The Clinical Establishment’s Act 2010 –enacted in 2012- aims at regulating the public and private health sector with an emphasis on Quacks, or Unqualified Medical Practitioners (UMP) in India, adherence to standards and the elimination of quackery. That the law has made little headway in terms of implementation shows the gulf that exists between intention and action. The legal perspective provides no scope whatsoever for unqualified medical practitioners to be functioning. And yet, the non-implementation of stated provisions by almost everyone in the regulatory chain highlights the failure of the health system to check what is happening. Health managers at the sub-national and sub-state level know what is happening but prefer to look the other way when they see that political will is absent and their own administrative resources deficient.
India’s public health system in crisis: Too many patients, not enough doctors
In India, there is one government allopathic doctor for every 10,000 people, one government hospital bed for every 2,000 people and one state-run hospital for every 1,00,000 people. we don’t need an epidemic, however predictable, for the public health system to collapse. It is a matter of routine that patients share beds and doctors are overworked.
Only one in five doctors in rural India are qualified to practice medicine, found a World Health Organization (WHO) report on India’s healthcare workforce, highlighting the widespread problem of quackery. The WHO report, published in 2016, said 31.4% of those calling themselves allopathic doctors were educated only up to Class 12 and 57.3% doctors did not have a medical qualification.
In India, self-styled doctors without formal training provide up to 75% of primary care visits
Mrs. Shailaja Chandra, former chief secretary Delhi, who has worked in the Union health ministry and authored the report, Unqualified Medical Practitioners this year, shares her findings, “The lack of medical qualifications was particularly high in rural areas. The report brought out that whereas 58% of the doctors in urban areas had a medical degree, only 19% of those in rural areas had such a qualification,”.
“In the absence of doctors, quacks provide a service and cannot be wished away”, she further adds “What we need is an updated assessment of quackery by state and district, better enforcement to ensure they don’t indulge in high-risk practices such as use of injections and IV fluids, and selective training so they cause the least harm while improving access to first-line health care”.
Brushing dust under the carpet
Paradoxically over the year’s health policy experts have favoured the accreditation of UMPs (Unqualified Medical Practitioners ) even as professional bodies have overtly pushed for punitive action. These contradictions present enormous challenges for those who make policy. At least two state Governments have recently favoured training the UMPs as the less harmful approach and have plans to use them in the public health arena with some safeguards. The main challenges that need to be confronted can be summarized with the question: Is it better to stop the most harmful of the practices or continue to ignore a situation which although hugely disconcerting, seems to have no solutions? These are hard choices but a way out must be found as the UMP phenomenon has become too widespread to continue to be disregarded. Most importantly there has to be recognition of what the poor wage earner seeks –easy access, cheap and effective treatment and the security of going to a person known to the community. These perceived advantages cannot be easily supplanted by a health systems approach howsoever sound it may appear, because nothing can match what the UMP offers.
It is a well-known fact that in many States, quacks are operating in large numbers. Laws are so weak that even if the frauds are caught, they get bail on the following day and start practicing again.
Power hierarchy of the private sector
The UMP – much in demand but still a cog. Several studies have shown that the presence of UMPs is larger than all allopathic medical doctors collectively. Experts have referred to various research studies in which there is enough evidence to show that more than 80% of the population is dependent on the informal sector for outpatient care. The public health system too depends upon and equips UMPs to detect cases of tuberculosis, HIV AIDS and vector-borne diseases during seasonal outbreaks.
The phenomenon of UMPs must, therefore, be viewed not as an aberration and an island of occasional failure but as an extensive and integral part of the country’s health care system-albeit run privately and illegally. Owing to its scale it impacts on the health of consumers which must be seen as a public responsibility and addressed but not without understanding the role they play vis-à-vis private sector qualified doctors from whom they derive their limited knowledge as well as training about medical practice.
Qualified quacks!!! What are we up-to?
Offlate opinions have been raised to bring the quacks into the mainstream of health care service by providing a short duration crash course on some basic treatment procedures. In fact, in West Bengal, one such ‘study’ and ‘pilot project’ is already underway. But it is bound to raise eyebrows in many quarters of intellectuals. Health is an important subject and crash course shouldn’t be done to handover the lives of gullible patients to people with little or no knowledge. Little learning is always dangerous, as we say.
Whatever it may be, but everyone knows that lot needs to be done, effort needs to be put and policies need to be exercised…to do what?
Better look the other way…but how long can we??