Unlicensed medical practitioners in tribal dominated rural areas of central India: bottleneck in malaria elimination
In India, Accredited Social Health Activists (ASHAs) deliver services for diagnosis and treatment of malaria, although unlicensed medical practitioners (UMPs) (informal health providers) are most preferred in communities. A cross sectional survey was conducted to: (i) assess knowledge and treatment-seeking practices in the community, and (ii) explore the diagnosis and treatment practices related to malaria of UMPs working in rural and tribal-dominated high malaria endemic areas of central India, and whether they adhere to the national guidelines.
A multi-stage sampling method and survey technique was adopted. Heads of the households and UMPs were interviewed using a structured interview schedule to assess knowledge and malaria treatment practices.
Knowledge regarding malaria symptoms was generally accurate, but misconceptions emerged related to malaria transmission and mosquito breeding places. Modern preventive measures were poorly accessed by the households. UMPs were the most preferred health providers (49%) and the first choice in households for seeking treatment. UMPs typically lacked knowledge of the names of malaria parasite species and species-specific diagnosis and treatment. Further, irrational use of anti-malarial drugs was common.
UMPs were the most preferred type of health care providers in rural communities where health infrastructure is poor. The study suggests enhancing training of UMPs on national guidelines for malaria diagnosis and treatment to strengthen their ability to contribute to achievement of India’s malaria elimination goals.
KeywordsIrrational use of antimalarial drugs Monotherapy of artemisinin Plasmodium falciparum Tribal malaria Unlicensed medical practitioner
Accredited Social Health Activists
unlicensed medical practitioners
World Health Organization
artemisinin based combination therapy
annual parasite incidence
probability proportional to size
auxiliary nurse midwives
primary health centres
community health centres
integrated child development scheme
rapid diagnostic test
Medical Council of India
The World Health Organization (WHO) recommends use of artemisinin-based combination therapy (ACT) for treatment of uncomplicated Plasmodium falciparum malaria . In India, ACT has been the first-line treatment of confirmed P. falciparum malaria nationwide since 2010, after artemisinin monotherapy was banned in 2009 . Chloroquine is the first-line drug for treatment of confirmed Plasmodium vivax malaria . Primaquine is also recommended in a single dose for P. falciparum and a 14-day dose for P. vivax . Malaria is the most common cause of fever in tribal-dominated areas of central India ; P. falciparum and P. vivax are the most common species in this area, with P. falciparum the most dominant species . Anopheles culicifacies is the primary vector of malaria in central India .
People living in tribal-dominated hilly forested areas are highly vulnerable to malarial infections due to geo-climatic factors and poor access to health facilities. Further, in many communities, a poor understanding of the aetiology of malaria and various cultural practices add to this vulnerability [6, 7]. Low literacy levels and poor economic conditions also pose constraints for prompt diagnosis and treatment-seeking in the community . Under the umbrella of the National Rural Health Mission, a cadre of female community volunteers known as Accredited Social Health Activists (ASHAs) was created to deliver rural health care services, mainly related to maternal and child health and vector borne diseases . However, in many rural communities, particularly in tribal areas, unlicensed medical practitioners (UMPs) (informal health providers) are most preferred providers, including for treatment of malaria .
According to an estimate in India, among private health providers 57% had no recognized medical qualification, but they practice some form of allopathic medicine [9, 10]. They mainly treat common illnesses like diarrhoea, fever, malaria, vomiting, rashes, joint pains, respiratory distress, abdominal pain, flu, and typhoid. Poor health infrastructure and absenteeism among formal health workers make rural UMPs easier to reach , which has resulted in a treatment system in rural tribal areas whereby UMPs play a significant role as health service providers. Although, they do not have the legal right or status to provide health care services, their role is critical because they work in remote rural areas where medical facilities are scarce .
A cross sectional survey was conducted with two main objectives: (i) to assess the knowledge and treatment-seeking practices of the community, and (ii) to explore the diagnosis and treatment practices related to malaria of UMPs working in rural and tribal-dominated high malaria endemic areas of central India, and its adherence to the national guidelines.
Sample size and sampling methods
In India, about 50% of the population receive health care services for febrile illness from informal providers [7, 11, 12]. Based on this proportion, a sample size was determined for household-level interviews to assess the utilization of health care services. Considering 5% precision and a design effect of 2, with an additional 30% to account for non-responses, a sample of 1000 households was determined for the household survey.
All surveys were conducted in Hindi, the most common language locally, by trained interviewers with graduate-level educational qualification. Structured interview schedule was designed to interview the head of the each household to collect data on educational status and occupation of the family members, knowledge related to malaria aetiology, mode of transmission, mosquito breeding places, prevention and treatment-seeking practices of the heads of the households using recall method for 2 weeks reference period of febrile illness. Availability of health infrastructure nearby the studied villages and distance from village was observed and recorded by the interviewers from various sources. As the UMPs were not legally-authorized health care providers, they were difficult to identify and approach for the study. Therefore, household respondents were asked to help the investigators identify UMPs who were providing health care services in the community. Once a group of UMPs were identified, they were further used through snowballing technique to identify and recruit additional UMPs. Surveys with UMPs used a semi-structured, pre-tested interview schedule consisting variables to inquire their educational status, knowledge related to malaria aetiology, mode of transmission, common species of human plasmodia and their methods of diagnosis and treatment practices related to malaria. Average number of patients treated and the cost of treatment per patient was estimated based on responses reported by UMPs during interview using recall method for 1 week preceding the survey as reference period.
Data entry and analysis
Survey interview schedules were checked for completeness; illogical or inconsistent responses were edited before leaving the field site. Random spot checks and back-checks during interviews were conducted to ensure data quality control. Data were double key-entered in CSPro 7.1.3 (US Census Bureau) with built-in data entry application and edit checks for quality control. Data were then exported to R v3.5.0 for Windows (R foundation for statistical computing) for statistical analysis. Numerically coded categorical variables were cross-tabulated in frequency and percentage distribution and continuous variables were summarized in mean and standard deviation (SD).
Demographic and Socio-economic characteristics of the households
Education and occupation of study population and UMPs
Households (N = 1010)
UMPs (N = 140)
Educational status (above 6 years of age)
N = 4552
Major occupation (above 14 years of age)
N = 3709
Common ailments, knowledge, prevention and treatment-seeking practices of the households for malaria
Knowledge of malaria aetiology among community and UMPs
Households (N = 1010)
UMPs (N = 140)
Main symptoms of malaria
Fever with chills & rigor
Cold & cough, throat sore, runny nose
Mode of transmission of malaria
Mosquito bite causes malaria
Other fly, bedbug, contaminated food/water etc.
Mosquito breeding place
Mud, swamp, cow dung
Sleeping under bednet
Elimination of mosquito breeding places
Smoke burning leaves and cow dung
Mosquito repellent like coil cake
Indoor residual spray with insecticide
Common ailments in the area
Cold & cough
Other (typhoid, viral fever)
Malaria a serious health problem
Malaria is fatal
Species of human malaria parasite
P. falciparum and P. vivax
Wrong answer i.e. filaria, dengue etc.
Most common species in the area
P. falciparum only
P. vivax only
P. falciparum and P. vivax both
Wrong answer i.e. filaria, dengue etc.
Methods for malaria diagnosis
Blood test by RDT only
Blood test by microscopy only
Blood test by RDT and microscopy both
Malaria prevention and treatment seeking practices among community
Prevention practices from mosquito bite
House was sprayed with insecticide (IRS)
IRS including kitchen
Household like IRS
Household feels that IRS is effective
House was whitewash (Mean ± SD) per year
1.9 ± 0.7
Household heard about insecticide treated bednets
Household owned bednet
No. of bednet (Mean ± SD) per household
1.6 ± 0.9
Reasons for not owing/using bednet (N = 439)
Mosquito not bite
Owned insecticide treated bednet (N = 571)
Bednet provided by the government agency (N = 571)
Using any preventive measures to protect from mosquito bite
Sleeping under bednet regularly
Using mosquito repellent coil, cake, cream
Smoke formation by burning leaves, cow dung
Roping body oil
Any one suffered from suspected malaria in 2 weeks preceding the surveya
Initial source of treatment sought (N = 390)
Unqualified health providers
PHC/CHC govt hospital
Malaria diagnosis/treatment is available within the village
Treatment was freely provided
Availed free malaria treatment within the village
Satisfied with provided free malaria treatment
UMPs were the most preferred health providers (49%) in the community, and were residents’ first choice for seeking treatment of ailments. About 15% of the households sought treatment from faith/herbal healers, 15% went to community health workers like ASHAs, Auxiliary Nurse Midwives (ANMs), 15% visited government hospitals like primary health centres (PHCs) or community health centres (CHCs), and 6% went to private hospitals as their first choice for treatment during an illness. However, 60–70% of the household heads believed that diagnosis and treatment of febrile illness was freely available within the village and was provided by the ASHAs, which contrasts sharply with their practices (Table 3).
Health infrastructure availability
Health infrastructure availability in study villages
(N = 53)
Health Infrastructure available in the villages
Aagnawadi (ICDS) centre
Aaganwadi (ICDS) assistant
Aaganwadi (ICDS) worker
Aaganwadi (ICDS) is functioning regularly
ASHA worker is residing in the village
Health sub-centre available in the village
Nurse is residing in the village
Health committee is functioning in the village
Distance of Health facilities from the village
PHCs (mean ± SD) km
13.2 ± 1.9
CHCs (mean ± SD) km
28.6 ± 10.1
Distance of bus stop (mean ± SD) km
6.4 ± 3.6
Vehicle available in emergency in the villages
Knowledge, perception, and practices of UMPs
A total of 168 UMPs were identified of which 28 were not willing to participate in the study, rest 140 UMPs were interviewed. All the UMPs were male with an average age of 33.3 (SD: 8.1) years. About 50% of the participants had completed up to secondary level of school education, 24% were graduates (with non-medical degree), 6% were post-graduates with non-medical degrees, and 6% had acquired a short term certificate or diploma in Medical Laboratory Technology, Certificate of Training of “Jan Swasthya Rakshak” (Village Health Guide). The remaining 10% had other training certificates from unrecognized agencies or organizations (Table 1).
The UMPs had 2–15 years of experience (average of 8.3; SD: 3.1 years) providing health care services and were treating patients mostly for common illness such as malaria, typhoid, cold and cough, diarrhoea, and skin diseases. Most (79%) of the UMPs knew about the aetiology (cause and clinical symptoms) of malaria. However, the remaining 21% of the UMPs had misconceptions about the mode of transmission of the disease and reported that house flies, bedbugs, and consuming contaminated water or food also caused malaria infection. More than 50% of the UMPs were not aware of the proper breeding places of mosquitoes and lacked knowledge regarding modern preventive measures for malaria (Table 2). Knowledge about human plasmodia was also inadequate; 82% of the UMPs knew only P. falciparum species, 11% knew only P. vivax, 7% knew both P. falciparum and P. vivax. Around 6% reported filaria and dengue as names of species of Plasmodium (Table 2).
The average charge for the diagnosis and treatment of any disease was 4.27 USD per patient, which varied with type of the disease and patient condition. In 1 week before the survey, an average of 47.3 (SD: 34.9) patients were treated by the UMPs, of which 27.4 (SD: 24.7) patients had febrile illness and were suspected to be infected with malaria. Overall, 38% of UMPs admitted that they usually provide anti-malarial treatment to the suspected malaria cases without confirmed diagnosis; the remaining 62% mentioned that they provide treatment only after blood test using malaria rapid diagnostic test kit (RDT). Some of most recently used RDTs were physically verified by the interviewers during the survey. The malaria RDTs were procured from the local market. Injectable modes of treatment were most favoured (67%) as per the choice exercised by the patients. Only 9% of the UMPs had heard about the national policy for diagnosis and treatment of malaria, though none had actually read the guidelines. Four percent of the UMPs mentioned that they had also treated serious and complicated malaria cases, which is not advised by the guidelines (such cases should refer to nearest health facilities).
Treatment practices of UMPs particularly for malaria
N = 140
Total length (mean ± SD) of medical practice (year)
8.3 ± 3.1
Attended any training programme
Training provided by govt. agency
Training period (months) (mean ± SD)
7.3 ± 3.5
Training on malaria diagnosis and treatment
Major common diseases in area
Providing services on following health issues
Maternal health care
Child health care
Common diseases (diarrhoea, skin diseases, typhoid, piles, asthma)
No. of patients treated in last week (mean ± SD)
47.3 ± 34.9
No. of fever cases treated in last week (mean ± SD)
27.4 ± 24.7
No. of malaria patient treated in last week (mean ± SD)
17.6 ± 5.8
Usually treat suspected malaria cases based on clinical symptoms
Treat suspected malaria cases only after blood test using RDTs
Having malaria RDT in stock (physically verified)
Source of RDT procured
Source of antimalarial procured
Mode of treatment preferred
Cause of preference of injectable
Patient psychology (client’s preference)
Fast recovery (provider’s preference)
Treated complicated/serious malaria patient
Heard about national diagnosis and treatment guidelines of malaria
Treatment practices of malaria patients
E-Mal (artesunate injection)
Malaria incidence was most pronounced in tribal dominated areas of the country . These tribal dominated areas are hilly, forested, and inaccessible in much of the rainy season, which is the main transmission season for malaria . Tribal communities preferred informal health providers, such as faith/traditional healers and unqualified or unlicensed medical practitioners. This preference is less by choice than by necessity due to low literacy levels, poor economic conditions, and inadequate health infrastructure which act to limit awareness of disease transmission and prevention, diagnosis, and treatment [6, 7, 11]. UMPs are the first source of treatment providers for more than half the population in rural tribal areas [7, 11, 12]. Although UMPs lack medical degrees, they have self-acquired knowledge and experience administering allopathic medicines.
Despite their knowledge and experience, the survey results found many examples of inappropriate treatment practices. UMPs frequently treated P. falciparum patients with monotherapy of artemisinin, often with incomplete doses which can create drug pressure and lead to drug resistance . It has also been reported in other studies that artemisinin mono-therapy has been prescribed by qualified allopathic and non-allopathic physicians for treatment of uncomplicated malaria in other areas . UMPs also treated P. vivax patients with artemisinin, while many P. falciparum patients were treated with chloroquine, which is against the national treatment guidelines for malaria . In addition, national guidelines state that quinine is only to be given to serious and complicated confirmed malaria patients under strict medical supervision .
This study confirmed that the poor health infrastructure in remote rural and inaccessible tribal dominant areas of the state compels community members to seek treatment from unlicensed private health providers, mainly because they cannot afford wage loss due to sickness . Alternative health services are only available at locations too far away to be accessible . Thus residents in these areas represent a vulnerable population unable to access malaria diagnosis and treatment services that adhere to national guidelines. While they do not receive the quality of services obtained by residents in other parts of India, their ability to access UMPs provides them with providers who are described as hospitable and able to provide hassle-free, relatively low-cost medicines and services. These findings conform with those of a study conducted by Das and Mohpal in Madhya Pradesh, which revealed that most private providers in rural areas lack formal medical training, but they had spent more time with the patients and thus win over their trust .
While few of the UMPs acknowledged that they treated serious and complicated malaria cases instead of referring them to the nearest health facility, it is important to recognize that such treatment represents an important contribution given the scarcity of government health infrastructure in remote rural areas. This lack of trained human resources is an important factor for poor health delivery in rural areas. The educational background and skills of UMPs related to diagnosis and treatment might be stronger than those of ASHAs, who are primary health care providers in rural communities. Therefore, it is recommended that UMPs be trained as per the national guidelines for diagnosis and treatment of common illnesses, including malaria, to enhance their ability to play a significant role to achieving India’s malaria elimination goals.
In 2009, a 6 months’ training programme was organized in the state of Andhra Pradesh to develop treatment skills of common ailments and awareness among UMPs . Similarly, in the state of Chhattisgarh, a three-year medical diploma course was initiated in 2001 to train health practitioners for rural areas. However, these programmes were aborted, mainly due to resistance from the Medical Council of India (MCI), the professional body regulating medical education in India. The MCI raised the issue that approval to practice medicine by UMPs may promote the irrational use of allopathic drugs and bring a medical catastrophe. In July 2019, the Government of India introduced National Medical Commission Bill, 2019, in assembly which may grant a limited license to certain mid-level practitioners (community health providers) connected with the modern medical profession to practice allopathic medicine. These mid-level practitioners may prescribe specified medicines in primary and preventive healthcare. In other situations, these practitioners may only prescribe medicines under the supervision of a registered medical practitioner .
Developing a well-designed training protocol for UMPs, particularly on anti-malarial treatment, may be useful in areas of India, along with limiting their role to be similar to that of health volunteers such as ASHAs and other programme-driven village-level health care providers, rather than giving them the status of a doctor. In addition to training and equipping UMPs to provide basic health services, including anti-malarial services, close monitoring of their capabilities should be enforced to ensure their credibility. Such activities, designed to incorporate trained UMPs into the existing programme for achieving India’s malaria elimination goals in hard-to-reach tribal areas, can only bring positive results.
All efforts were made to capture valid responses from the UMPs who participated in the study. Responses were collected only from UMPs who volunteered for the survey, and this might have resulted into certain amount of biasness. However, such bias was not so extensive and thus this possibility is not overly concerning.
The authors thank to Dr. Neena Valecha, former Director, ICMR-National Institute of Malaria Research, New Delhi, for providing support. The manuscript was approved by the Publication Screening Committee of ICMR-National Institute of Malaria Research, New Delhi (Reference no. 48/2018).
MPS: conceptualized the study, study design, data analysis, data interpretation and prepare the first draft. SKC, NS: monitoring of data collection, data interpretation, review and write the manuscript. KBS: data analysis and data interpretation, review and write the manuscript. RCD: data interpretation, review and write the manuscript. LLS: data interpretation finalized the manuscript on the basis of comments from other authors. All authors read and approved the final manuscript.
Study was carried out with financial support from Tribal Development and Research Institute, Ministry of Tribal Affairs, Government of Madhya Pradesh, Bhopal, India. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
Ethics approval and consent to participate
The study was approved by the Institutional Ethics Committee of ICMR-National Institute of Malaria Research, New Delhi, India. Informed consent from the heads of the households and UMPs was obtained before conducting interviews.
Consent for publication
All participants provided informed consent to have information shared through publication, with identifying information removed.
The authors declare that they have no competing interests.
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