Gautham Meenakshi, Shyamprasad K M, Singh Rajesh, Zachariah Anshi, Singh Rajkumari, Bloom Gerald
London School of Hygiene and Tropical Medicine, London, UK, Centre for Research in New International Economic Order, Chennai, India, Garhwal Community Development and Welfare Society, Tehri Garhwal, Uttarakhand, India and Institute of Development Studies, Brighton, UKLondon School of Hygiene and Tropical Medicine, London, UK, Centre for Research in New International Economic Order, Chennai, India, Garhwal Community Development and Welfare Society, Tehri Garhwal, Uttarakhand, India and Institute of Development Studies, Brighton, UK
London School of Hygiene and Tropical Medicine, London, UK, Centre for Research in New International Economic Order, Chennai, India, Garhwal Community Development and Welfare Society, Tehri Garhwal, Uttarakhand, India and Institute of Development Studies, Brighton, UK.
Health Policy Plan. 2014 Jul;29 Suppl 1(Suppl 1):i20-9. doi: 10.1093/heapol/czt050.
Rural households in India rely extensively on informal biomedical providers, who lack valid medical qualifications. Their numbers far exceed those of formal providers. Our study reports on the education, knowledge, practices and relationships of informal providers (IPs) in two very different districts: Tehri Garhwal in Uttarakhand (north) and Guntur in Andhra Pradesh (south). We mapped and interviewed IPs in all nine blocks of Tehri and in nine out of 57 blocks in Guntur, and then interviewed a smaller sample in depth (90 IPs in Tehri, 100 in Guntur) about market practices, relationships with the formal sector, and their knowledge of protocol-based management of fever, diarrhoea and respiratory conditions. We evaluated IPs' performance by observing their interactions with three patients per condition; nine patients per provider. IPs in the two districts had very different educational backgrounds-more years of schooling followed by various informal diplomas in Tehri and more apprenticeships in Guntur, yet their knowledge of management of the three conditions was similar and reasonably high (71% Tehri and 73% Guntur). IPs in Tehri were mostly clinic-based and dispensed a blend of allopathic and indigenous drugs. IPs in Guntur mostly provided door-to-door services and prescribed and dispensed mainly allopathic drugs. In Guntur, formal private doctors were important referral providers (with commissions) and source of new knowledge for IPs. At both sites, IPs prescribed inappropriate drugs, but the use of injections and antibiotics was higher in Guntur. Guntur IPs were well organized in state and block level associations that had successfully lobbied for a state government registration and training for themselves. We find that IPs are firmly established in rural India but their role has grown and evolved differently in different market settings. Interventions need to be tailored differently keeping in view these unique features.
印度农村家庭广泛依赖缺乏有效医学资质的非正规生物医学服务提供者。他们的数量远远超过正规服务提供者。我们的研究报告了两个截然不同地区的非正规服务提供者（IPs）的教育程度、知识水平、行医方式及人际关系：北方北阿坎德邦的特里加瓦尔和南方安得拉邦的贡图尔。我们绘制了特里加瓦尔所有9个街区以及贡图尔57个街区中的9个街区的非正规服务提供者分布图，并对他们进行了访谈，然后深入访谈了一个较小的样本（特里加瓦尔90名非正规服务提供者，贡图尔100名），了解他们的市场行为、与正规部门的关系，以及他们对基于诊疗规范的发烧、腹泻和呼吸道疾病管理的知识。我们通过观察他们与每种病症的三名患者的互动来评估非正规服务提供者的表现；每位提供者观察九名患者。两个地区的非正规服务提供者教育背景差异很大——特里加瓦尔的非正规服务提供者接受学校教育的年限更长，之后获得各种非正规文凭，而贡图尔的非正规服务提供者更多是学徒出身，但他们对这三种病症的管理知识相似且水平较高（特里加瓦尔为71%，贡图尔为73%）。特里加瓦尔的非正规服务提供者大多在诊所行医，配发西医和本土药物的混合药剂。贡图尔的非正规服务提供者大多提供上门服务，主要开处方并配发西药。在贡图尔，正规的私人医生是重要的转诊提供者（有佣金），也是非正规服务提供者新知识的来源。在两个地点，非正规服务提供者都开出了不适当的药物，但贡图尔使用注射剂和抗生素的比例更高。贡图尔的非正规服务提供者在州和街区层面的协会中组织良好，这些协会成功游说州政府为他们进行注册和培训。我们发现，非正规服务提供者在印度农村地区已稳固确立，但他们的角色在不同的市场环境中以不同方式发展演变。鉴于这些独特特征，干预措施需要进行不同的调整。
