Stanford - ISERDD Collective

INFORMAL PROVIDERS:Understanding Motivations and Behaviors

Partners for the reportStanford India Health Policy InitiativeInstitute of Socio-Economic Research on Develop-ment and Democracy (ISERDD)

AuthorsAlison Baskin Nicole DalalVeena DasPriyanka GoyalSophie HarkinsCharu NandaGeeta NandaSara SilbersteinChinar SinghManraj SinghRajan SinghJacob Svenson

Editing and content reviewLiz OgbuTeal Pennebaker

Graphic DesignSheetal Kalidindi

Acknowledgements

This field work would not have been possible without the steadfast collaboration and support of Veena Das and the Institute of Socio-Economic Research on Development and Democracy (ISERDD). We are also grateful to Liz Ogbu for contributing her design thinking expertise.

It is our hope that these insights and suggested opportunity areas will encourage policymakers, health care professional, researchers, and non-government organizations to pay further attention and pur-sue additional study on the topics and insights proposed in this report.

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TABLE OF CONTENTS

1. Executive Summary..................................................................................5

2. Background................................................................................................8

3. Research Methodology.............................................................................13

4. The Rural Primary Care Landscape..........................................................15

5. Theme - Opportunities for Entry.............................................................20

6. Theme -Determinants of Behavior as a Practicing Informal Provider...23

7. Conclusion.................................................................................................29

8. References................................................................................................30

9. Appendix...................................................................................................32

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Executive Summary

Rural health care resources in India include a complex network of providers with a spectrum of train-ing, skills, and services. The wide variety of providers -- which includes formal public and formal private prac-titioners, informal providers, and community health workers -- illustrates the vast array of opportunities for entry into the medical profession.

For the purposes of this report, we draw a clear distinction between formal and informal providers. We define informal providers as those who practice medicine for which they do not have a degree, and we define formal providers as MBBS physicians or providers who practice AYUSH medicine for which they have a govern-ment-recognized degree. The most common types of informal providers we encountered were those lacking degrees. We also encountered providers with AYUSH degrees who practiced allopathic medicine alone or in combination with other forms of medicine. Because the legality of mixing medicines is unclear, and some AYUSH doctors gain exposure to allopathic medicine during training, it is difficult to categorize them as formal or informal providers.5,6 In this paper, we choose to include AYUSH providers practicing allopathic medicine in our informal provider category due to lack of clarity on the extent of their training in allopathic medicine.

Informal providers practice widely in India and often prescribe medicine they have not been trained to distribute. Although there is a public health care system, the resources available through public sector facil-ities are inadequate to meet the needs of the rural population, creating an opening for informal providers to administer primary care for those who face high barriers to access.1 Informal providers in India account for 51-55% of all providers,2 with private formal providers typically relegating themselves to urban, affluent areas.1 In India, and in Uttar Pradesh in particular, rural villagers rely heavily on informal providers for health care.1 A survey of rural households showed that providers without formal medical training conduct 70 percent of primary care visits in the rural setting.3

There are many opportunities to informally enter into a health care related profession. Although the legality of practicing as an informal provider varies from state to state, becoming an informal provider seems to generally be perceived as a viable career option, even for those without higher education. While prior re-search endeavors have assessed access to different types of providers in rural Uttar Pradesh and in other states, research focusing on motivators of informal provider career choices and behaviors lacking. The dual focus of our study was to use ethnographic field research techniques to 1) examine the decision to become an informal provider and 2) study the determinants of behavior as an informal provider.

Because of the fragmented legal landscape towards practicing informal providers, they are not be-holden to the same regulatory mechanisms as are formal providers. If providers who do not meet regulatory standards in their respective states are identified by the government for performing illegal practices, they may be subject to penalties, such as jail time or having their practices shut down. Despite a low probability of contact with government oversight officials, informal providers are still afraid of these adverse consequences.

The debate over how the Indian government should address informal providers is complex. The pro-vision of care by untrained and unlicensed providers may harm patients whose conditions require a trained and practiced hand. Concerns regarding informal providers include lack of training as well as worries about

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harmful drug prescription and low quality of care.4 While some believe informal providers are doing a pub-lic health disservice by worsening outcomes, others believe that they provide primary care no worse than trained providers. Additionally, some believe that informal providers offer care that would otherwise be unat-tainable and relieve some of the burden from impacted public health facilities.2

We hope the insights we have included in this exploration provide context and an informed perspec-tive with which to approach this debate. Additionally, we also took note of related opportunity areas that future investigation could expand upon to further elucidate realities of the Indian rural health care system.

Findings were organized into a description of the landscape followed by broad thematic areas listed below:

Rural Primary Care Landscape

Our field observations provide context for our main insights. We include pertinent descriptions of pa-tients’ demand for pharmaceuticals, the pharmaceutical market for practitioners, as well as other providers’ perceptions of informal providers and broadly, how informal providers face competition and maintain their businesses. We hope to set the stage for the insights we make later in Sections 4 and 5.

Opportunities for entry

Uncertified, informal providers experience relatively low social and financial barriers to entry into their fields. In contrast, MBBS education programs are either highly competitive to enter into or have relatively high financial barriers. There are multiple factors that contribute to low barriers to entry for informal providers.

1.There are many opportunities for individuals to receive informal training as an entry point into becoming an informal provider. There are many opportunities in the rural setting to provide health care, many of which do not neces-sitate a formal degree. Informal providers often obtain some form of informal training, such as working in a public hospital or shadowing in a relative’s or a friend’s private clinic. Many informal providers believed such experiential learning and training made them just as qualified as formal providers to administer health care.

2.Pharmaceutical knowledge and supplies are easily accessible. Informal providers reported that pharmaceutical knowledge and supplies were readily accessible, al-lowing them to stay updated on pharmaceutical knowledge. While there are restrictive trade laws that pre-vent direct purchase of medical supplies by providers from stockists, several informal providers reported that they could easily purchase pharmaceuticals.

3.Opportunities for practicing are diverse. The efficacy of government-run mechanisms intended to deliver health care to rural villages seems inconsistent across villages, at times leaving room for informal providers to fill gaps in both primary and spe-cialty care resources. Thus, each individual community may have unique health care gaps contingent upon

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the performance of the local public health infrastructure. Resourceful informal providers can fill these gaps, further permeating the system.

Determinants of Behavior as a Practicing Informal Provider

1.Informal providers must strike a balance between keeping costs low while remaining financially solvent. According to informal providers, if patients could not afford their services, they would seek care from another, cheaper provider. Informal providers employed different methods of keeping their services afford-able for patients, including not charging consultation fees, allowing patients to pay on credit, and in some cases, forgiving charges

2.Maintaining a favorable reputation in the community motivates informal providers’ decision-making processes for when and how to treat patients. Informal providers formed their own barometers, often based on their experience, of when to refer pa-tients to other providers. Such referrals were made on the basis of perceived severity, urgency, and necessary resources to treat a patient’s condition. Practitioners also gained favorable reputations among community members through filling specialty care niches, addressing unmet or underrepresented medical needs within the community or making themselves more accessible to community members by fulfilling patient requests and providing convenient, constant care.

3.Patient Demands influence informal provider behavior, shaping medical care decisions. The most commonly reported example of this was through the dispensing and administering of drugs to satisfy patient desires, even if the provider did not feel it was particularly medically effective or necessary.

4.Informal providers are often intrinsically motivated to fulfill unmet health care needs as a service to their communities. This section looks at the intrinsic motivators of behavior that drive informal providers’ sustained prac-tices. A common response among providers was that they served their communities by providing low-cost health care for financially constrained patients

Understanding the motivations of health care providers has important implications for shaping gov-ernment health care policies. We hope that documentation of the existing landscape in which informal pro-viders practice, their motivations for becoming an informal provider, as well as major factors that influence informal providers’ decisions as they practice provides a foundational knowledge for policy makers and oth-ers interested in understanding informal providers and their actions.

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Section 1: Background

Types of Providers A 1998 World Bank survey found that 48.3 percent of health care utilization in rural areas is from informal providers, 16.7 percent from govern-ment doctors, 24.5 percent from private doctors or clinicians, and the remaining usage comes from in-digenous practitioner/faith healers, chemists, or charitable organizations, NGOs, or others.5 Through our own exploration of rural communities, we en-countered health care providers with diverse back-grounds and training.

There are several ways to enter the formal medicine sector in India. Those formally pursuing allopathic medicine will typically earn a Bachelor of Medicine, Bachelor of Surgery, or MBBS degree. Training for these degrees typically lasts 5.5 years, including a 1-year internship -- analogous to pursu-ing a medical degree in the United States. The Indian Government recognizes formalized degrees in five traditional medical disciplines as well: Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Home-opathy (together referred to as AYUSH). AYUSH phy-sicians often practice mixed care, treating patients with a combination of traditional and allopathic medicine.6

For the purposes of this report, we draw a clear distinction between formal and informal pro-viders. We define informal providers as those who practice medicine for which they do not have a de-gree, and we define formal providers as MBBS physi-cians or providers who practice AYUSH medicine for which they have a government-recognized degree. The most common types of informal providers we encountered were those lacking degrees. We also encountered providers with AYUSH degrees who practiced allopathic medicine alone or in combina-tion with other forms of medicine. Because the legal-ity of mixing medicines is unclear, and some AYUSH doctors gain exposure to allopathic medicine during

training, it is difficult to categorize them as formal or informal providers.5,6 In this paper, we choose to include AYUSH providers practicing allopathic med-icine in our informal provider category due to lack of clarity on the extent of their training in allopathic medicine.

The Public Health Care System Descrip-tion

In rural India, both informal private and for-mal private health care provisions are available, yet informal private care has often become the main source of care for rural villagers.7 In addition to the private care system, there is the public health care system, which consists of a hierarchy of govern-ment-run health care centers. These include sub-centers, Primary Health Centers (PHCs), Community Health Centers (CHCs), First Referral Unit, and dis-trict hospitals (listed in order of increasing size, pa-tient capacity, and services offered).

The public health care system is supposed to provide subsidized and free primary health care to low income and rural populations, but it suffers from some critical issues including the well-docu-mented challenges of physician absenteeism and bribery.8,9,10,11 Patients often report long wait times, often due to absentee physicians. Although public hospitals should only be staffed by formal providers, a World Bank study of provider training and quality metrics in urban and rural health care services re-ported that 67 percent of public providers had no formal medical qualifications.7

In some cases, the public health care system and the informal private sector act as substitutes for one another, with individuals choosing to seek pri-mary care at one or the other. At other times, these two systems act as complements to one another -- with individuals seeking primary care from informal

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providers and then seeking out more specialized fol-low up care from the public sector.

The public health care system uses govern-ment-employed liaisons called Community Health Workers (CHWs) to access individuals in rural com-munities and extend their reach of influence directly into villages. CHWs include Accredited Social Health Activists (ASHAs), Anganwadis and Auxiliary Nurse Midwives (ANMs), which interact with the public health care infrastructure. ASHAs, often appoint-ed by the village headman, act as liaisons between pregnant women and government-run facilities. They keep track of an assigned list of pregnant wom-en in the village to which they are appointed, advise women on pre- and post-natal nutrition, help with community vaccination days, and provide resourc-es for family planning. They are commissioned by the government Rs. 600 (9.4 USD) for accompanying women to deliver in a government facility, but they are otherwise unpaid. 12

Anganwadis run childhood daycare and as-sist with vaccination days, both of which take place at Anganwadi centers, typically a communal space with a couple buildings for children. Anganwadis also offer advice on nutrition to parents of the children they oversee, administer government-appropriated nutritional packets to children, and may also advise mothers and pregnant women on other health con-cerns.

ANMs receive training in nursing and deliver-ies. They are typically the CHWs who run vaccination days, and are often assisted by Anganwadis.

Role of the Government in Regulating the Practice of Informal Providers

In 1956, the nation re-enacted the Indian Med-ical Council Act after having repealed it years earlier. This legislation established the Medical Council of

India (MCI), which serves as the statutory body re-sponsible for regulating the medical qualifications of practitioners, as well as establishing and monitoring the country’s medical institutions and colleges. 13

The government of India has set up a moni-toring and penalty system enlisting the Directorate of Health Services and the MCI to ensure that prac-ticing health care providers are not unqualified.12 In addition to specifying its stance on prosecuting vio-lators under the Indian Medical Council Act, the Su-preme Court of India has noted that there exist un-qualified individuals “who [do] not have knowledge of a particular system of medicine but [practice] in that system and are mere [pretenders] of medical knowledge or skills.”12

As specified in Section 15.3 of the Indian Med-ical Council Act, punishment of up to one year im-prisonment and/or a fine of Rs. 1000 (16 USD) may result.14,15 The pervasiveness of unqualified provid-ers within the rural health care system points to sys-temic gaps preventing this schema from functioning adequately and efficiently.

However, despite the Indian Medical Coun-cil Act, the government acknowledges certain gaps in the health care system. There is a disconnect be-tween policy and practice that allows for the per-meation of informal providers into the health care system. Reasons for this include the nation’s large population; inadequate infrastructure; poor moni-toring and vigilance of health care delivery on a reg-ular basis; and long, tedious law enforcement proce-dures.14

National Health Mission Given that informal providers deliver a dom-inating proportion of health care to households in rural India, the national government has recognized the necessity of taking a formal stance to address

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the informal providers’ medical practices.1 One example of this effort is through the launch of the National Health Mission, which is run by the Ministry of Health and Family Welfare.16 The NHM has made efforts to train a subset of non-MBBS government-affiliated Community Health Workers (CHWs).11 For example, the NHM’s ASHA program trains local village women to become ASHAs who encourage households’ use of public facili-ties to try to increase rates of institutional deliveries. As a submission of the NHM, the Ministry launched the National Rural Health Mission (NRHM) in 200514, which aims to address poor health and infrastructure indica-tors in rural areas across eighteen states. Table 1 contains a list of NRHM initiatives.

Table 1: National Rural Health Mission Initiatives

Janani Suraksha Yojana (JSY)14 A national conditional cash transfer scheme to in-centivize women of low socioeconomic status to give birth in a health facility.

After delivery in a government or accredited private health facility, eligible women receive Rs. 600 (9.4 USD) in urban areas and Rs. 700 (10.9 USD) in rural areas. Women are eligible for the cash benefitonly for their first two live births, and only if they have a government-issued BPL card or if they are from a scheduled (low) caste or tribe.

IIn ten high-focus states (including Uttar Pradesh but not Gujarat), all women—irrespective of socio-economic status and parity—are eligible for the cash benefit of Rs. 1000 (15.7 USD) in urban areas and Rs. 1400 (22.0 USD) in rural areas.

Reproductive and Child Health Programme-II (RCH-II)17

A national program introduced in 2005 that focuses on addressing the reproductive health needs of the population through evidence-based technical inter-vention through a wide range of service delivery net-work. The objective is to reduce three critical health indicators: total fertility rate, infant mortality rate, and maternal mortality rate.

Pulse polio programme18 First launched in 1995, children 0 to 5 years are given polio drops during national and subnational immu-nization rounds every year. All states have developed a Rapid Response Team (RRT) to respond to any po-lio outbreak in the country.

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In UP, every newborn child is identified and vaccinat-ed during the polio immunization campaigns and is tracked for eight subsequent rounds.

Sterilization compensation scheme19 A compensation that is offered to sterilization and IUD Insertion users.

After a vasectomy in a government health facility, el-igible men receive Rs. 1100 (17.3 USD). After a tubec-tomy in a government health facility, eligible wom-en receive Rs. 250 (3.9 USD) or Rs. 600 (9.4 USD) in a high-focused state.

Compensation is also offered for the motivator and the hospital staff, as well as for the supplies.

After a vasectomy or tubectomy in a private health facility provided free of charge, the facility received Rs. 1300 (20.4 USD) and 1350 (21.2 USD) respectively. Compensation is also offered for the motivator.

After an IUD insertion in a government health facility, eligible women receive Rs. 20 (.3 USD).

Janani Shishu Suraksh Karyakarm (JSSK)20 Introduced in 2011, the initiative entitles all preg-nant women delivering in public health institutions to free and no-expense delivery, including caesarean section. Additionally, both the mother and the new- born can receive the following provisions until 30 days after birth: (1) free and zero expense treatment, (2) free drugs and consumables, (3) free diagnostics and diet, (4) free provision of blood, (5) free transport from home to health institutions, (6) free transport between facilities in case of referral, (7) free trans-portation from institutions to home, and (8) exemp-tion from all kinds of user charges.

Rashstriya Bal Swasthya Karyakram (RBSK)21 An initiative aimed at early identification and early intervention for children from birth to 18 years, cov-ering the 4 Ds: defects atbirth, deficiencies, diseases, and developmental de- lays including disability. .

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First level of screening is done at all delivery points through existing MOs, staff nurses and ANMs. Be- tween 48 hours to 6 weeks, the screening of new-borns is done by the ASHA at home. At 6 weeks of age to 6 years, outreach screening is done by a dedicated mobile block level team at Anganwadi centers, and at from 6 to 18 years of age, screening is done at school.

Comparing Informal Providers to Formal Providers

Our report does not seek to measure the dif-ference in quality of health care between informal and formal providers. In fact, previous research has aimed to do just this. The data gathered by one re-port on the quality of care in rural and urban India reflects low levels of medical training among health care providers in the public and private sectors of ru-ral Madhya Pradesh, which include both formal and informal providers. The report also showed that care by these providers does not adhere to treatment guidelines and that there exists a lack of provid-er-patient communication.7

Like the study by Das et. al, a different study of 138 Primary Health Centers (PHCs) in rural Chhat-tisgarh found that the differences between physician and informal providers, from the patient perspec-tive, were relatively small.5 The patients of Medical Officers and informal providers reported similar lev-els of satisfaction, trust, and perceived quality, with no significant differences in patient outcomes.5 The report also noted that absenteeism at clinician posts resulted in undermined public trust and quality per-ception of government health services.5 This prem-ise, although not thoroughly discussed in our report, was observed to occur in the field.

Despite these studies, there is incomplete in-formation about the precise types of care provided by informal providers, as well as their background

and training—or lack thereof. Indeed, it is very diffi-cult to measure quality; some metrics, such as those evaluated in a 2013 review by Sudhinaraset et. al, have included inadequate drug prescription and use; a discrepancy between the providers' knowl-edge and their practices; the nature of advice given to patients; and the finding that providers do not ad-here to national health care guidelines.6

AIM OF OUR STUDY: Our research aims to examine both the mo-tivations to become an informal provider and the determinants of informal providers’ behavior in rural India. The inferences we draw from our observations are meant to guide further research and promote di-alogue among policy makers about informal provid-ers -- especially given the current national focus on universal health care coverage in India.

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Data was collected in the northern state of Uttar Pradesh (UP). The UP health care system is es-pecially weak compared to other states in the area. In particular, UP’s institutional delivery rates and other health indicators are some of the lowest in In-dia.

Within UP, our field work was focused on the district of Allahabad. It served as a suitable area due to the existence of CHCs, PHCs, and subcenters as well as the abundance of private providers and nurs-ing homes. Furthermore, as illustrated in Table 1, Allahabad district’s health indicators, which include percentage of institutional deliveries and mean ma-ternal education, are in line with UP averages. We categorized villages based on their demographics and their proximity to Allahabad, the nearest major highway, and the nearest public health facility.

We attempted to select a sample of villages that were representative of these different charac-teristics. We visited informal and formal private pro-vider clinics, as well as public health care facilities, including CHCs, PHCs, and subcenters.

Qualitative Methods For seven weeks, we employed an inter-view-based approach to collecting qualitative data in the field. We conducted semi-structured interviews with both formal and informal health care providers. They were conducted in Hindi, and ranged in length from 30 to 90 minutes. Members of the team translat-ed for the non-Hindi speakers, and multiple people always took notes to improve quality, detail, and ac-curacy of the data. Researchers also noted any auxil-iary observations. For example, when visiting health facilities, we observed the sanitation techniques, the hygiene of the workers, and other factors that affect the health care environment.

At the end of every data collection day, the

research team debriefed over the day’s findings. Raw data, individual interpretations, and group consen-sus on findings from the field were stored electroni-cally on a regular basis. This was done to capture in-dividual reactions, which were later explored during the data analysis phase. Raw data was also used as concrete reference material during analyses.

Interviewee Profiles: We interviewed informal providers, formal private providers, and formal public providers, as well as Community Health Workers (CHWs), includ-ing Accredited Social Health Activists (ASHAs), Auxil-iary Nurse Midwives (ANMs) and Anganwadis. While the CHWs were not the primary focus of this re-search, their perspectives did provide valuable con-text of the local health system. The majority of the data collected for this report comes from interviews with private providers. We identified informal private providers in villages by asking community members to name health care providers in their villages. We also sought out private providers who practiced on main roads next to the villages we visited. We also interviewed and observed both private and public providers in facilities that community members cit-ed. Data Analysis: Upon returning from the field, we synthe-sized the data through clustering data points from a representative selection of interviews. This process produced broad thematic areas. We then identified multiple patterns within each theme. From these patterns, we developed insights about the infor-mal provider motivations, particularly around entry into their respective fields and decisions in practice. Topics that we felt warrant further investigation by potential stakeholders or researchers have been framed as opportunity areas. The insights and op-portunity areas are detailed in subsequent sections of this report.

Section 2: RESEARCH METHODOLOGYIdentifying Districts, Blocks, and Villages

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Interview Clustering by type , actor and state

Generate themes using representative interview

by manual sorting

Generating insights based on themes and

interviews

Generating opportunity Areas

Conducting Semi-structured, focused

Qualitative Interviews

Interview Transcription from Field Notes

Figure 3: Flowchart Diagram of Research Methodology

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Section 3: The Rural Primary Care Landscape

Drawing on key field observations, this section provides a more complete understanding of provider motivations and the environment in which they practice. We documented the rural health care system’s com-munity dynamics as well as the supply-side landscape of rural health care in the villages outside of Allahabad. These observations describe where informal providers practice and illuminate the realities of the health care system.

Informal providers practice in a competitive environment.

Often a village – or within a series of nearby villages -- had more than one provider. In these instances, informal providers directly competed with other informal and formal providers. Sometimes, this competition was explicit, with practices located on the same road. These practitioners provided treatment to overlapping patient populations. At other times, such competition was not observed but was referenced by informal pro-viders as a reason for adopting particular financial practices, such as keeping their prices low compared to other informal providers or not charging any consultation fees.

Informal providers often use a personal barometer to determine when to refer patients to other providers or pathology labs, indicating the existence of a

pervasive referral network. Local informal providers reported seeing a broad range of illnesses and conditions because they were often the first points of contact for community members. If a patient did not show signs of improvement -- generally three to four days after prescribing a particular treatment -- most providers directed the patient to one particular hospital or clinic or, more commonly, provided the patient with a list of recommended provider options for subsequent care. In this latter case, patients would be advised to seek the care that they believed to be the most suitable for them. Referrals were not typically made to other providers with the same educa-tion or experience level.. Alternatively, a small subset of providers would choose not to refer out and instead give a second round of treatment if the patient did not improve with the first.

Some providers referred patients when they had an illness or condition that the provider elected not to treat. Examples included cases of Tuberculosis or conditions requiring the attention of a more specialized provider. Generally speaking, these were the cases that providers considered to be “serious conditions,” ones warranting immedi-ate attention from a degreed professional because of severity or urgency.

Informal providers also routinely referred patients to specific pathology labs. Providers with

Opportunity Areas

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loyalties to a particular lab cited a lab’s test reliability as a reason for continued business there, meaning that they believed the results were of better quality than others. In many of these “reliable” pathology labs, pro-viders reported that they knew and trusted that there were trained and/or licensed pathologists performing the diagnostics, as compared to other facilities with tests being done by lesser-qualified staff. Informal pro-viders cited a lab’s convenience and location relative to the provider and/or patient, as well as the existence of financial incentives for the provider as other rea-sons for a specific referral.

Oftentimes, when providers spoke of the referral system, they mentioned a commission giv-en to the referring provider from the recipient pro-vider. This commission was generally a percentage cut from the patient fees charged by the recipient provider. Providers consistently acknowledged the existence of a widespread commission system, though most spoke pejoratively of it and denied participating. However, the disconnect between the reported prevalence of the commission system and how few people said they participated in it raised concerns about how willing providers were to speak candidly about the topic.

Providers of all training levels reported some level of interaction with other providers and health care systems.

The following table explains some of the perceptions that different health care providers had about other health care providers. Although this table does not comprehensively represent all the differing views in the rural health care system, it does offer insight into some of the more commonly reported sentiments we heard in the field. Both informal and formal providers voiced positive and negative opinions of the role in rural health care that informal providers play. Similarly, views on the public health system and community health workers varied. When formal providers held negative perceptions of other providers, CHWs or the pub-lic health system, they tended to voice these opinions strongly and to cite specific inadequacies of providers or the public health system, in contrast to their positive perceptions, which tended to be more general.

Opportunity Areas

Table 2: Provider Perceptions of Each Other

Opinions of MBBS

Opinions of Informal Providers

Opinions of Community Health Workers

Opinions of Public Health Sysyem

SpeakerMBBS

Positive Views:· • Informal providers

should exist• The government

should train infor-mal providers·

Positive Views:· • ASHAs and ANMs are

doing good work for villages, even if the provider was not part of the public system

Positive Views:· • No positive views

reported by private MBBS providers

• Public MBBS provid-er believed they were

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Opinions of MBBS

Opinions of Informal Providers

Opinions of Community Health Workers

Opinions of Public Health Sysyem

• Informal providers are needed to man-age at a “very basic level;” where else would the poor go?

• Informal providers still have experi-ence, are work-ing “based on experience”· An informal provider promised to refer patient base ·

• It is not possible to just “get rid of” in-formal providers, the system would not function with-out them

Negative Views:· • Informal providers

should be eliminat-ed·

• Informal providers will say that they have knowledge of treatment even if they do not

• Informal providers take minor illness-es and make them worse.

• In rural areas, informal providers falsely claim to “serve the people "

Negative Views:· • ASHAs may discour-

age people from going to the doctor

• Anganwadis may misrepresent vil-lage demographic information

working hard to improve quality

Negative Views:· • Too many patients in

public facilities; doc-tors have to move quickly between pa-tients, compromising quality

• Low probability of seeing a doctor in a government hospital

• Government doctors have limitations on medicines that they can prescribe and have little motivation because of fixed sala-ries

• Government doctors have no interest in diagnosing or treat-ing patients

• Public facilities should be improved·

• Hospitality is poor in many government hospitals·

• Biggest differences be-tween public and pri-vate facilities is quality of care and quantity of patients·

• Government hospitals are unable to treat all incoming patients.

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Opinions of MBBS

Opinions of Informal Providers

Opinions of Community Health Workers

Opinions of Public Health Sysyem

• Government should shut down all in-formal providers, people should just go to small public facilities

• Informal providers are killing people·

• “Informal provid-ers kill one person per day”·

• It is possible that informal providers are hurting people but it is probably rare·

• If informal provid-ers were trained it would only create more of a disparity between the rich and poor because the training would probably be sub-standard

Speaker Informal Provider

Negative Views:· • Heard of

formal providers complain-ing about specific informal providers in order to get them shut down

Positive Views:·• Informal providers

in an area may call each other for advice·

• Believes informal providers are fine because they must have learned from somewhere

Negative Views:• Claims that dais

practice without much training

Positive Views:·• ASHA and ANM are

doing good work• ASHA does good work

on sterlization

Negative Views:• There is little com-

munication between ASHAs and provid-ers; there should be more.·

• Heard of ANMs admin-istering the wrong in-jections

Positive Views:· • From a cost perspec-

tive, a patient should try public facilities first even though they may not be seen

Negative Views: • Public facilities consis-

tently very busy, not very good care deliv-ered·

• Government hospi-tal is sometimes very crowded

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Opinions of MBBS

Opinions of Informal Providers

Opinions of Community Health Workers

Opinions of Public Health Sysyem

• Informal provider quote regarding views on MBBS: “I may not have a [driver’s] license but I can drive as well as anyone with one”

• If one informal pro-vider cannot treat a condition, other informal providers will not be able to either

• Informal providers may give incor-rect medications or treatments be-cause they do not have training, which represents a major issue

providers will not be• Heard of ANMs ad-

ministering the wrong injections·

• Thinks older ANMs were more knowl-edgeable than the ones today·

• Dai expressed tension with ASHA and her abilities·

• ASHA delivers supplies but cannot deliver ba-bies·

• Perceive that an ASHA solely distributes sup-plies but is incapable with deliveries

Speaker: CHW

• Community health worker refuses to interact with informal pro-viders, looks down on them

• ASHA will come to provider with pa-tients and then do follow up in three day

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In rural UP, there is a low barrier to entry for practicing medicine. This seems to be an important factor that contributes to people’s decision to enter the medical field as an informal provider, as they perceive this to be a relatively easy field to enter. The factors that produce this low barrier include the lack of value placed on having a formal degree (both by providers and by community members), the accessibility of pharmaceutical knowledge and products, and a wide array of opportunities to enter the medical field.

Formal degrees are not necessary for entering the field, since both providers and patients view experience as more important than formal education.

Many informal providers freely reported that they had no formal training. They defended their lack of training, claiming it did not affect their ability to practice and to make a decent living in the medical field—although admitting that a more formal degree like an MBBS may lead to a higher salary. Many informal pro-viders said that despite not holding a particular degree, they were fully qualified for the work because of their experience in the health care field. One informal provider encapsulated this sentiment when he used a metaphor to draw a comparison between practicing medicine without a formal degree and driving without a driver’s license, “ While I may not have a [driver’s] license, I can drive as well as anyone with one.” Many in-formal providers consistently reported that it was relatively easy to gain this experience, oftentimes by work-ing with or by shadowing a family member or other contact that practiced medicine.

Additionally, many informal providers claimed that their care was no different than that provided by more formally qualified providers, like those with MBBS degrees. Experience was believed to be just as im-portant to that group’s practice, even though they had some level of formal training.

Individuals who desired experiential entry into medicine could also find work relatively easily through auxiliary jobs, such as working as ward-boys or government compounders. This low barrier to entry appears to encourage people to work as informal providers.

Diversity of opportunities in the medical field encourages informal providers to fill the various niches available.

The medical field in rural UP is very diverse, and there are opportunities for providers to fill different roles. Although the need for formal qualifications somewhat limits these opportunities, in general, the low barrier to entry means that it is relatively easy for people to fill various roles in the health care system. For ex-ample, if an ASHA or other CHW cannot or will not fulfill the needs of the community, other informal providers may seize the opportunity to fill the open niche. In one community, the lack of a channel between households and the public health system seemed to contribute to the popularity of a dai, who performed most deliveries in the village and was highly respected in the community. She was able to make a stable income to support her family and had a high social standing in the village. In another village, where connections to the public health system were similarly weak, we found a successful female informal provider who specialized in ma-

Section 4: Opportunities for Entry

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Opportunity Areas

ternal and women’s health and who handled many deliveries. Informal providers fulfilled unmet health care niches in other areas besides maternal and women’s health, including Bengali medicine (detailed in Section 5), and pediatric care.

There are many unmet needs in rural villages that informal providers may identify and fulfill. Due to the sometimes-opportunistic entries into those fields, informal providers often have career trajectories that vary wildly from medicine. For example, the female informal provider above ran an orphanage before enter-ing medicine. An enterprising individual can viably find a position or niche to fill in a health care setting as diverse as rural UP, no matter their background.

Easy accessibility of pharmaceutical knowledge and supplies enables informal providers to practice.

The distribution and accessibility of pharmaceutical products for providers was a key component of the health care system in rural UP. Prescription pharmaceuticals were easily obtainable, as was knowledge about them. This ease of availability further contributed to the low barrier to entry into the medical field. Providers learned about how to obtain and administer pharmaceuticals through widely available tools such as a CIMS manual (often referred to as “Drugs Today”) and Medical Representatives (MRs), among others. Ad-ditionally, providers purchased pharmaceutical products from MRs or from a wholesale market.

CIMS MANUAL Informal providers often used CIMS manuals as references tool known as the CIMS manual. It served as a major source of information about new pharmaceuticals and the distribution of medicine. This reliance on a commonly available resource further illustrates the low barrier to entry into medical practice.

MEDICAL REPRESENTATIVES Informal providers also used MRs to learn about new drugs and medicines. MRs are employed by phar-maceutical manufacturers or distributors to act as salesmen. They visit providers and advertise their wares. However, MRs often provided more services to informal providers than selling drugs and medicines -- often acting as sources of new knowledge about drugs. Providers reported that despite not always buying products from MRs, they still regarded them as important sources of new information about medicines.

EASILY AVAILABLE DRUGS While there are restrictive trade laws that prevent direct purchase of medical supplies by pro-viders from stockists, providers could obtain med-icine from the previously mentioned MRs, from a local wholesale market, or from local pharmacies. Informal providers bought medicines from the vis-

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iting MRs or went to the wholesale market, depending on which source had better prices. Providers, irre-spective of their qualifications or education levels, often used Leader Road Wholesale Market as the source of some or all of their medications. In addition to these sources, there is an abundance of local pharmacies from which informal providers and patients can buy a wide variety of medicines such as antibiotics, steroids, and others. While some providers ordered from MRs and had drugs delivered to their practices, others went directly to Leader Road every week. All seemed to have easy access to any necessary drugs without the threat of governmental or outside intervention. Because pharmaceuticals are so easily available, it is much easier for informal providers to enter the medical field and dispense medicines informally.

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Section 5: Determinants of Behavior as a Practicing Informal Provider

After informal providers enter the field there are several factors that motivate their practice behav-iors. Although our interviews did not aim to assess the quality of the health care provided, we sought to iden-tify why providers continue to provide health care in rural areas and how these considerations impact how they perceive the care they provide. formal providers enter the field there are several factors that motivate their practice behaviors. Although our interviews did not aim to assess the quality of the health care provided, we sought to identify why providers continue to provide health care in rural areas and how these consider-ations impact how they perceive the care they provide.

Informal providers must strike a balance between keeping costs low while remaining financially solvent.

Informal providers feel pressure to maintain competitive prices to retain patients and stay in the mar-ket. Methods of keeping prices low included not charging consultation fees, giving discounts or charging mar-ket price on medicines, allowing patients to use a credit system, or, at times, forgiving payments.

We most often observed informal providers practicing in rural areas where there was largely no im-mediate access to formal providers. In these settings, there were anywhere from one to several informal pro-viders looking to capitalize upon the market of customers. No matter the number of informal providers in a community, these providers noted the need to employ several methods to retain patients, many of which were financially rooted.

In rural areas, providers’ primary patient base was comprised of individuals who could often not af-ford to pay for private, formalized care. Nevertheless, providers noted that their desires to compete with the household perception of private formal hospitals as being “superior” to the local informal providers affects their behavior as practitioners.

Their main methods to retain patients differentiated them from other more qualified providers. Infor-mal providers mostly did not charge consultation fees, instead charging only for medicines. This price break was granted for two reasons: maintaining a reputation and the inability of patients to pay for more expensive services. Patient retention in these areas was critical, especially given that word of mouth was a primary mode of advertising each provider’s respective services. Because many of the villagers in these areas were either farmers or daily wage-based laborers who make very modest livings, they were unable to afford more expensive care. Therefore, informal providers needed to maintain favorable impressions within the commu-nity to sustain their businesses.

As one provider noted, “if people can barely pay for medicines, if at all, then how will they pay for fur-ther consultation fees?” At the same time, informal providers also recognized that they provided a cheaper financial option for patients. An informal provider noted that if a poor person made Rs. 100 (1.6 USD) per day, this person would not be able to afford a private provider who charged consultation fees among other medi-cal fees. This option would result in charges of upwards of Rs. 300 (4.8 USD), making this financially unviable despite potential quality differences. Therefore, the informal providers viewed this pricing differential as key

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to providing patients with much-needed care.

An informal provider’s medicine-dispensing patterns might also be dictated by the patient’s ability to pay. For example, an informal provider noted that he would only dispense one to two days of medication at a time because patients would not be able to pay for extended doses. In this case, the patients’ symptoms and reaction to the medicine could also be monitored, and the patient could be treated as necessary. This maintained low prices for the customer while also sustaining communication with the patient, as the patient would have to report back with updates in order to receive more medicine. Many patients could not afford even minimal medicine costs, particularly because their daily wages were very low. This money was used for other household responsibilities in addition to medical care and often was not sufficient.

To keep track of the credits extended, informal providers maintained handwritten lists and accounts of their patients, noting the medicines and charges that customers would eventually pay. Informal providers acknowledged that this system often leads to financial losses. Some patients could only repay in multiple installments; others would take several days to pay their bills. Additionally, a notable percentage never paid the informal providers; such individuals were often very poor. Informal providers recognized that these types of losses were nearly inevitable to maintain clientele.

Some informal providers charged different customers at varying rates for medicine. If a person was un-able to afford the medicine, an informal provider might reduce the price to make this a viable source of care. To compensate for this loss of profit, providers might use generic medicines, which were often considerably cheaper.

Table 3: How Informal Providers Built Favorable Reputations

Accessible 24 Hour Care • Were available for consultation in cases of emer-gencies 24 hours a day/7 days a week

• Made house calls • Established practices in highly visible and easily

accessible central location in villageSpecialization • Some informal providers established themselves

as specialty care providers which helped attract clientele

• Female providers fulfilled unmet maternal health care needs, providing support for pregnant wom-en in village

• Bengali doctors practiced a particular form of tra-ditional medicine with a focus on skin conditions and hemorrhoids

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Maintaining a favorable reputation in the community motivated informal providers’ decision-making processes for when and how to treat patients.

In small rural communities, reputation formed a key component of an informal provider’s’ practice, influencing the success of the business as well as their community presence. Due to the illegality of their prac-tice, informal providers cannot advertise, making reputation even more critical to maintaining their practices. Many of these providers noted that their customer bases consisted primarily of repeat customers and that new customers would come to them from nearby areas upon hearing of the care they provided.

Informal providers built favorable reputations by referring patients whose conditions are outside of their scope of expertise, providing accessible 24/7 care, and delivering niched services in rural settings. Infor-mal providers recognized their niche of treating lower-level ailments. In fact, many informal providers refused to involve themselves in more complicated cases, suggesting that patients seek out other providers in those cases. In these instances, providers often referred patients out to other providers. They noted that if a case were to turn out poorly, their business would be affected, since that patient’s family and other community members would be skeptical of the level of care provided. Providers acknowledge that a relatively clean track record with few case complications helped their practice and influenced what types of medical issues they saw.

Accessible 24-hour care

Informal providers set themselves apart by providing convenient care to patients in rural areas. In con-trast to formal providers, who often have established clinic hours, informal providers, who sometimes lived in the villages in which they practiced, would offer 24/7 consultations in cases of emergency. Apart from their normal clinic hours, these informal providers were often located in the heart of their villages, allowing people to contact them at any hour. Furthermore, informal providers made home visits in certain cases, making them a personalized and convenient option in rural areas. This service distinguished them as a desirable source of care, particularly due to transportation constraints to other facilities.

Because informal providers could not outwardly advertise their practices, they said patients often had difficulty finding their practices. This motivated providers to move their practices to highly visible and easily accessible locations. Not only did this mitigate the difficulties patients had finding a particular practice, but it also increased a provider’s traffic and was a mechanism to compensate for limited advertisement.

Specialty Care

Informal providers at times provided care that filled a particular niche in rural settings, administering “specialty” care of some sort. Notable examples from our field studies include pregnancy care, skin treat-ment, and care for piles (hemorrhoids). Informal providers used this specialty care to establish a positive reputation and address perceived community health needs.

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Female informal providers addressing pregnancy Of the three female informal providers interviewed, all worked with pregnant women and provided delivery services. These women either had their own delivery clinics or worked as a dai, delivering several babies per month. All of these women noted that they were well established and fulfilled their communities’ desires to have a local private provider to deliver babies. One female provider noted that it was important for her to do her job where she lived, which was a relatively remote area. She stated that there are not many resources for women in rural areas, making this work even more important to support women. Specifically, she reported that her ability to be reliably accessible to women at any time of day made her an important and valued community resource.

Bengali Doctors Though Bengali Doctors do not necessarily hail from the state of Bengal, they are colloquially known by this title, indicating their style of treatment. These providers explained that their informal training consist-ed of exchanging trade secrets for treating skin conditions and piles with other Bengali Doctors. Because of their unique medicines and style of treatment, the term “Bengali Doctor” is often associated with informal specialized care. These informal providers recognized that people associate them with this type of care and subsequently capitalize upon these expectations by continuing to provide this specialized care. These provid-ers were happy to fulfill this niche, as it helps to establish their practice.

Informal providers did not feel they compromised their reputation despite having to sometimes operate under a false pretense to evade government regulation.

Unregistered providers who were illegally practicing medicine intentionally misrepresented their prac-tices most often as medical stores. For the purpose of evading regulatory trouble, certificates were proudly offered up by the providers to support their alleged right to operate as a medical store or NGO. One provider even sought out an alternate form of “registration” in order to legitimize the practice, registering as an NGO. Providers felt that these business operations did not change their value within the community, believing that community members sought them out for services to an equal extent in comparison to alternate business practices.

Patient demands influenced informal provider behavior, shaping medical care decisions.

Providers of all education levels consistently reported that all patients expected to receive medicine during their medical treatment visits. Irrespective of a provider’s education level and business practices, patients routinely, if not always, expected to receive some form of medicine upon a visit to a medical provider. According to providers, patients expected a prescription, though they did not normally request a specific medicine. These expectations were so firmly engrained into the health care system that some providers, especially MBBS providers, expressed feelings of pressure to administer medicines, even when they felt that such medicines were unnecessary for the patient’s condition. In order to ease such tension, providers said they administered medicine that would

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not hurt the patient, but would provide the patient “peace of mind.” One MBBS provider described giving out B-Complex vitamins when other medicines were not appropriate.

Informal providers claimed that patients might insist upon receiving certain medications based on hearsay, past use, or other sources of information. Informal providers typically used their own judgment about which medicines to give to patients. Based on patient experience with medicines and reported side effects, providers altered their repertoire of drugs used in order to maximize drug suitability and achieve op-timal patient satisfaction.

Perceived patient demand for particular types of medicine influenced the medicine that informal providers prescribed. High patient demand for allopathic and homeopathic medicines was observed. Providers often devi-ated from prescribing medicine that they might have been trained to provide in order to prescribe medicine that better meet the desires of patients. These providers were typically trained in Unani or Ayurvedic med-icine, holding either a BUMS degree or BAMS degree. One such BUMS provider explained that he prescribes sixty percent homeopathic medicine and forty percent allopathic medicine. His patients are normally given prescriptions for homeopathic or allopathic medicines and then directed to pick up their medicine from a drug store. Another provider, also educated in Unani medicine, reported that his practice mixes allopathic, Ayurvedic, and homeopathic medicines to suit the desires of his patients.

Providers consistently reported high patient demand for allopathic medicines. A BAMS degreed provid-er noted that he predominantly dispenses allopathic medicine and rarely dispenses the less-desired Ayurve-dic medicine. Such variability within these providers’ prescription and dispensing patterns demonstrates that patient demands for allopathic and homeopathic medicines seem to influence practitioner behavior.

Despite perceiving injections as less preferable than oral medicine, informal providers feel pressured to give into demands for injections. Informal providers held varying opinions about injection use. Many noted that injections could have adverse side effects, and they were hesitant to freely administer them. However, providers believe that there are several conditions for which injections are necessary, including malaria, dehydration, stomach pain, and excessive diarrhea or vomiting leading to fluid loss. Additionally, while many acknowledged that it was not their preferable route of medicine administration, several informal providers said that satisfying patient de-mands was important to maintain their reputations. For instance, some informal providers noted that uned-ucated or older people often believed that the injections, due to a faster mechanism of action, were more de-sirable. Such patients often demanded injections to reduce their pain or other symptoms. If a patient insisted, informal providers often gave in to these requests by administering either the requested injection or a place-bo vitamin injection. If individuals brought in injections to an informal provider, some would be comfortable administering this injection.

In general, most informal providers preferred to selectively use oral medicine before injections. This contradicts prior research that has reported that informal providers freely administer injections. It is worth noting that informal providers are not aware of any regulation about which injections they could use or any

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recommendations or instruction about the proper use of injections.

Informal providers are often intrinsically motivated to fulfill unmet health care needs as a service to their communities.

Maintaining a positive reputation among village members helped informal and private providers main-tain their patient base. While exhibiting leniency for patients with fewer financial resources was an important component of how providers maintained a favorable reputation, acting charitably also seemed to play a role in being lenient towards patients with fewer financial resources.

Many providers, especially small informal providers, expressed an awareness of the low socioeconom-ic status of the majority of their patients. This awareness was often used as justification for allowing patients to pay on a credit system, for trying to keep prices for clinic visits and treatments low, and even for forgiving some costs. One formal provider who ran a women’s health clinic said that although she does not get fully re-imbursed for RSBY services, she continues serving patients with RSBY cards because she is benefitting society and government programs such as RSBY and JSY are beneficial. Informal providers commonly expressed that they were serving their communities in a charitable or noble manner. For example, one informal provider who contracted MBBS physicians to practice in his clinic said he ran on small margins and cited the “Muslim pillar of charity” as to why he serves poor patients.

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Section 6: Conclusion

Although informal provider practice is currently a much debated topic, little is known about informal provider motivations for practicing medicine and the factors that affect their clinical decisions. Both of these areas in turn affect patient wellbeing and health outcomes. It is imperative that policymakers, those invested in improving rural health care and those interested in government’s interactions with informal providers more thoroughly explore informal providers’ roles with-in rural communities. Our research demonstrates that rural informal providers do not function in a vacuum. Rather, they re-spond to and work directly with other established and formalized components of the health care system, in-cluding both private formal providers and the public health care network in rural communities via community health workers. Additionally, the threat of government oversight sometimes motivates informal providers’ business practices, including how they advertise or register their businesses.

We broadly describe a population of rural informal providers with an intricate set of behavioral moti-vations. They might enter medicine because it is an accessible job. Yet, after they begin practicing, the desires to both help and satisfy patients in their communities are major motivations. Simultaneously, they are mind-ful of how their clinical decisions, such as whether to administer an injection, may affect their reputation, clientele, and the survival of their business. It is not our prerogative to pass judgment on informal provider practice and its overall effect on rural health, nor do we intend to advocate to policymakers on how to approach informal providers legislatively. Rather we attempt to highlight and assess the factors—both intrinsic and external—that may influence infor-mal providers and their behaviors.

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Section 7: References

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3. MAQARI Team. Mapping medical providers in rural India: four key trends [Internet] Centre for Policy Research; New Delhi: [cited 2012 Nov 6]. 2011 http://cprindia.org/sites/default/files/policy%20brief_1.pdf.

4. George A, Iyer A. “Unfree markets: Socially embedded informal health providers in northern Karnataka, India.” Social Science & Medicine. 2013: 96: 297-304. Doi: 10.1016/j.socscimed.2013.01.022.

5. Elamon, Joy. “Query: Informal Health Care Providers in India-Examples, Referrals.” ftp://ftp.solutionexchange. net.in/public/mch/cr/cr-se-mch-16081001.pdf

6. Rao KD, Stierman E, Bhatnagar A, Gupta G, Gaffar A. “As good as physicians: patient perceptions of phy sicians and non-physician clinicians in rural primary health centers in India.” Global Health, Science and Prac- tice 2013;1(3):397-406. doi:10.9745/GHSP-D-13-00085.

7. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D (2013) “What is the Role of Informal Healthcare Provid ers in Developing Countries? A Systematic Review.” PloS ONE 8(2): e54978. doi:10.1371/journal.pone.0054978

8. Das, et. al. “In Urban and Rural India, A Standardized Patient Study Showed Low Levels of Provider Training and Huge Quality Gaps.” Health Aff(millwood). 2012 December; 31(12); 2774-2784. doi:10.1377/ hlthaff.2011.1356.

9. Aitken M, Backliwal A, Chang M, Udeshi A. “Understanding Healthcare Acces in India What is the current state?” IMS Institute for Healthcare Informatics. 2013.

10. Chaudhury N, Hammer J, Kremer M, Muralidharan K, Rogers FH. “Missing in action: teacher and health worker absence in developing countries.” J Econ Perspect. 2006 Winter; 20(1):91-116.

11. Lewis, Maureen, “Governance and Corruption in Public Health Care Systems.” Center for Global Development Working Paper. January 2006. No. 78. Available at SSRN: http://ssrn.com/abstract=984046 or http://dx.doi.org/10.2139/ssrn.984046

12. Choi, Bina, ISERDD, Meera Ragavan, Himabindu Reddy, and Roshan Shankar. “Institutional Deliveries in Rural India: Understanding Behaviors and Motivations.” Stanford-ISERDD Collective. 2013. 17-18.

13. Kumar, Ashok. “Regulation of Medical Practitioners in India.” Government of India. 2014.

14. The Indian Medical Council Act. 7 Indian Parliament. [15] 3, 102 (1956). 30 December 1956. http://www.mciin dia.org/acts/Complete-Act-1.pdf

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15. Lim, S. S. et al. “India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.” The Lancet. 375, 2009-20223 (2010).

16. National Health Mission. Ministry of Health & Family Welfare, Government of India. December 16, 2013. http:// nrhm.gov.in/nhm/about-nhm/goals.html.

17. Reproductive and Child Health. At <http://www.nihfw.org/Activities/Projects_RCH.html>

18. Pulse Polio Programme. (National Rural Health Mission, 2013).

19. Revised Rates of Contraception. (Jansankhya Sthirata Kosh). at <http://www.jsk.gov.in/revised_contracep tion.asp>

20. “A brief note on Janani Shishu Suraksha Karyakram, the new initiative of Ministry of Health and Family Wel- fare.” (National Health Mission, Ministry of Health and Family Welfare). at <http://nrhm.gov.in/index.php? option=com_content&view=article&id=79&Itemid=194>

21. “Rastriya Bal Swasthya Karyakram (RBSK)- Child Health Screening and Early Intervention Services under NHM. (National Rural Health Mission).” at <http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-im munization/child-health/guidelines.html>

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Health Indicator Allahabad UP Averages

% institutional deliveries 25 26.6Mean maternal age at birth 19.6 19.7Mean maternal education 1.59 1.60Mean wealth index 0.054 -.054% Villages with trained birth attendant 93.7 81.6% Villages with SC 92.1 88.9% Villages with PHC 26.3 31.9% Villages with District Hospital 0 1.56% Villages with Private Hospital 23.7 18.3% Villages with primary school (govt) 89.5 87.4% Villages with primary school (private) 84.2 91.6

*Data from: DLHS

Table 1: Public Health and Maternal Health Care Indicators for Allahabad and UP*

Table 2: Breakdown of Villages Visited Based on Relative Location (See Map on page 32)

Village Name Block District District fromnearest PHC/CHC

Distance from majorroad (such as state or national highway or any busy con-nected road?

Kaudihar Kaudihar Allahabad 0 km 0Bhagayapur 7 km 3Fathupur 7 km 3Tikari 8 km 4Hathgah 7 km 0Naseerpur Navabganj Allahabad 6 km 9Korali 4 km 7Malak Chaturlipuri Soraon Allahabad 4 km 0.5Prashadpur 2.5 km 0.5Phaphamou Phaphamau Allahabad 0 km 0Karchhana Karchhana Allahabad 0 km 0Shamri Kondhiyara Allahabad 7 km 3

Section 7: Appendix

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Village Name Block District District fromnearest PHC/CHC

Distance from majorroad (such as state or national highway or any busy con-nected road?

Akoda 7 km 7Kareha 3 km 3Salempur Saidabad Allahabad 3 km 7Fathuha 3Mohanganj 6Bhagwatpur Kaudihar II Allahabad 1 km 0Barwa 1 km 0.5Sallahpur Chale Kaushambi 6 km 0Bahadurpur Manjhanpur Kaushambi 10 km 2MalikpurBhagatpurNaini 0

Table 3: Number of Public Health Facilities Visited in Allahabad District

Facility Types Visited

District Hospitals 1Community Health Center 2Primary Health Center 0Subcenters 1Private Hospital 7Private Clinic 20

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Actor Interview Type Total

Superintendent Personal Interview 1ASHA Personal Interview 5

Focus Group 2ANM Personal Interview 4Anganwadi Personal Interview 4Dai Personal Interview 1Men Focus Group 8Women Focus Group 10Ambulance Staff Personal Interview 1Village Headman Personal Interview 1Formal Medical Providers Personal Interviews 10Informal Medical Providers Personal Interviews 9Paramedical Providers Personal Interviews 10Medical Represtatives Personal Interview 2Medical Stockists Personal Interview 2

Table 4: Number of Interviews Conducted, by Actor, Interview Type