The available studies on private sector in India suggest that a considerable section of the population in both rural and urban areas access the services of individual private practitioners for primary level care (Sunder, R: 1992; Krishnan: 1994). Micro-level studies show that the poor from both rural and urban areas use these practitioners as a first resort for acute conditions but also use government facilities (Nanda & Baru: 1994; Bisht: 1993; Kakade: 1998). These utilisation studies further show that the private practitioners are resorted to for a variety of minor illnesses as a first level of contact for curative care. These studies also indicate the type of practitioners being resorted to for treatment. There is much heterogeneity among providers in terms of qualifications, systems of medicine, and practices. They include herbalists, indigenous and folk practitioners, compounders and other (Vishwanathan & Rhode: 1994; Soman: 1992). These practitioners being easily available and accessible locally are utilised extensively. Studies conducted in urban slums and rural areas indicate that the better off sections in these areas use private practitioners but the really poor are unable to afford the charges and hence, either opt for the government hospitals or often go without care (Bisht: 1993; Desai: 1997; Nair: 1993; Soman: 1992; Vijaya: 1997; Krishnan: 1994; Kakade: 1998)

A few studies have shown that the knowledge regarding treatment is largely guided by the information that they receive from chemists and drug manufacturers’ representatives about the drugs to be prescribed. Studies by Phadke and Greenhalgh have amply demonstrated the nexus between the marketing network of the pharmaceutical industry and prescribing patterns of doctors, both qualified and unqualified (Greenhalgh: 1986; Phadke: 1998; Thaver: 1998; Shah: 1997). Given the poor knowledge base of these practitioners it is not surprising that their treatment of even common ailments are often irrational, ineffective, and sometimes harmful. Studies that have looked into provider behaviour with respect to specific diseases like tuberculosis and diarrhoea reveal the same (Uplekar: 1991; Bhandari: 1994; Balambal et al: 1997).

Given that these are the predominant source for curative care for the large majority of people especially in rural areas and since there is little prospect of their being replaced in the foreseeable future by qualified government or private doctors, there is a strong case, even if a second best one, for a purposeful initiative to train and upgrade their skills. The purpose of the training programme should be familiarise private practitioners with the basics of rational therapeutics. It should also include standardised regimens for treating common ailments as well as major communicable diseases covered by the national disease control programmes. In addition there is also a need for guidelines for referral to a higher level of care when required and reporting of cases to the public health surveillance system.

Role of Private Practitioners in Epidemic Situation

Apart from routine treatment rendered by private practitioners, they are also being resorted to by communities during epidemic situations. Studies that have looked at the management of epidemics in urban areas show that the private sector has been unable to respond to crisis situations and is ill equipped to avert deaths. During the outbreak of the Cholera epidemic in the slums of Delhi in 1988 it was seen that it was unable to recognise the gravity of the situation, or provide rational therapy. Once the epidemic was publicly recognised, both the private practitioners and those affected preferred treatment at public hospitals for those with diarrhoeal disease. The running back and forth between private practitioners and public hospitals led to loss of valuable time and unnecessary deaths (Priya: 1989). In the case of the plague in Surat, it was the public hospitals and doctors who treated people because the private sector was ill equipped to respond and actually left the city when the plague broke out (Shah: 1997). A similar situation occurred in the Adilabad district of Andhra Pradesh when there was an outbreak of gastro-enteritis. The private practitioners who were sought by the people during this crisis used irrational drugs and indiscriminate use of IV fluids as a result of which a number of people died.¹ All these studies point to the dire need for rationalising and registering this level of the private sector and evolving methods for training them over time. The process of registration, and, later, training of private practitioners in order to integrate them with the existing primary health care network, needs to be initiated across states and sustained over time.

Prior to recommending training programmes there is a need for registering all practitioners irrespective of whether they are qualified or not. Since many of these studies indicate a range of common ailments for which people resort to these practitioners, any effort at initiating training programmes must not be restricted to their involvement in vertical programmes which are disease specific, but needs to address a range of the common ailments as reported by the macro and micro level studies. The training has to be seen as an ongoing process whereby there is dissemination of information as a part of a network of practitioners providing primary level care.

Role of Professional Organisations

Any effort at registering or licensing has been consistently opposed by the Indian Medial Association (IMA), though banning quackery has been an important campaign carried out over the years.² The demands of the IMA are not very realistic because the State is not in a position to expand its services to such an extent that it replaces these practitioners nor are qualified practitioners willing to move to remote rural areas, as is evident from the macro and micro level studies.

Given that there are few alternatives that can replace these practitioners, it is important to regularise, give them the required training, and define the range of services they can be expected to provide. It may in fact be a good idea if the Licentiate Medical Practitioner Scheme is reviewed and revived. Here, it is possible to draw on the experiences of training of barefoot doctors in China where the State defined the scope of the conditions that they can treat and trained them accordingly. This can be done only after there is a systematic effort to register these practitioners at the district level with panchayats playing an important role in the process of registration. It needs to be mentioned here that in the search for studies on private practitioners, there are very few that provide details regarding their social background, process of skill acquisition and methods of updating their knowledge base (Singh: 1993; Vishwanathan & Rhode: 1994). This requires more attention in future research.

1. As reported by a PHC medical officer from Adilabad district; Also discussed in a forthcoming paper by Baru and Sadhana on the same subject in Economic and Political Weekly.

2. Based on interviews with IMA president both in Delhi and UP; newspaper reports over the years. A caste wise analysis was done of the IMA membership of Agra and Aligarh, UP.

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