Occupational Therapy Private Practice in Tamil Nadu, India: A State-wide Survey.

Abstract

Many occupational therapists in India have entered private practice in recent years. This preliminary study aimed to understand the factors that influence the occupational therapy private practice sector in Tamil Nadu, India. An electronic survey was sent via email and Facebook private messaging to 55 private OT practitioners in Tamil Nadu in November 2016. The response rate was 31%. The findings highlighted ‘desire for autonomy’ as a key factor that motivates occupational therapists to enter private practice and ‘dearth of manpower’ as a major challenge for occupational therapy entrepreneurs in Tamil Nadu. Some implications for occupational therapy entrepreneurs that arose from the results are presented in the discussion.

Key words: Occupational therapists, Private sector, Surveys and Questionnaires, Motivation.

Full text

Introduction
Private practice is defined as a professional
business that is not controlled or paid for by the
government or a larger company (Merriam
Webster, n.d.). Though many occupational
therapists (OTs) in India engage in private
practice, little data exists describing this sector.
Private practice in occupational therapy (OT)
has its benefits and risks. On one hand,
running a successful private practice is
rewarding and satisfying (Doctorly, n.d.). On
the other hand, it may limit the opportunities for
professional networking and engaging in
multidisciplinary/interdisciplinary patient care
practices. Also, private practice reduces the
opportunities for OTs to educate other health
professionals on the role of OT.
In addition, private practice may make OT
services expensive, thereby limiting the access
to OT services for people in lower-middle and
low socioeconomic classes.
In the Indian context, several factors influence
successful private practice, such as referrals,
staffing, reimbursement, therapists’
communication skills, socioeconomic status of
clients, literacy level of clients, and location of
practice. Despite the challenges and
disadvantages associated with private practice
and the profession’s limited visibility,
intriguingly, many OT professionals in India are
attracted to private practice.
Tamil Nadu - State business profile
Tamil Nadu (TN) is the third largest contributor
to India’s gross domestic product (Statistics
Times, 2016) and the leading industrial state in
India (Business Times, 2016). The state has
nearly 8.5 lakh (0.85 million) micro, small, and
medium enterprises (MSMEs), 26% of which
are service enterprises (MSME, n.d.).
According to the TN State Industrial Profile
2014-15 (MSME, n.d.), many service
Research Article
Occupational Therapy Private Practice in Tamil Nadu, India: A State-wide
Survey
Mani, K.
ABSTRACT
Many occupational therapists in India have been entering into private practice in recent years.
This preliminary study aimed to understand the factors that influence the occupational therapy
private practice sector in Tamil Nadu, India. An electronic survey was sent via email and
Facebook private messaging to 55 private OT practitioners in Tamil Nadu in November 2016. The
response rate was 31%. The findings highlighted ‘desire for autonomy’ as a key factor that
motivates occupational therapists to enter private practice and ‘dearth of manpower’ as a major
challenge for occupational therapy entrepreneurs in Tamil Nadu. Some implications for
occupational therapy entrepreneurs that arose from the results are presented in the discussion.
Key words: Occupational therapists, Private sector, Surveys and Questionnaires, Motivation.
Dr. Karthik Mani, OTD, OTR/L is
Chief OT, VOTC, India; Assistant
Director, External & Regulatory Affairs,
NBCOT, USA.
Email: kmani@votc.co.in

enterprises were situated in the state capital
Chennai. In alignment with this finding, the
majority of OT private practices, which are
service enterprises, are located in Chennai
(TNAIOTA, 2016).
According to the Micro, Small and Medium
Enterprises Development Act (MSMED) of
2006, service enterprises with investments up
to one million INR
1
(excluding land and
buildings) are micro enterprises (MSME, n.d.).
Occupational therapy private practices would
typically fall under this category since, at the
time of this writing, material investments for OT
clinics are less than one million INR.
Tamil Nadu – State occupational therapy
profile
Tamil Nadu is a state with a large number of
OT practitioners. Similar to Maharashtra, TN
has several OT educational institutions.
Although there was a decline in the number of
active OT educational programs in the last
decade, some of the closed programs have
reopened recently. Further, two new OT
programs began to operate in the 2017-2018
academic year (NIEPMD 2017; SRU, 2017).
Though TN witnessed an exodus of its early
OT graduates to foreign nations, the increased
demand for OT services encouraged many
professionals to continue to practice in the
state. The data on the number of active OT
practitioners in the state is currently
unavailable. Occupational therapists in TN
work in different practice settings such as
hospitals, special schools, outpatient OT
clinics, and non-governmental organizations.
The growth of OT private practice in TN began
in the early 2000s, bringing with it a relatively
increased visibility and accessibility of OT
services in the state. This growth was fostered
by the surge in supply-demand imbalance due
to personnel shortages and increased demand
for services. The increased health literacy and
affordability of TN’s urban population may also
have contributed to this growth.
1
Indian National Rupee
The OT practice in TN is largely unregulated.
At the time of this writing, the state of TN has
not yet come under the purview of The Clinical
Establishments Act of 2010 (MHFW, n.d.).
Some OT private practice establishments in TN
have expanded their scope to operate as
special schools or non-profit organizations and
obtained registration under The Tamil Nadu
Societies Registration Act of 1975.
Due to the growing trend of OT private practice
in India, and TN in particular, it is critical to
examine the related motivating factors,
challenges, and success indicators. In the
present study, TN OT private practitioners
were surveyed on (i) factors that motivated
them to enter private practice, (ii) current
challenges related to private practice, and (iii)
factors that are critical to success in private
practice. The overarching aim of this survey
study is to understand the factors that influence
the OT private practice sector in TN.
Methodology
A convenience sample of 55 private practice
owners were selected for this study from the
TN branch of the All India Occupational
Therapy Association’s (TNAIOTA) OT Clinics
Directory (TNAIOTA, 2016). An electronic
survey was sent to the sample via email and
Facebook (FB) private messaging in November
2016. Two subsequent reminders were sent to
all participants through the same channels.
The first reminder was sent eight days after the
date of the initial invitation, and the second
reminder was sent 20 days after the date of the
initial invitation. The survey was closed 10
days after the last reminder was sent.
Response to the survey indicated participants’
informed consent. Twenty one practitioners
(Response rate – 31%) responded to the
survey. As response rates of electronic
surveys are typically around 30% (Ramshaw,
2017), a 31% for this survey may be
considered acceptable. However, one must
exert caution when generalizing the findings.
Instrument

A ten-item survey was developed using
SurveyMonkey™ (SurveyMonkey Inc., San
Mateo, California) and reviewed by
experienced OTs prior to its use in the study.
Survey items included demographic
information, motivating factors to enter private
practice, contemporary challenges in private
practice, and success indicators. The data
were analyzed with descriptive statistics.
Results
As some respondents did not respond to all
questions, the total number of responses to
each question vary slightly. Out of 21
respondents, 20 respondents (95%) identified
pediatrics as their primary area of practice.
One respondent selected the response option
‘other’ and identified ‘all types’ as his/her
primary area of practice. At the time of this
study, 12 (57%) respondents have been in
private practice for more than a decade, 3
(14%) for 7-10 years, 3 (14%) for 4-6 years,
and 3 (14%) for 0-3 years. Before entering
private practice, respondents worked in a
variety of practice settings (Hospitals – 37%;
Schools/Special Schools – 32%; Outpatient
settings – 22%; & NGOs – 11%). Of 19
respondents who responded to the item on the
highest level of education in OT, 13 (68%) had
a bachelor’s level degree, 5 (26%) had a
master’s level degree, and 1 had a doctoral
level degree.
Motivating factors
When asked to rank the factors that motivated
them to enter private practice, respondents’
responses were mixed. However, based on
average ranking, respondents ranked ‘more
autonomy’ first, ‘flexible working hours’ second,
‘higher income’ third, and ‘independence in
clinical decision making’ fourth. Table 1
depicts the ranking of motivating factors by
respondents.
Size of the occupational therapy staff team
The OT staff team of OT private practices in
TN ranged from less than two to 10. The
majority (56%) of respondents revealed that
their staff team consists of 3-5 OTs. Two
respondents stated that they have 6-10 OTs on
their staff team. Figure 1 shows the size of OT
staff teams in OT private practices in TN.
Nearly half (44%) of the respondents reported
that less than 25% of their staff team had
graduate education. No respondent reported a
staff team completely made up of graduates
(individuals with master’s or higher-level
degrees).
Figure 1. Size of occupational therapy
teams in occupational therapy private
practices in Tamil Nadu.
Challenges involved in private practice
Respondents were asked to identify the
challenges they faced in private practice by
selecting from a list of seven options, with an
option to write in other challenges. Multiple
options could be selected. Staffing shortage
(50%), lack of awareness (44%), and attracting
a referral base (39%) were the top three
challenges that respondents identified. Write-
in responses included non-co-operative clients,
lack of regulation, and encroachment of other
professionals within the OT domain. Figure 2
presents the challenges identified by
respondents.
Reimbursement for private practice
Of 16 respondents who responded to the
survey item on how their clients pay for
services, as expected, 12 (75%) respondents
reported ‘out-of-pocket, three (18.75%)
reported ‘health insurance,’ and one
0
5
10
15
<2 3-5 6-10 11-15
NO OF RESPONDENTS
OT STAFF TEAM SIZE

Table 1. Respondents’ ranking of motivating factors to enter private practice.
respondent selected the ‘other’ option and
commented ‘different mode.’
Success indicators
Seventeen respondents ranked success
indicators of private practice based on their
perception. Five respondents ranked
‘establishing customer loyalty’ first, and four
other respondents ranked ‘OT knowledge and
skills’ first. With the exception of ‘reliable
referral base,’ all other response options were
ranked first by at least one respondent. ‘Work
experience’ was ranked low as a success
indicator, with 59% of the respondents ranking
it a five or a six out of seven. Seven
respondents ranked ‘targeted marketing efforts’
as least critical to success when compared to
other variables presented. Table 2 presents
the ranking of success indicators by
respondents.
Discussion
This study surveyed OT private practitioners in
Tamil Nadu, India. As TN is one of the states
with a large number of OT practitioners in India
(Mani & Provident, 2017), the findings of this
state-level survey could be generalized to the
entire nation, with caution. Several interesting
trends emerged from data analysis.
Dominance of pediatrics
The majority of OT private practitioners in TN
practice in the area of pediatrics. The
dominance of pediatrics in the OT private
practice sector could be due to more
availability of referrals or an increased visibility
of OTs’ role in this area of practice among the
medical community. Another reason for this
could be the increase in the demand for
pediatric OT services due to the
unprecedented increase in the number of
children with developmental disorders in recent
years.
Desire for autonomy
Respondents’ ranking of motivating factors
revealed an inverse relationship between
‘years of experience in private practice’ and
‘need for autonomy and independence in
clinical decision making.’ Similar to the
findings in the literature (Briddle & Hawkens,
1990; McClain et al., 1992), many practitioners
identified ‘desire for autonomy’ as a factor that
motivated them to enter private practice.
However, those who had been in private
practice for a long time ranked ‘flexible work
hours’ and ‘higher income’ above ‘more
autonomy.’ The author has witnessed the
practice of private practice owners working as
consultants who provide consultations, perform
assessments, plan treatment, and advise
entry-level practitioners to implement the
treatment plan. It is unclear whether the
observed inverse relationship is related to this
practice.
Motivating Factors
No of
respondents
ranked 1
No of
respondents
ranked 2
No of
respondents
ranked 3
No of
respondents
ranked 4
More autonomy
6 (28.57%)
7 (33.33%)
4 (19.05%)
4 (19.05%)
Higher income
5 (23.81%)
5 (23.81%)
3 (14.29%)
8 (38.10%)
Flexible work hours
4 (19.05%)
7 (33.33%)
8 (38.10%)
2 (9.52%)
Independence in clinical
decision making
6 (28.57%)
2 (9.52%)
6 (28.57%)
7 (33.33%)

Figure 2. Challenges involved in private
practice as identified by the respondents.
Education and Work Experience
Many respondents have a bachelor’s level
education in OT and did not work in the private
practice sector before entering private practice.
Only four respondents had worked in
outpatient settings prior to entering private
practice. Also, many respondents perceived
that work experience was not critical to
success in private practice. Based on these
results, it appears that education level and
experience in the private practice sector do not
influence an OT’s decision to enter private
practice.
Staffing shortage and retention.
As expected, ‘staffing shortage’ emerged as
the biggest challenge for private practitioners in
TN. The lack of OT practitioners in TN and an
increased demand for OT services may have
contributed to this shortage. This finding
indicates the need for manpower development
in the field of OT in TN. Fortunately, as stated
earlier, several OT educational programs have
7
9
4
5
2
8
6
4
0246810
Attracting a referral base
Staffing shortage
Staff retention
Client retention
Reimbursement related
challenges
Lack of awareness of OT
services
Unavailability/limited
availability of modern gadgets
Other
CHALLENGES
No of respondents
Table 2. Respondents’ ranking of success indicators in occupational therapy private practice.
Success
Indicators
Rank 1
Rank 2
Rank 3
Rank 4
Rank 5
Rank 6
Rank 7
Establishing
customer
loyalty
5
(29.41%)
3
(17.65%)
3
(17.65%)
2
(11.76%)
1 (5.88%)
2
(11.76%)
1 (5.88%)
Occupational
therapy related
knowledge and
skills
4
(23.53%)
2
(11.76%)
2
(17.65%)
3
(17.65%)
2
(11.76%)
2
(11.76%)
1 (5.88%)
Reliable
referral base
0 (0.00%)
3
(17.65%)
4
(23.53%)
2
(11.76%)
4
(23.53%)
4
(23.53%)
0 (0.00%)
Securing word-
of-mouth
referrals
2
(11.76%)
2
(11.76%)
1 (5.88%)
5
(29.41%)
2
(11.76%)
2
(11.76%)
3
(17.65%)
Targeted
marketing
efforts
3
(17.65%)
2
(11.76%)
2
(11.76%)
0 (0.00%)
2
(11.76%)
1 (5.88%)
7
(41.18%)
Work
experience
1 (5.88%)
3
(17.65%)
1 (5.88%)
1 (5.88%)
5
(29.41%)
5
(29.41%)
1 (5.88%)
Effective
communication
skills
2
(11.76%)
2
(11.76%)
3
(17.65%)
4
(23.53%)
1 (5.88%)
1 (5.88%)
4
(23.53%)
17
(100%)
17
(100%)
17
(100%)
17
(100%)
17
(100%)
17 (100%)
17
(100%)
(Values in cells indicate the number and percentage of respondents.)

launched or reopened in the state, so a
number of new practitioners will begin to enter
the field.
Respondents who have larger OT staff teams
also identified staff retention as a challenge.
Leadership and managerial training focused on
human resource management may help OT
entrepreneurs to overcome this challenge.
Lack of regulation
One respondent who has been in private
practice for 7-10 years identified the lack of
licensure or regulation as a challenge. The
same respondent ranked ‘establishing
customer loyalty’ first in the list of success
indicators. This shows the practitioner’s belief
that a license or registration would enhance
practitioners’ credibility among their clients and
the general public. Another respondent
identified ‘fake therapy centers’ and
‘professional encroachment by other
professionals’ as challenges. Though it is
unclear what the respondent meant by fake
therapy centers, one could connect this
comment to the issue of regulation; strict
regulations would protect the profession from
fraudulent practices and professional
encroachment. Further, a regulated profession
may also attract the recognition of health
insurance providers. This survey shows the
emergence of reimbursement through health
insurance for OT services in TN as three
respondents stated that their services were
reimbursed through health insurance.
Marketing
Many respondents did not perceive marketing
as a critical success indicator. This could be
due to the current demand-driven nature of OT
private practices in TN. The OT entrepreneurs
may appreciate the need for marketing when
the supply and demand curve changes its
trajectory.
Practitioners’ perceived ranking of success
indicators may also be influenced by their
values and location of practice (urban,
suburban, or rural). For instance, a practitioner
who values relationship may perceive
customer loyalty and reliable business
relationship with referral sources superior to
other success indicators. However, a
practitioner who values successful outcomes
may perceive OT knowledge and skills superior
to other variables. Similarly, the urban-literate
society may expect a professional therapist-
patient relationship, which may encourage a
practitioner to value job skills and work
experience. In contrast, clients in some
suburban and rural areas may expect a trust-
based relationship, which may encourage a
practitioner to value loyalty, open
communication, and word of mouth opinions.
Limitations
● This study did not investigated related
variables like income differences after the
move into private practice, work experience
prior to the move into private practice, risks
involved in private practice, influence of culture
and geographical location on private practice,
professional migration from other parts of the
country, etc.
● Sampling bias – OT entrepreneurs who
are not identified in the TNAIOTA OT Clinics
Directory are not included in this study.
Recommendations
● Replication of this study with more items
to gain an in-depth perspective on issues
related to private practice is needed.
● Replication of this study with a large
sample size is needed.
● Replication of this study in other states
such as Maharashtra and Karnataka or at a
national level may prove beneficial.
Insights for Occupational Therapy
Entrepreneurs
● Occupational therapy entrepreneurs in
TN and India have many untapped market
opportunities. They may establish private
practices focusing on the practice areas of

mental health, physical dysfunction, geriatrics,
and ergonomics.
● Occupational therapy entrepreneurs
may benefit from leadership and managerial
training or an advanced degree in
management.
● Occupational therapy entrepreneurs
should support the efforts of OT professional
bodies toward awareness promotion,
manpower generation, and professional
regulation.
● Occupational therapy entrepreneurs
must provide entry-level practitioners
opportunities for clinical decision making.
Conclusion
The OT private practice in TN is thriving and is
dominated by the pediatric area of practice.
This study found ‘desire for autonomy’ as one
of the critical motivators that drive OTs into
private practice. The dearth of OT manpower,
lack of awareness, and lack of regulation are
some major challenges that OT entrepreneurs
in TN and India need to address to develop
their profession and ensure sustainability of
their businesses.
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