Kamat V R
Department of Anthropology, Emory University, Atlanta, GA 30322, USA.
Soc Sci Med. 2001 Mar;52(6):885-909. doi: 10.1016/s0277-9536(00)00191-x.
The increased emphasis on privatization of the health care sector in many developing countries by international financial institutions and national governments expects an expanding role for private health care practitioners in the management of major communicable diseases such as tuberculosis, malaria, acute respiratory infections (ARIs) and sexually transmitted diseases (STDs). Largely unexamined in the Indian context, however, is the socio-cultural context, the micro-level political environment in which private practitioners carry out their activities, and the quality of care they provide to their patients. Examining these aspects is significant given the impressive growth of the country's private health sector during the past decade. This paper reports the results of an ethnographic study carried out in Mumbai (Bombay) and Nav Mumbai (New Bombay), India on private general practitioners (GPs) and their role in the management of malaria at a time when these two neighboring cities were in the midst of the worst malaria epidemic in over 60 years. Described are the characteristics of a sample of 48 private practitioners from the two cities, and their clinics. This is followed by a discussion of the data gathered through untructured interviews with practitioners and patients, and complemented by observational data on doctor-patient encounters gathered at 16 clinics over a 9-month period. The findings of the study suggest that many practitioners in Mumbai and Navi Mumbai were poorly qualified and did not play a supportive role in the two cities' public health departments to bring the epidemic under control. The majority of the practitioners adopted diagnostic and treatment practices that were not consistent with the guidelines laid down by WHO and India's National Malaria Eradication Programme. Very few practitioners, especially those practicing in low-income areas, relied on a peripheral blood-smear test to make a diagnosis. Practitioners whose clientele was mostly the poor commonly resorted to giving one-day treatment to febrile patients that included injectable antimalarials and broad spectrum antibiotics. Such practitioners justified their mode of diagnosis and treatment by asserting that they were only responding to the demands placed on them by their patients who could not afford a blood-smear test or a full prescription. The paper argues that practitioners who acquiesced to patient demands were at once exacerbating the health problems of their patients and jeopardizing the prospects for the epidemic to be brought under control. Driven primarily by the need to retain the patronage of patients and maintain one's popularity in a highly competitive health arena, many providers practiced medicine that was unethical and dangerous. The paper concludes by discussing the ramifications of this study for malaria control in Mumbai and Navi Mumbai, and highlights a few salient health policy issues concerning the growth of the private health sector in India and its regulation.
国际金融机构和许多发展中国家的政府日益强调医疗保健部门的私有化，这意味着私人医疗从业者在诸如结核病、疟疾、急性呼吸道感染（ARI）和性传播疾病（STD）等主要传染病的管理中将发挥越来越大的作用。然而，在印度的背景下，很大程度上未被审视的是社会文化背景、私人从业者开展活动的微观政治环境以及他们为患者提供的护理质量。鉴于该国私人医疗部门在过去十年中令人瞩目的增长，审视这些方面具有重要意义。本文报告了一项在印度孟买和新孟买进行的人种学研究结果，该研究聚焦于私人全科医生（GP）以及在这两个相邻城市处于60多年来最严重的疟疾疫情期间他们在疟疾管理中的作用。文中描述了来自这两个城市的48名私人从业者及其诊所的样本特征。接下来讨论了通过对从业者和患者进行非结构化访谈收集的数据，并辅以在9个月期间在16家诊所收集的医患互动观察数据。研究结果表明，孟买和新孟买的许多从业者资质不佳，在这两个城市的公共卫生部门控制疫情方面未发挥支持作用。大多数从业者采用的诊断和治疗方法与世界卫生组织和印度国家疟疾根除计划制定的指南不一致。很少有从业者，尤其是那些在低收入地区执业的从业者，依靠外周血涂片检查来进行诊断。客户大多为穷人的从业者通常会对发热患者进行为期一天的治疗，包括注射抗疟疾药物和广谱抗生素。这些从业者为自己的诊断和治疗方式辩护，称他们只是在回应那些负担不起血涂片检查或完整处方的患者对他们的要求。本文认为，默许患者要求的从业者既加剧了患者的健康问题，又危及疫情得到控制的前景。主要出于留住患者惠顾并在竞争激烈的医疗领域保持知名度的需要，许多医疗服务提供者的行医方式既不道德又危险。本文最后讨论了这项研究对孟买和新孟买疟疾控制的影响，并强调了一些与印度私人医疗部门的增长及其监管有关的突出卫生政策问题。
