Reflections on Informal and Formal Sector Providers in Rural Uttar Pradesh, India

Nicole Dalal, Alison Baskin, Sara Silberstein, & Jake Svenson

“Ah! I have to go. There’s a C-section upstairs.” And just like that, we hurriedly grabbed our backpacks and notebooks and rushed from the cramped office where we were interviewing Dr A.* We ran to keep up with him as he led us through crowds of people in the clinic hallway waiting to be seen. We skipped up two flights of concrete stairs to the second floor, where the hallways had no exterior walls so that the sky could be seen. Filing cautiously into a tiled room, nurses gathered hot towels and crowded around a severely jaundiced woman. She had been in labor for 24 hours, and the nurses and doctors did not know why she was jaundiced.

“We are not sure if the baby will be alive,” a nurse told us in Hindi as another rubbed iodine over the woman’s stomach. With inelegant strokes, Dr. A began to cut.

Just five minutes earlier, Dr. A sat across from us in his office telling us that he was not trained, nor legally qualified, to practice surgeries, but that he assisted surgeons and specialists.

But this was not the case here — he called the shots as an OBGYN stood watch, barely speaking a word. He made the incisions; he delivered the baby; he cut the umbilical cord. He performed a procedure that doctors in the U.S. do not perform without at least four years of training. And yet, there was still a line out the door of his clinic. Illegal practice of untrained health providers is rampant in Uttar Pradesh, a state with some of the lowest health indicators in India. But for many individuals, such healthcare providers constitute the care they can feasibly access, regardless of whether they recognize the disparities in training between formal (those with government-recognized degrees) and informal providers.

The regulation of informal providers may seem a clear-cut issue: informal providers are harming patients and should be phased out. However, the issue is much more complicated. Many villagers in rural India have limited health care options, and local informal village providers are one of the only available, affordable care options that they have. The informal providers we interviewed were limited in the scope of what they could treat, but they provided some symptomatic relief to the poorest in India. They dispensed medicines, arranged transportation to medical facilities, acted as health counselors, and were integral, trusted community members. Despite the initial simplicity of the dilemma, it became apparent to us that the issue is actually quite intricate. As one degree-holding provider remarked, he disapproved of informal providers, but, as he recognized, “where else would the people go?”

Formal providers of healthcare in India obtain an “MBBS” degree after 5.5 years of allopathic medical training and often spend extra years specializing to obtain an “MD” degree. These formal providers value their own training in medicine and note the differences in care provided. Some MBBS providers believe that informal providers “kill one person every day,” as one MBBS doctor mentioned, through their improper use of medical equipment, over-prescription of medicines like antibiotics, or misdiagnosis of critical medical problems. By the time patients arrive at formal providers’ clinics after being treated by informal providers, their conditions are often beyond the scope of treatment, rendering formal providers helpless to assist patients. However, other providers acknowledge that without the services of informal providers, poor patients would be left without any medical care, irrespective of quality, due to financial concerns.

While there is no conclusive answer about the impact informal providers have on the rural health care system, it is undeniable that they play a primary role in serving an unmet need in the community. This issue is not unique to Uttar Pradesh, or even India, as other developing nations face similar circumstances. While some governments have made efforts to formalize the informal provider sector via training and education programs, others have chosen to regulate, and in some cases prosecute, individuals who are practicing without training or credentials. While India’s policy currently enacts a formal degree requirement for practicing providers, the question as to whether this is the right policy remains.

Regardless, enforcement of this policy has yet to be fully effective, made evident throughout our research. It appears that while informal providers may harm the patients they treat, their existence is propagated by a demand that may only be supplied by changes to the rural health care system. To determine which changes must be made, it is important to examine the motivations of these informal providers and understand the behavioral drivers of community members’ pursuit of health care. Only once policymakers know and fully understand the reasons that drive healthcare decisions will they be able to effectively address the rural healthcare system.

The experience discussed in this article is the effort of the Stanford India Health Policy Initiative (SIHPI), which was fully funded by the Freeman Spogli Institute. It included an eight-week stay in India, with the authors primarily based in the Indian state of Uttar Pradesh, more specifically in the city of Allahabad. Research was compiled with the help of the Delhi based Institute for Socioeconomic Research in Democracy and Development.

* In order to preserve anonymity, his name has been abbreviated.