Barriers of mistrust : Public and private health care providers in Madhya Pradesh, India

Sammanfattning: Background: In India, the foundations for a public role in the health sector were set at the time of her independence in 1947. Like other former colonies emerging from the war, India envisioned heavy state involvement in the provision of health services to all. The private health sector, at the time was limited to a few mission hospitals and some practitioners of Indian systems of medicine. Since then, there has been the steady growth of a heterogeneous, popular private health sector based on fee-for-service payments; so that now 93% of all hospitals and 85% of all qualified physicians are in the private sector. Aim: The thesis aims to study private and public health care providers and their characteristics in the province of Madhya Pradesh, India. Associations between provider distribution (both sectors) and social, demographic and economic characteristics of different districts of the province are also studied. The thesis also explores perceptions that policy makers in each health sector (public or private) have towards the other. Methods: In 2004, a survey to map all health care providers serving the 60.4 million people living in the province s 394 towns and 52117 villages (spread over 304000 sq. km) was done in collaboration with the Department of Public Health and Family Welfare, Government of Madhya Pradesh (Paper I) as part of the development of a management information system in the province. Providers were identified regardless of qualification and responded to a brief questionnaire administered by trained interviewers. The distribution of these providers in the province was analyzed (Papers II and IV).To study associations, background socioeconomic and demographic characteristics were obtained from secondary data sources, including the Census of India, government department records and the Madhya Pradesh Human Development Report. In particular, possible statistical associations between provider density and vulnerable population subgroups (the scheduled castes and tribes) were studied (Paper V). To explore perceptions that policy makers in the public and private health sectors had of each other (in terms of the motivations, kind of clients served, the attitudes of each sector toward the other), in-depth interviews with 16 provincial policy makers in the public and private health sectors were done (Paper III). Results: A total of 263,309 providers were identified. A typology was developed based on qualification. Of the 24,807 qualified physicians identified, 19,176 (77.3%) practiced in urban areas (where 26% of the population resides). Overall, three times as many physicians worked in the private sector as in the public sector. Private and public physicians were more densely (12 times and 3 times respectively) located in urban than in rural areas. Only 12.8% of qualified physicians practicing solo in the province were women. Access to women physicians was lower in the less-urban districts. In the case of the 94,019 qualified nondoctors (70% private), 67,153 (71.5%) served in rural areas, with a similar density in rural and urban areas. Only 3.4% were women. In addition, 55,393 traditional birth attendants (99.9% women) and 89,090 unqualified providers (80% men) were enumerated. Multiple formal and traditional systems of medicine were practiced. Most providers (84.4%) and institutions (94.5%) functioned for-profit. All provider densities were negatively correlated to scheduled caste proportions and positively to scheduled tribe proportions in the districts. With regard to perception, policy makers in the public and private health sectors perceived the other sector with a degree of mutual suspicion; morality and value conflicts between the two sectors were evident. The barriers of mistrust between the public and private sectors, which hinder true dialogue, are complex. They have social, moral and economic bases. The best chance of addressing these barriers is through necessary structural change, before any real long term significant partnership between the two sectors is possible. Conclusions: The thesis highlights the heterogeneity and dominance of the private health sector, and the distribution of different provider groups in rural and urban areas/districts. Rather than an absolute shortage of manpower, maldistribution seems a problem here. Access to women providers is low, important in a setting where women would prefer seeing women providers. The possibility that scheduled castes might have lower access to health care providers than the rest of the population is presented, a finding with important political implications. The barriers to trust between the public and private health sectors in the setting are complex. Addressing these as a step to making real collaboration possible, calls for deeper more structural changes in the working of the health system, including a redressal of the regressive fee-for-service payment mechanism. The government must consider some form of health insurance for more vulnerable groups of people.