Improving primary healthcare: An evidence-based approach towards informal providers

What does inverting the S-I-A triangle mean for India?

The Indian health system is in a state of flux with rapid change at ground level. Our mainstream public sector outreach is increasing through Ayushman Bharat Wellness Centres and an increased focus on non-communicable diseases (NCDs), tuberculosis control and countering the spiralling menace of antimicrobial resistance. This seems to be working given that a recent paper from Rajasthan showed that expanding wellness centres led to a decline in mortality for the elderly as NCDs were more likely to be detected and managed¹³.

The question we then pose is whether the strategic inclusion of the informal healthcare providers might add further value and help us achieve our PHC goals even as the outreach of the public sector continues apace. While this question has been posed before¹⁴, what we bring to the table is an evidence-based approach to the question, which allows for further discussion to happen on the basis of the best available scientific evidence. We draw on two examples, documenting how such evidence can be generated in the case of informal providers.

Our first example asks whether training informal providers can improve their diagnosis and management of patients. This is not a foregone conclusion, but both perceived wisdom and careful economic theorizing suggest that such training can backfire if, for instance, it falsely increases the confidence of the population in their abilities and emboldens them to practice in a manner that is not commensurate with their training. To evaluate this question, researchers studied the Liver Foundation’s pioneering multitopic training programme, which included more than 50 classes over a nine-month period¹⁵. The team first randomized informal providers into a treatment group that received the training and a control group that did not. They then sent “standardized patients” or people recruited from the local community to present the same condition to multiple providers in both treatment as well as control groups. Uniquely, the team used a “triple-blind” randomized design, whereby Liver Foundation did not know what healthcare providers would be assessed on, healthcare providers did not know who the standardized patients were and standardized patients did not know which providers were in the treatment versus control groups. This strict design, which is a first for the evaluation of any training programme worldwide, ensured that the results accurately captured the impact of the programme on outcomes, independent of any biases or teaching to the test.

This landmark study showed that the training programme significantly improved correct management among informal providers so much so that the care they now provided was similar to that provided in PHCs in the few cases that such facilities were available¹⁵. However, it was also noted that the programme was unsuccessful at decreasing the use of antibiotics or other unnecessary medications.

The results of this trial inspired the Government of West Bengal to initiate a State-wide training programme for informal healthcare providers in 2017 that is still ongoing¹⁶. For this, nursing training centres are chosen as the training hubs and nursing tutors as the trainers. The curriculum has been developed by medical academics ratified by a Government committee and is being implemented in teaching classroom sessions of 4 h each week for 24 wk. Prior to initiating the programme, Accredited Social Health Activist (ASHA) workers enumerated informal health workers across the State and from this list, 50 in each community development block are included through a lottery for the six-month training course.

Our second example asks whether the trust and acceptance of informal healthcare providers can be utilized in emergency situations. During COVID-19, it became apparent that many patients could be managed at an off-hospital site as long as there was clear communication and the possibility of rapid transfer to a hospital if needed. The Liver Foundation, in coordination with local governments, set up eight COVID Care Centres, each led by a registered MBBS doctor and staffed by a combination of informal providers and nurses. These eight COVID Care Centres admitted a total of 113 patients between May 18 and July 5, 2021, 58 per cent of whom were female with an average age of 54 yr. The assessment of these centres showed that the patients came from large catchment areas and the vast majority were normally discharged (82%). The remaining were referred (16%) or made their own arrangements (2%). Encouragingly, there were no patient deaths and out of the 13 patients that arrived with critically low SpO₂ levels, eight could be stabilized at the Covid Care Centres and discharged in good condition^17.

These two examples indicate two different circumstances, ranging from regular care under ‘business as usual’ situations to care under emergency conditions. In both cases, the Liver Foundation was able to leverage the available resources to improve the availability and quality of care for rural populations in difficult to reach areas, ensuring that the programme juxtaposed trained providers with available resources on the ground. While the opportunistic use of informal providers is common on the ground, the discussed approach adds value by systematically marrying ground-level implementation with the generation of the best evidence of its efficacy. Both programmes provide some grounds for optimism in the ability to use informal providers to improve primary care in areas where fully qualified doctors are hard to find. Indeed, there is similar evidence to show that informal healthcare providers also have an important role to play in public health issues that seek innovative human resource solutions, such as tuberculosis control^18,19.