Informal Providers, Pluralistic Health Systems, and India's COVID-19 Response: A Cross-Sectional Telephonic Study

Background: Informal providers (IP) have a large presence in India’s health workforce; they are usually first contact primary care providers for rural populations. Patients with COVID-19 symptoms will likely first see an IP. This study aims to understand COVID-19 knowledge and management practices of IPs and trained practitioners of Indian systems of medicine (AYUSH), and medical doctors (MBBS) in the state of Bihar, India.Methods: In a 2019 household survey we identified primary care providers who had served patients in the last month. Providers were contacted via telephone in July 2020 when Bihar was experiencing a rapid increase in COVID cases. Using structured questionnaires we interviewed 452 IPs, 57 AYUSH, and 38 MBBS doctors (including 23 government doctors) from 224 villages across 34 of 38 districts in Bihar.Findings: Most providers experienced a fall in patient visits during the pandemic. Most IPs and qualified private providers had no engagement with government agencies; their principal source of COVID-19 information was television and newspapers. IP knowledge levels of COVID-19 and its prevention was comparable with qualified providers. There was low stated compliance among IPs (16%) and qualified providers (15% of MBBS doctors, and 12% of AYUSH practitioners) with all WHO recommended practices for suspect COVID-19 cases.Interpretation: Government action to improve IP and other primary care provider COVID-19 knowledge and case management will strengthen efforts to control the pandemic, particularly in rural areas. Because IPs are embedded within communities, they can make important contributions to contact tracing efforts and public health messaging.Funding Statement: Bill and Melinda Gates Foundation, India.Declaration of Interests: None declared for KDR, JK, MKP, and NK. PN is employee of the funding agency.Ethics Approval Statement: Ethical approval was granted by the Indian Institutional Review Board in India (Reference number: 1007/IRB/20-21) as well as Johns Hopkins University Institutional Review Board. The purpose of the study was explained and oral informed consent was obtained from each respondent.