India: Service Availability & Readiness

A program in India highlights some value in training informal providers - those with no formal medical education - in locations where there is minimal formal provider availability. In rural India, up to 75% of primary care visits are made to providers with no formal medical education.1 Although this practice is illegal, it is driven by widespread shortages in formally trained health care providers. Training of informal providers is a controversial practice; while some argue that it will improve the quality of care for patients who utilize their services, others believe that it encourages an illegal and unsafe practice. Regardless of views on training of informal providers, it is clear that provider availability and competence is a major barrier to quality care in parts of India. A nine-month program in West Bengal provided training to informal providers. Average attendance to these trainings was 56% and was influenced by distance to the training and weather conditions. The three outcomes studied related to a provider’s ability to refer for severe conditions, manage conditions, and appropriately diagnose and treat conditions. Training had the greatest effect for providers who delivered low quality of care at baseline. The program resulted in increased adherence to condition-specific checklists, increased correct case management, and an increased patient caseload in villages without a public-sector clinic.1 This latter finding may address concerns that training informal providers will make their practice more widespread; where patients had the choice to attend a formally trained provider, caseloads in the informal sector did not increase. This study shows the value of training to improve provider availability and competence but should be used in tandem with system-wide efforts to bolster the formal health workforce.


  1. Das J, Chowdhury A, Hussam R, Banerjee AV. The impact of training informal health care providers in India: A randomized controlled trial. Science. 2016 Oct 7;354(6308).