt and sugar (ORS) in the case of a baby with diarrhoea, seven out of 10 low competence doctors are likely to prescribe metronidazole, loperamide and furoxone, which are not only unneccesary, but are actually harmful. In the case of TB, chances are that five out of 10 such practitioners will try to treat you themselves, rather than refer you to a specialist, as needs to be done. Worse, if you are a pregnant woman suffering from high blood pressure that could be fatal for you and the baby, then in six cases out of 10, the chances are that you would die. The logic of the practitioner is not difficult to follow. As one doctor in the study said, ‘‘If I tell the mother that she should go home and only give the child water with salt and sugar, she will never come back to me; she will go to the next doctor who will give her all the medicines, and then she will think that he is better than me.’’
Going to a public dispensary has a different set of problems. The doctor has very little time to spend with each patient. Since one of the main issues that doctors in public service raise is that their workload is much higher, the study takes this into account. Unfortunately, it finds that this better qualified doctor—who is an MBBS, since non-MBBS doctors are not hired by the government—has little incentive to treat the patient or have him return to him next time. At every quality level, public providers perform worse than private providers—they ask fewer questions about the history of the illness and they are less likely to perform a physical examination. In two-thirds of the cases, a low-quality public practitioner—the kind a poor person is likely to see—does no physical examination. He asks less than two questions and spends less than 2 minutes on the patient. The extent to which he uses his full knowledge is much lower than what a private provider does.
The study reveals something that few medical experts, who emphasise qualifications, focus on: It shows that the behaviour of the public versus private providers has more to do with their incentives and less to do with their qualifications. Public providers, on government salaries, have little incentive to spend much time with patients. Private providers end up catering to the demands of the patients and resorting to treatments that are not medically sound.
How do countries achieve better healthcare for their population? In the rich world, most primary care physicians are paid by the government on the basis of how many patients they attract. The government does not pay for services via salary, as there is too little incentive to take good care of each patient. So, for example, England has ‘‘capitation’’—primary physicians get paid on the basis of how many people sign up with them. Canada has a ‘‘single payer’’ (the government) financing scheme but every visit to the doctor is paid for separately.
What is the way to improve the quality of healthcare in India? There are no quick fixes to be found. Answers do not lie in increasing the number of doctors in primary health centres or having more private clinics. Answers do not lie in merely increasing the expenditure on public health. Yet, answers do need to be found if the Indian public is to get better healthcare than at present.
Ila Patnaik