New study increases concern over quality of healthcare and medical education in India

BMJ 2012; 345 doi: (Published 12 December 2012) Cite this as: BMJ 2012;345:e8437
  1. Ganapati Mudur
  1. 1New Delhi

A study has found that healthcare professionals—doctors and non-doctors—in rural and urban India achieved low rates of diagnosis and deviated from standard treatment guidelines. It has increased concerns about the quality of healthcare services and medical education in India.

The study found only “small differences” between doctors and other healthcare providers without medical qualifications in their adherence to standard checklists during diagnosis and “no differences” in providing the correct diagnosis or appropriate treatment. The study indicated that equipment in clinics and doctors’ educational qualifications were only “weakly associated” with the quality of care.1

Jishnu Das, a senior economist at the World Bank in Washington, DC, and the study’s principal investigator, told the BMJ, “We’re questioning assumptions that a combination of qualifications and equipment can guarantee quality. We find this is not necessarily true.”

The study relied on standardised patients recruited from local communities who walked into the clinics of 241 healthcare providers in a rural area of Madhya Pradesh and 64 providers in New Delhi.

In both samples the study found low rates of diagnosis, poor adherence to treatment guidelines, and frequent use of harmful or unnecessary drugs. For instance, in the rural sample only 31% of the standardised patients who described symptoms of unstable angina and nearly 48% who reported symptoms of asthma were given the correct drugs. Providers prescribed wrong or harmful treatment to 62% of the patients reporting asthma symptoms.

Only 12% of standardised patients who reported a child with symptoms of dysentery were asked to give the child oral rehydration therapy. The overall rate of correct treatment for all three conditions was 41% in the rural area, slightly lower than the 45% in the urban area.

Some doctors said that the study highlights the need to restructure undergraduate, postgraduate, and continuing medical education in India. “The existing course work and the exams focus too much on theoretical knowledge and too little on practical clinical skills,” said Raghunandan Kothari, a senior ophthalmologist in a private medical college in the western Indian town of Vadodara.

“But several other factors impact quality too,” Kothari told the BMJ.

Many private medical colleges in India accept students who would be ineligible for admission through merit alone, and India has an estimated shortage of 30% in the medical faculty, Kothari wrote in a commentary calling for sweeping changes in undergraduate and postgraduate medical education, published earlier this year in the National Medical Journal of India.2

“We are aware of quality issues in healthcare services,” said Gowda Karekallappa Ramachandrappa, national president of the Indian Medical Association. “We have asked the government many times to act against unqualified practitioners and to introduce a system for mandatory recertification of doctors,” Ramachandrappa told the BMJ.

In 2002 the Indian government issued guidelines asking all doctors to spend at least 30 hours in continuing medical education programmes every five years, but the requirement has not yet been linked to their licence to practise. “The association organises continuing education programmes, but many don’t attend,” Ramachandrappa said.

A member of the Indian Medical Association who asked not to be named said that it would be “absolutely wrong” to try to extrapolate the findings from the two sample sites in the study. “Quality will vary from place to place—that’s all that this shows.”

But health sector analysts are hoping that the study will prompt Indian health policy makers to revise notions that investments in infrastructure and increasing the number of qualified doctors will bring quality in healthcare services.

“Instead, patient safety and quality of care should be at the core of the institutional culture,” said Kavita Narayan, the associate head of the hospital services unit at the Public Health Foundation of India, an academic institution in New Delhi.

Public health experts say that the study highlights India’s dependence on unqualified practitioners in providing healthcare. About 67% of the sample healthcare providers in rural Madhya Pradesh and nearly 48% in New Delhi had no formal medical training.

“Many patients in India firstly walk into the clinics of unqualified practitioners,” said Madhukar Pai, an epidemiologist and head of the tuberculosis research group at McGill University in Montreal. The emergence of drug resistant tuberculosis in India has been attributed in the past to inappropriate prescriptions by doctors and unqualified practitioners, among other factors. Pai said, “Engaging with both qualified and unqualified practitioners will be critical in improving healthcare services in the country.”


Cite this as: BMJ 2012;345:e8437