Walking a tightrope: perspectives of non-degree allopathic providers (NDAPs) on providing diabetes and hypertension care in urban informal settlements of Mumbai Metropolitan Region

Background In India, Non-Degree Allopathic Providers (NDAPs), who do not have formal training in allopathic medicine, play a prominent role in basic healthcare delivery in both rural areas and urban informal settlements. Often recognized as providers of 'first contact' care for minor acute ailments, there is little information regarding the roles they play in providing services for non-communicable diseases (NCDs). In this study, we explore the roles played by NDAPs in diagnosing and managing two NCDs--diabetes and hypertension--in urban informal settlements of the Mumbai Metropolitan Region. Methods This is a qualitative study involving data collection with 25 NDAPs (19 males and 6 females). Data was collected between December 2022 and September 2023. Data was coded inductively, and an iterative process of coding was followed to derive key themes. These themes were further refined through reflections within the author group. The qualitative software NVivo Version 10.3 was used to facilitate the analysis process. Results All NDAPs we spoke to noted an increase in diabetes and hypertension patients in the urban informal settlements they worked in. All of them provided medication for 'quick relief' to patients from the bothersome symptoms of the two diseases. But in some cases, NDAPs also reported acting as counsellors, patient navigators, and local supervisors of therapy initiated by other doctors. Generally, risk-averse, NDAPs were cautious about how much of the diagnosis and treatment process they participated in. Those with informal and formal connections with private, qualified allopathic providers involved themselves more extensively in the management of the two NCDs. NDAPs had limited ties with the public health system and preferred sending patients to other private doctors if they felt a case was beyond their purview. Conclusion The informal health sector in India is currently offering a range of services to address the needs of patients with NCDs. Our study suggests that the strong presence of this sector in resource-constrained communities can be leveraged by the public health system to enable community-level screening for NCDs, facilitate access to specialist care, improve treatment adherence, and promote wellness initiatives. In light of the changing epidemiological burden, our study underscores that despite the contentious nature of practices in the informal health sector, overlooking this group of providers is no longer an option for health pol