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?

The increased emphasis on privatization of the health care sector in many developing countries by international financial institutions and national governments expects an expanding role for private health care practitioners in the management of major communicable diseases such as tuberculosis, malaria, acute respiratory infections (ARIs) and sexually transmitted diseases (STDs). Largely unexamined in the Indian context, however, is the socio-cultural context, the micro-level political environment in which private practitioners carry out their activities, and the quality of care they provide to their patients. Examining these aspects is significant given the impressive growth of the country's private health sector during the past decade. This paper reports the results of an ethnographic study carried out in Mumbai (Bombay) and Nav Mumbai (New Bombay), India on private general practitioners (GPs) and their role in the management of malaria at a time when these two neighboring cities were in the midst of the worst malaria epidemic in over 60 years. Described are the characteristics of a sample of 48 private practitioners from the two cities, and their clinics. This is followed by a discussion of the data gathered through untructured interviews with practitioners and patients, and complemented by observational data on doctor-patient encounters gathered at 16 clinics over a 9-month period. The findings of the study suggest that many practitioners in Mumbai and Navi Mumbai were poorly qualified and did not play a supportive role in the two cities' public health departments to bring the epidemic under control. The majority of the practitioners adopted diagnostic and treatment practices that were not consistent with the guidelines laid down by WHO and India's National Malaria Eradication Programme. Very few practitioners, especially those practicing in low-income areas, relied on a peripheral blood-smear test to make a diagnosis. Practitioners whose clientele was mostly the poor commonly resorted to giving one-day treatment to febrile patients that included injectable antimalarials and broad spectrum antibiotics. Such practitioners justified their mode of diagnosis and treatment by asserting that they were only responding to the demands placed on them by their patients who could not afford a blood-smear test or a full prescription. The paper argues that practitioners who acquiesced to patient demands were at once exacerbating the health problems of their patients and jeopardizing the prospects for the epidemic to be brought under control. Driven primarily by the need to retain the patronage of patients and maintain one's popularity in a highly competitive health arena, many providers practiced medicine that was unethical and dangerous. The paper concludes by discussing the ramifications of this study for malaria control in Mumbai and Navi Mumbai, and highlights a few salient health policy issues concerning the growth of the private health sector in India and its regulation.