Do qualifications matter? A qualitative study of how villagers decide their health care providers in a developing economy

INTRODUCTION: The National Rural Health Mission (NRHM) was launched in India in 2005 to address the health needs of under-served populations in rural areas, and to support universal access to care. Despite this initiative, unaccredited informal providers (IPs) often remain patients’ first point of contact, which has led to inconsistencies in treatment, and has compromised the quality of care. AIM: To explore the factors that influence patients’ decisions about healthcare providers in rural areas of central India. METHODS: Nine focus group discussions (FGDs) were held in nine villages in central India. Framework analysis using an inductive approach was used to analyse the data. RESULTS: The crosscutting theme across the discussions was not choice but need—the need for affordable and accessible health care regardless of the provider’s qualification. Results highlighted that IPs play a pivotal role in villagers’ lives. Formal healthcare services were accessed infrequently, and mainly when a condition was judged severe or possibly even fatal. Even then, affordability was carefully weighed. Villagers’ distance from formal providers contributed to high cost and low preference of formal providers. When opting for IPs, familiarity and trust were more important to villagers than qualifications. IPs have operated in rural communities in India for a long time and have adapted their services to meet the needs, preferences, social norms, and economic conditions of villagers. CONCLUSION: IPs have captured a niche and are often the first contact point in rural settings even when patients ultimately are diagnosed and treated by trained doctors. Merely tackling the undersupply of qualified doctors is not effective or sufficient to impact on the rural healthcare system: the strong and prevalent influence of IPs needs to be addressed also.