Understanding informal markets: the roles and perspectives of RMPs in West Bengal and Karnataka, India

Asha George, Barun Kanjilal, Aditi Iyer

Who are RMPs?

• ‘Registered / Rural Medical Practitioners’: – ‘a person who has permission to practice’ – no longer true but regulations not enforced

• Practice allopathic medicine with no formal training– (1) with no formal training in any system of medicine– (2) with degrees from institutions unrecognized by

government medical education boards– (3) with Indian Systems of Medicine medical degrees from

institutions recognised by government medical education boards (AYUSH: Ayurveda, Yoga, Unani, Siddha, Homeopathy) (also understood as cross-practice)

Karnataka

West Bengal

Data Sources

• West Bengal (Malda, Bankura, and North 24 Parganas districts)– household survey, n= 3152

• two stage sampling, first 35 primary sampling units (PSUs) based on PPS (probability proportion to size), then 30 households from each sampling unit based on a systematic random process

– provider survey, n= 71 RMPs • random selection of rural PSUs from household survey, then lists of

RMPs in selected PSUs developed and at least one selected

• Karnataka (Koppal district)– provider census, n= 91 RMPs

• from 60 villages in project site and surrounding towns and market villages

• 49 no degrees vs. 42 unofficial degrees

– Observation and interaction over approximately 9 months continuously & 4 years intermittently

Karnataka: Census of private providers in project area, 60 villages

with approximately 82,000 people

• 35 spiritual healers• 133 traditional healers• 178 traditional birth attendants

• 152 provision stores selling tablets• 2 medical shops

• 47 RMPs• 1 Ayurvedic doctor• No private qualified allopathic doctors (except for

government doctors moonlighting)

Table 1: Percentage of households usually seeking treatment for minor ailments, by sources of care % of households usually seeking treatment for minor ailments from

Total Rural Urban

Number of households interviewed

3152 2404 748

RMP 68.3 80.1 30.5 Local chemist shop 26.8 18.3 54.1 Traditional healers 2.5 2.9 1.2 Government facilities

53.8 56.8 44.3

Private qualified doctor

41.2 32.2 70.1

Government doctor doing private practice

11.2 8.6 19.7

Others 6.9 6.4 8.3 * Total is more than 100% due to multiple responses

West Bengal: How important are RMPs as a source of care for rural and urban households?

Table 2: Percentage of affected persons actually sought treatment from RMPs, by per capita expenditure quintiles % of persons sought treatment for minor ailments from RMPs

Rural Urban

No. of persons treated

% of them

treated by

RMPs

No. of persons treated

% of them

treated by

RMPs

Poorest quintile 1,056 53.69 295 33.90 Next 20% 1,083 52.26 309 26.86 Next 20% 1,075 53.67 296 15.20 Next 20% 1,079 59.50 284 10.92 Least poor quintile 991 48.94 266 4.89 Total 5,284 53.69 1,450 18.76

West Bengal: Which households use RMPs?

Figure 1. Average out-of-pocket payments for treatment of minor ailments, by sources of treatment (in Rs.)

73.574.6

339

67.8

137.5

231.9

0

50

100

150

200

250

300

350

KM

Rural Urban

RMP

Public

Private qualified

West Bengal: How much do households spend out of pocket per provider?

West Bengal: How far do households go to access each provider?

Figure 2. Average distance to sources of treatment for minor ailments, (in Kilometers)

0.68

1.48

6

0.370.66

1.34

0

1

2

3

4

5

6

KM

Rural Urban

RMP

PHC

Private clinic

West Bengal

Household reported preferences for RMPs1. close location 2. always available3. cheap…..4. availability of

medicines5. scope to pay later or by

installments

RMP reported practices

• 90% of RMPs reported working around the clock,

• 80% provided medicines

• 85% negotiated delayed payment

Karnataka: RMPs No fixed location or timings

…the RMP method. This means going from door to door to give treatment. People will not come to the clinic. (Upper caste RMP with unofficial degree)

If we fix timings for our clinic, it’s an insult to the patient. One cannot know when one is going to fall sick. Only if we are ready to give treatment whenever it is needed, we will be known as good doctors. If I sleep for two nights in a week, I am lucky. (Upper caste RMP with no degree)

Karnataka: Setting up practice Main motivations

• People contact Known people were here. They used to come to my

uncle for treatment. They told me that there was no doctor here. That is why I came. (Muslim RMP with no degree)

• Main reason: good earningsI came here for the sake of filling my stomach as the

income is good. (Lower caste RMP with no degree)

• No RMP listed helping people as a motivation

Karnataka: RMP Credibility Although not bound by treatment protocols or regulatory

standards, RMPs are still answerable to patient demands• Do not collect payments until cure is tangibleWhen I give treatment, in case the patient doesn’t get immediate

relief, they behave badly…they trouble me without giving me any money, so I have to keep quiet. (Upper caste RMP with unofficial degree)

• Scare tactics when complaints ariseI told him that without my treatment, he had chances of getting

typhoid. All doctors do like this because people don’t believe us. (Upper caste RMP with unofficial degree)

• Cross-practice & curative commoditiesIf we ask a patient with high fever to drink cumin and ginger

solution, they won’t bother to return to us for health. We have to give them injections and tablets. (Upper caste RMP without any degree)

Karnataka: RMP self-restraint

• I do not treat serious patients…I can fight with disease, but not with the God of Death (Yama). In case the patient dies, the community will blame us. (RMP with unofficial degree)

• Even if I am not confident that I can give treatment, I send serious patients elsewhere. If something goes wrong, we are the ones who will get a bad name. (RMP with unofficial degree)

• Reputation matters• RMPs clinical periphery of formal providers• Complimentary vs. competitive

Karnataka: RMP referral

• Those less qualified more likely to refer to government vs. private

• If it’s a major ailment involving more syringes or expenses, I send them to the government hospital. (RMP with unofficial degree)

• Strategic co-production: provider networks share information as well as patients

• Financial: RMPs also received kickbacks from Govt & more formal private providers

West Bengal: Do RMPs facilitate timely access to care?

• 60 % rural hospitalized persons initiated their treatment with RMPs

• And prior to hospitalization they on average undertook treatment for 33 days and spent on average Rs. 1400

Karnataka: RMP fees

• Balance of power assumed to be with providers

• But ‘free’ care for the poor = delayed payment• Not concession but fait accompliWe cannot demand any fixed amount from the

people in the villages. If we insist on a fixed amount, from the next day onwards people will stop coming. Then we will have to sit swatting flies. Our practice will end and we will have to leave. (Muslim RMP without any degree)

Karnataka: RMP fees• Delayed payments ensures continuity of care. Reflects not

a one time exchange, but series of interactions Here many people go for daily wages. When they get earnings

they will pay…They treat us like their own family members and we also look after them with the same love. (Muslim RMP without any degree)

• Patients inability to pay: daily wage & seasonal employment

• Entails financial riskNo doctor will stay for a long time because people are very

rough. After taking treatment, they will ask for credit. I have yet to recover Rs. 8,000. From where can I raise this money? (RMP with an unofficial degree)

Karnataka: RMP fees

• Securing clients through fee structureFor house visits to regular patients I charge Rs.10, but

for others I charge Rs.20. (upper caste RMP without any degree)

• Inability to charge known peopleMy earning is not so good after coming here, because

here people are well known to me. But I don’t want to practice in other places, as here I am closer to my native place. Therefore I am running transportation now and have lost interest in my RMP practice. (RMP with no degree)

Reciprocity & Fragile Dependency• ‘People contact’: relocation & protection• Communities have few alternativesOnce there was a police complaint against me and the police came.

But the village people told the police to leave me alone, because if there is any problem at night, there is no one in this place to help them. (upper caste RMP with an unofficial degree)

• But communities can retaliate through rumor and mob violence

One person had a heart attack and despite my pumping on his chest, he expired. The villagers started spreading rumours that I had done something to kill the patient (upper caste RMP with unofficial degree)

Once an RMP doctor handled a delivery case, but the baby could not be saved. As the baby died, people beat the RMP (RMP without any degree)

Conclusions: Informal markets as negotiated social institutions mixing

economic and social interests

Within these negotiations, trust, reciprocity, reputation emerge, both as a function of familiarity and rapport, as well as a function of vulnerability and a lack of alternatives. This calls for a more nuanced understanding of agency, trust and reciprocity, as not just mythic behaviors or aspirational ideals, but also as fragile and negotiated relationships within the political-economies they inhabit.

Quality of market and service provision overall: networks, incentives, vulnerabilities vs. narrow focus on individual provider quality of care in isolation from their social and political economy contexts

Acknowledgements

• Families and providers as respondents• Field investigators, NGO and government

collaborators• Donors:

– West Bengal FHS 1 & 2: DfID– Karnataka Gender and Health Equity Project: SIDA,

MacArthur Foundation, Rockefeller Foundation, Ford Foundation

• Mentors: Gita Sen, Amar Jesani, Hilary Standing