Year : 2011 | Volume
: 55 | Issue : 2 | Page : 107--114
The allure of the private practitioner: Is this the only alternative for the urban poor in India?
Nupur Barua1, Chandrakant S Pandav2,
1 DFID South Asia Research Hub, British High Commission, New Delhi, India
2 Professor and Head, Centre for Community Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Chandrakant S Pandav
Professor and Head, Centre for Community Medicine,Old OT Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029
The main objective of the study has been to identify trajectories of health seeking behaviour of the urban poor, particularly their use of the private health sector, with the aim to identify strategies to improve quality of health care for this burgeoning population. This article presents findings from a slum settlement in Delhi where ethnographic sub-studies were carried out over two years among private health providers and selected households alongside a survey of household expenditure patterns. The primary research tools were in-depth interviews with practitioners and key informants as well as observations of clinical interactions. Illness narratives and case studies were documented over two years. The software package q.s.r. Nvivo was used for coding and content analysis. It was found that almost 90% of the respondents exclusively depend on local unlicensed and unregistered practitioners for basic primary health care. Long distances, time-consuming procedures, rude behaviour and, in many cases, bribes that had to be paid to staff in the hospitals were cited as major deterrents to utilising government facilities. Despite the public health consequences of inappropriate treatment protocols and misuse of drugs by these untrained private providers, in the absence of a structured urban primary health care system in the country, they seem to be the only alternative for the burgeoning urban poor in vast metros such as Delhi.
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Barua N, Pandav CS. The allure of the private practitioner: Is this the only alternative for the urban poor in India?.Indian J Public Health 2011;55:107-114
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Barua N, Pandav CS. The allure of the private practitioner: Is this the only alternative for the urban poor in India?. Indian J Public Health [serial online] 2011 [cited 2023 Feb 5 ];55:107-114
Available from: https://www.ijph.in/text.asp?2011/55/2/107/85242
The project Health Systems Reform and Ethics: Private Practitioners in Poor Urban Neighbourhoods in India, Indonesia and Thailand is a multi-disciplinary multi-country research study on the private health sector in urban poor settlements. The study was carried out simultaneously by the All India Institute of Medical Sciences (India), Aarhus University (Denmark), Naresuan University (Thailand) and Gadjah Mada University (Indonesia) and funded by Danida's research council, Consultative Research Committee for Development Research (FFU), Denmark during 2004-2008.
The main objective of the project was to identify strategies to improve quality of care for the urban poor in India, Indonesia and Thailand. The specific objectives were: (a) to determine constraints for poor patients' treatment-related decision-making; (b) to identify treatment patterns of local private practitioners with negative consequences for healthcare, and (c) and describe their health policy implications. Four complementary sub-studies were carried out to give a detailed and multi-faceted understanding of the local health systems under study. Sub-study 1 was a desk study of existing regulatory mechanisms, including ethical codes and legislation with direct implications for general private practitioners; sub-study 2 an ethnographic study of health systems ethics among private practitioners; sub-study 3 an interview-based study of family level treatment decision making; and sub-study 4 a survey of health expenditure patterns at the household level. This paper presents the findings from sub-studies 2 and 3 carried out in Delhi but also draws on relevant findings from the other sub-studies.
Material and Methods
The study was conducted in Midanpuri, a slum settlement in south Delhi. Located near one of the city's most affluent neighbourhoods, it has an estimated population size of around 25-30,000, and is composed almost entirely of migrants from neighbouring villages and from the states of Uttar Pradesh, Rajasthan, Bihar, Haryana, Madhya Pradesh, Uttaranchal, Kerala, Karnataka and Andhra Pradesh. During the period of field work, there were 27 private clinics run by 'less-than-fully-qualified' health care providers  in the slum. There was no government health centre at the time of the study with the two closest dispensaries being located approximately three kilometres away.
Two ethnographic sub-studies were carried out simultaneously: sub-study 2 on private practitioners and sub-study 3 on select households. A total of 25 private practitioners were enrolled for the study, 18 practitioners located in the slum, and seven located in markets within a 3-4 kilometre radius from the settlement. Two of the total number of 27 practitioners refused to enrol in the study. From a total of 207 households enrolled to track household expenditure on health (sub-study 4), 25 households were selected for in-depth case studies to explore the families' treatment seeking behaviour and, in particular, to examine decision-making processes and reasons for choice between private and public health services. Respondents were selected randomly by selecting one household at a time, obtaining consent and then selecting the next household. Where possible, respondents were also selected during exit interviews at the clinics of practitioners.
Field work was conducted over two years. A combination of ethnographic methods was deployed to generate data for both sub-studies. Unstructured, and later semi-structured, interviews were combined with observation in both households as well as clinics. The primary respondent was the head of the household, both in male as well as female-headed households. However, other members of the household, particularly women, were interviewed extensively to understand the dynamics of decision making processes. Informal group discussions were held to elicit individual and collective responses on possible measures to improve health care in slums. All the households were visited at least once a month over a two-year period. Extensive field notes were taken to record the observations. The duration of the interviews were of an average of 45-60 minutes although in several cases interviews continued up to two hours. Almost all the interviews were audio-taped and conducted in Hindi, translated into English and subsequently transcribed. The interviews were initially manually examined and transcriptions were subsequently imported into the qualitative data analysis software package q.s.r. Nvivo for coding and content analysis. Pseudonyms were used to protect the patients' and practitioners' confidentiality. Data analysis was carried out simultaneously as fieldwork progressed and guided data collection.
During analysis the recorded interviews were regularly revisited to ensure accuracy of transcriptions and to make sure that important data were not lost in the process. Coding themes and concepts were empirically driven and developed from experiential accounts of respondents using the Grounded Theory approach.  Scheurich (cf. Werner, Isaksen and Malterud)  writes that "reality is not something out in the universe to be discovered, but rather is contingent upon people who construct it". Thus, patient narratives serve as a medium to explain, present and negotiate the meaning of illness  and provide an avenue to link an "inner emotional world" with "an external phenomenal world of actions and circumstances".  These narratives were used both to construct the experiential reality as well as to explore the various institutional structures that influence the production of the life stories. Analysis of these narratives made it possible to not only situate the physician and patient in their socio-cultural milieu but also provide insight into the meanings given by both the actors to a common event, viz. illness.
A detailed digital map (to scale) of the neighbourhood was also prepared. Due to the very large area, it was decided that an approximate household mapping would be done of the entire area and three 'blocks' (clusters) covering approximately 500 households would be selected for detailed household mapping. All the households were selected from these blocks, namely A, C, and E. All the private clinics within the neighbourhood were plotted. In addition, private medical facilities utilized by the respondents within an area of approximately 4-5 km radius from the neighbourhood were also marked.
Ethical clearance for the study was obtained from AIIMS and consent of study subjects was attained not only at the beginning of the study but maintained through the process of data collection.
There were 27 private clinics run by 'less-than-fully-qualified' health care providers in the study area. An antenatal care clinic run by an NGO called Asha was located in the slum. In addition, two free dispensaries were located in the outer periphery. Run by charitable organizations, these dispensaries were used largely for eye problems and conditions related to child health. There was no government health centre in the slum with the two closest dispensaries being located approximately three kilometres away, one in Ber Sarai and the other in Mahipalpur. There was one pharmacy located inside the settlement. Owned by a private individual and manned by a hired help, it sold medicines on the basis of their marked price. The helper refused to participate in the study as the owner of his shop declined permission to do so.
Different faces of poverty
High alcohol consumption, drug use, extensive use of gutka, powdered tobacco, and sedatives were recorded among the respondents. A large number of mental conditions, many of them undiagnosed, were also reported. Although women were reluctant to talk about domestic violence, almost half of them were found to be victims of physical violence. At least one member from the 25 households was found to visit a health care provider once every five days. While there is no slum specific data on morbidity, every household we interviewed reported at least two illnesses most of which could be classified as acute respiratory problems and water borne diseases within a recall period of one week. During the summer months there was a surge in epidemic prone infections. In all, 31 chronic conditions were reported from the 25 households (on the basis of a classification of a chronic condition as one lasting three months or more). Although there was general awareness about sexually transmitted diseases and HIV/AIDS, knowledge regarding its methods of transmission was very poor. Of the deliveries that were reported during field work, despite the availability of institutional delivery services in the city, 38% had taken place in hospitals relative to the majority that were delivered at home with the help of traditional birth attendants.
Treatment seeking behavior
There was an almost exclusive dependence on the less-than-fully-qualified practitioners within the jhuggi for treatment of "everyday illness conditions" like cold, cough, fevers, headache, joint pains, and minor injuries. On further probing respondents classified "minor common ailments" as conditions which did not persist beyond two to three days, or warrant missing work or lead to any chronic or permanent disability - largely conditions that did not require emergency medical attention. Everyday illness conditions comprised an array of symptoms that included fevers (of indeterminate origin), cold, cough, headache, diarrhoea, sleeplessness, fatigue and body pain. Interestingly, "tension" was frequently quoted and seemed to be a well accepted condition among the respondents." In the 25 households which were followed for in-depth study, 31 chronic conditions, 69 episodes of hospitalization, 92 illnesses trajectories were documented in detail.
For conditions which required "further treatment", private practitioners in the neighbouring areas were consulted. Instances of such conditions are tuberculosis (TB), heart disease, acute respiratory conditions, HIV/AIDS, and other chronic conditions. The decision to seek medical care was seldom guided by the perceived cause of illness. Rather, it was a pragmatic decision to deal with the condition effectively enough to return to work as quickly as possible with the available resources at that time. What the respondents looked for was basic care. During the two years of fieldwork, only two cases were reported of visits to the government dispensary located in a neighbouring locality. The need to commute to the dispensary, the long waiting time and the lack of medicines in the dispensary were cited as deterrents to visit the dispensary. There was little mention of traditional healers; the only exceptions being for male sexual health and mental illness.
There was a single-minded focus on getting immediate 'action' with a purpose to return to work as quickly as possible. This "quick-fix, quick profit mentality"  of the private practitioners was stoically accepted by the patients. While many of the inhabitants of Midanpuri were aware of the fact that these daktar (doctors) do not possess the "right qualifications", and often they drew distinctions between a bada daktar ('big doctor') and "these doctors", they were at the same time convinced that these practitioners had "knowledge about medicines" and were a pragmatic solution for "ordinary" or "not so serious" conditions like fevers, body ache, stomach disorders and cough and cold. This concurs with another study on the role of private practitioners in the management of malaria in Mumbai  where patients were clear that they visited these practitioners primarily to "get medicines" and their expectations of these visits did not extend beyond finding an immediate reprieve to their problem. As a key respondent said, Of course they are not big doctors. But how is that important? Will a big doctor set up his clinic here? There are 25,000 people and no [government] dispensary. So what do we do? Wait for these big doctors to come and save us….? At least these doctors are here when we need them, and they know about medicines…they are good enough for us…
Access was found to be the major determinant of health seeking behaviour. Physical access (distance to the clinic, availability of the practitioner and ready dispensation of drugs) was cited as the most important factor. Social access came a close second. The low fees and the flexible payment options offered by the neighbourhood practitioners were considered extremely convenient for wage earners. The cost of consulting a neighbourhood practitioner at Rs 35 per visit, compared favourably to not only qualified private practitioners but even government-run facilities. While consultation with a doctor in a government facility was free, transportation and more importantly, purchase of medicines from pharmacies drove costs to an average of Rs 68 per visit, which was almost twice that of a less-than-fully-qualified practitioner. Often, additional costs were inflicted when circuitous procedures and long queues in the hospitals resulted in losing the day's wages.
"These sarkari [government] places are the last places where you must go. They are good only if the problem is serious and if you need to have operation. Not much cost. But these things [common conditions]…at least a week … And who can afford to lose wages for that much time…. That's why I come here when I am ill. Only to private [practitioners]… a respondent at a clinic of 'less-than-fully-qualified' health care provider."
Quality of care figured prominently in patient narratives. Government hospitals were considered "difficult to deal with" in connection with their time consuming and often circuitous procedures, long queues, and in some cases bribes that had to be paid to hospital staff. Private practitioners, in contrast, were at hand when needed and were perceived to be much easier to negotiate. Besides, the ready dispensation of medicines and administration of injections (often on demand) qualified as "better care". In two-thirds of the 92 illness trajectories that were documented in detail, practitioners were changed more than four times. Despite cost being one of the main determinants in choosing a treatment provider, a large number of people in fact said that they were willing to pay for higher quality care which, as they lament time and again, was neither accessible nor available to them.
Why not the free public sector?
Competence in government facilities was clearly considered higher by the respondents but long distances to these facilities, circuitous and time-consuming registration procedures,  and waiting time were cited as major deterrents. Narratives of care seeking for stigmatized conditions were replete with the need for privacy and sensitivity that the private practitioners offered. A 48 year old construction labourer, and father of four children says, It is all right for the hoardings to be screaming about AIDS…you only know what happens when it happens to you. I got myself tested and they told me that I had AIDS. Only my wife knows…how can we tell other people? I have seen what happened to Gunaram [his neighbour] the moment his neighbours found out that he had AIDS…that was it! They don't even want to drink tea with him in the evenings….so will I risk my wife and my daughters in the locality…? In the public hospitals you go to the AIDS clinic, and everyone will know you have AIDS. Sooner or later somebody will see you there …then it is all over…and these people in these clinics…how they treat you….like diseased dogs in the street…like you a criminal…so I prefer to go to the private doctor in Katwaria [Sarai]…at least I sit inside his clinic by myself, he talks to me properly and he gives me medicines…
In contrast, experiential accounts of government facilities were dominated by a total lack of concern by the non-medical staff; senior doctors who were not approachable and the younger, inexperienced doctors who were brusque and did not listen to what the patient had to say. Several respondents recounted how they had to pay bribes to staff in government hospitals to get ahead in the waiting line. In contrast, positive responses to service received from the private health care providers were tied to clinic opening times, fees, waiting times, and accessibility of the practitioners. Under the circumstances, there was an unambiguous preference for "better care" by the neighbourhood practitioners, who might be less-than-fully-qualified, in comparison to inadequate or "no care" in a government facility.  Government hospitals, however, were cited as the main option in connection with conditions which required inpatient care and surgical intervention. A 37 year old male said, We get harassed when we go to these big places… We have to go stand in queue early in the morning to get a parchi [patient card] done. Sometimes it takes many days to get just that done. And the doctors are so rude. They spend 2 minutes with us - just write names of medicines, we buy the medicines from outside. If we have to get tests done, wait endlessly to show the results. They don't even listen to us…. What's the point in all this?
The research team was witness to two police raids in the neighbourhood that were conducted to weed out unlicensed practitioners from the area. Local networks within the neighbourhood relayed information about imminent raids and the practitioners were often helped to 'close down' their clinics. Signboards outside the clinics were hidden or pulled down and certificates with (? fake) registration numbers hidden. After the raids were conducted, the practitioners 're-opened' their clinics and continued to practice from the next day. This strong inbuilt social defense highlights the community support enjoyed by the unlicensed practitioners. Thus, it makes more sense to find ways to involve, rather than outlaw them.
The obvious benefits associated with having a health care at hand propelled choice on most counts, even if the people are aware that the local practitioners might not possess the 'best' qualifications. The absence of qualified doctors in the slum was a common ground for argument in favour of the unlicensed practitioners' presence in the settlement by both themselves as well as the inhabitants of the area. In slums such as Midanpuri, where no qualified medical practitioners are available, it is not so much about exercising choice from a variety of options as it is about making do with what is available.
Health care providers in Midanpuri
During the two years of field work, the number of clinics run by less-than-fully-qualified practitioners in Midanpuri increased from 15 to 27. Of these, five of them displayed certificates that indicated that they were 'Registered Medical Practitioners'. It was not possible, however, to determine the authenticity of these certificates. The majority of them were unlicensed practitioners, not registered in any system of medicine. Three-fourths were undergraduate and did not possess formal degrees and the remaining were 'trained' outside Delhi through short-term diploma courses in Ayurveda and Homeopathy. Seven of them produced certificates from institutions which are not recognized by the government. All of them, without exception, were found to administer allopathic drugs. The timings of the clinic are designed to 'fit' the work schedule of the inhabitants of the settlement. Drugs, they said, were purchased from chemists, from medical representatives and even government outlets. The latter was facilitated by staff employed in these dispensaries. There was no system of registration in the clinics of the less-than-fully-qualified practitioners and no records were maintained of the patients. Treatment was provided purely on an episodic basis. No evidence was found of either any inpatient procedures or deliveries conducted. Immunization services were also not provided. Referrals to abortion clinics on demand, however, were very common. Referrals to diagnostic facilities for X-rays and blood testing were common. No network between the diagnostic facilities and unlicensed private practitioners was seen. There were very few referrals to other (qualified/ medical) doctors. Referrals to government-run hospitals were more frequent. However, most of these referrals were made in acute conditions after at least 4-5 visits to the practitioner. In a majority of the cases, the conditions seemed to have deteriorated significantly by the time the referrals were made.
Almost all the practitioners we interviewed spoke of aspirations to 'become better doctors'. They evinced an eagerness to participate in workshops and be part of national programmes run by the government. The research team was constantly asked, particularly towards the end of the project, whether they would assist in training them, or in acquiring higher skills.
Of the 471 interactions recorded during observations in the of private practitioners, three-fourths were related to acute conditions, predominantly fever (of indeterminate origin), cold, diarrhoea, asthma, cough, body pain, weakness, TB, skin problems, mental problems, sexually-transmitted diseases, injuries, and conditions reported as 'BP' (blood pressure). A striking number of repeated abortions were also recorded.
The interactions with the practitioner were usually short with the average consultation lasting no more than 3-5 minutes. There was an almost exclusive focus on curative care and "what the patient wants". Perceived strictly as a business, these practitioners seemed to have an exacting assessment of the prevailing market forces, and delivered accordingly. If patient interest centred around medication, the focus was explicitly on the medicines alone but in cases where attendant causes of illness were sought, references to diet and the environment were offered by the practitioner. The atmosphere in the clinics was invariably relaxed. Continuing conversation with other patients waiting to be seen or with the companion accompanying the patient was common.
The payment system was flexible and ranged between [INSIDE:1] 20-40, depending on the amount of tablets or injections administered. The practitioners insisted that there was no consultation fee and they charged only for the medicines. The reality, however, is that the consolidated amount of money that is charged includes consultation as well as the medicines. Notwithstanding the actual breakup, fee levels were kept low but ensured that there was some profit after paying for capital costs.
Referrals to diagnostic facilities for X-rays and blood testing were common. However, specific networks to diagnostic centres of laboratories were not discerned. There were very few referrals to other (qualified/ medical) doctors among both groups. Interestingly, referrals to government-run hospitals were common. Most of these referrals, however, were made in acute conditions after at least 4-5 visits to the practitioner. In a majority of the cases, the conditions seem to have deteriorated significantly by the time the referrals were made.
Although making a prescription audit was beyond the mandate of the study, observations in the clinics of private practitioners demonstrated that there was an excessive use of antibiotics and injections. Although in approximately one-third of the cases, loose medicines without a counterfoil are given which made it difficult to identify each medicine individually, it was possible to determine that these medicines were largely antibiotics, painkillers and tranquilizers. The injections were largely administered with corticosteroids. Several instances of reuse of disposable injections by the less-than-fully-qualified practitioners were recorded.
Virtually all prescriptions in the 471 clinical interactions with both groups of practitioners had multi-drug combinations, the most common combination of drugs being antibiotics, analgesics and multivitamins. While injections for pain, tranquilisers, multi-vitamins and pain killers were the main choice among the less-than-fully-qualified practitioners, antibiotics emerged as the most common category of medicine among qualified private practitioners. Of the 37 prescriptions recorded in the qualified private practitioners' clinic, 32 prescriptions contained at least one antibiotic. While both categories used anti-tuberculosis drugs, none of them observed the Directly Observed Treatment, Short Course strategy. None of the less-than-fully-qualified practitioners had any knowledge of the National Tuberculosis Control Programme guidelines while the qualified private practitioners said that they did know of the guidelines but "did not have the time" to "follow" them.
In the clinics of the less-than-fully-qualified practitioners, direct request for medicines for specific ailments was found to be common.The practitioners in turn gave clear instructions on how to "take the tablets". Loose medicines were explained in detail according to colour, size and shape and doses are prepared into pudiyas (small individual paper packets). Generic descriptions were provided with medicines being specified as "for heart", "for bones", "for tension", "for sadness", "for BP". Doses were given according to the amount of money in hand; if money was not cited by the patient as a constraint, doses would be given for two days at a time. The sale of partial doses of medicine in particular was cited as a huge boon by a majority of patients who were dependent on daily wages.
It was noted that the neighbourhood practitioners often received patients who had already consulted other qualified medical practitioners and visited them for follow up consultations. It was common practice for these practitioners to scrutinize prescriptions given by the qualified practitioners and dispense the same set of medicines. Many of them retained these prescriptions and administered the same cocktail of drugs to other patients who reported similar symptoms.
Choices that the urban poor make for health care have implications not only for the individuals treated and the development of drug resistance but also for disease transmission to the wider population living in congested urban settings. While the public health consequences of the inappropriate treatment protocols used by the less-than-fully qualified practitioners, in particular their delayed referrals to appropriate facilities and their misuse of drugs, are well known, these practitioners very often are the only ones 'on the spot' to provide basic primary health care to the approximately 25,000 people inhabiting slum settlements such as Midanpuri. These practitioners seem to fill an important gap between the poor perceived quality of public health services and the high cost of the 'fully qualified' private health care. Their piecemeal medication options and convenient location within easy reach are a boon for this population who would otherwise stand to lose a day's wages waiting in queue in over-crowded government hospitals. In the absence of an urban primary care system, they are perceived to be providing least some health care at low cost where none other exists.
Since these practitioners appear to be the 'backbone' of providing health for the urban poor, it would be better to co-opt them into intervention programmes for the poor rather than police them. The main challenge, however, would be to bring them into the overall public policy net. Since they often evinced enthusiasm in acquiring higher skills and in participating in government-run programmes, a system could be devised whereby a special cadre of practitioners could be trained to deliver a select range of services in difficult-to-reach populations in the slums. They could be trained to recognize and refer complicated cases to government facilities if clear definition of parameters for enrolment and standard treatment guidelines were framed to define the exact nature of their functions. A monthly surveillance system would help to monitor the practices of these private practitioners that they are not providing healthcare outside their training. Public awareness campaigns could focus on educating consumers about inappropriate treatment protocols like re-use of disposable syringes and to provide feedback to public authorities. Lessons could be drawn from the INFECTOM (INformation, performance FEedback, ConTracting, Ongoing Monitoring) strategy developed by the BASICS project to improve case management practices of private practitioners in childhood illnesses;  in-service training for management of diarrhoea and acute respiratory infections by private practitioners in Mexico;  and training shop-keepers to provide anti-malarial drugs in Kenya.  It would be crucial, however, to maintain focus on accurately assessing training needs on an on-going basis and providing the necessary upgrading of skills.
These measures, however, will not work effectively unless complimentary measures are enforced to confront the local context in the slums. Provision of basic amenities like housing, security of tenure, clean drinking water, sanitation and electricity should be accorded highest priority. Public health programmes in slums should be monitored regularly to ensure quality of services. Unless health facilities are responsive to the requirements of the urban poor, there will not be optimal utilization of its services and the existing ambivalence towards government institutions will continue. This could be achieved by allocation of qualified doctors in all under-served areas, perhaps through a compulsory student roster like out-patient wards in hospitals, and regular mobile clinics in slums. A separate health insurance scheme or the urban poor under the National Urban Health Mission will ensure that health care payments do not exceed their ability to pay. Coordination between various service providers such as the state health department, Urban Local Bodies, Integrated Child Development Scheme, the Swarana Jayanti Shahri Rozgar Yojna scheme for construction workers, and NGOs will ensure that work is not carried out in silos and will optimize the effectiveness of programmes. Unfortunately, no single strategy will work.
The authors would like to acknowledge the following: Dr. Jens Seeberg for conceptualising the study, providing crucial direction and having secured funding for the project; research assistants - Otojit Kshetrimayum, Birendra Suna, Kripabar Baruah, Subhas Nayak, Mrinal Das, Yaoreiphy Horam and Malvika Maheshwari - for having collected data amidst several challenges in the field; Dr Kusum Verma for guidance during the initial stages of the project; and Dr Kapil Yadav for his insightful comments on the article. The study would not have been possible without the cooperation of our respondents from the field. The authors are particularly grateful to the families as well as the private health care providers of Midanpuri. The name of the slum has been changed to retain anonymity of the field site.
|1||Berman P. Rethinking health care systems: Private health care provision in India. World Dev 1998;26:1463-79.|
|2||Strauss A, Corbin J. Basics if Qualitative Research - Grounded Theory Procedures and Techniques. Newbury Park: Sage Publications; 1990.|
|3||Werner A, Isaksen LW, Malterud K. 'I am not the kind of woman who complains of everything': Illness stories on self and shame in women with chronic pain. Soc Sci Med 2004;59:1035-45.|
|4||Hyden LC. Illness and narrative. Sociol Health Illn 1997;19:48-69.|
|5||Mattingly C, Garro LC. Narrative representations of illness and healing. Introduction. Soc Sci Med 1994;38:771-4. |
|6||Kamat VR, Nichter M. Pharmacies, self-medication and pharmaceutical marketing in Bombay, India. Soc Sci Med 1998;47:779-94.|
|7||Kamat VR. Private practitioners and their role in the resurgence of malaria in Mumbai (Bombay) and Navi Mumbai (New Bombay), India: Serving the affected or aiding an epidemic? Soc Sci Med 2001;52:885-909.|
|8||Bhat R. Characteristics of private medical practice in India: A provider perspective. Health Policy Plan 1999;14:26-37.|
|9||Berman P. Rethinking health care systems: private health care provision in India. World Dev 1998;26:1463-79.|
|10||Chakraborty S, D'Souza SA, Northrup RS. Improving private practitioner care of sick children: Testing new approaches in rural Bihar. Health Policy Plan 2000;15:400-7.|
|11||Bojalil R, Guisafre H, Espinosa P, Viniegra L, Martinez H, Palafox M, et al. Clinical training unit for diarrhoea and acute respiratory infections: An intervention for primary care physicians in Mexico. Bull World Health Organ 1999;77:936-45.|
|12||Hausmann-Muela S, Ribera JM, Nyamongo I. Health-seeking behaviour and the health system response. Working Paper No. 14. London: London School of Hygiene and Tropical Medicine; 2003.|