Poor quality and high costs are associated with the informal provision of health care. New research in Bangladesh, India and Nigeria offers innovative strategies to improve performance. Poor people often use informal providers for health care. In Bangladesh formally trained workers account for only five percent of providers. The private sector comprises around 180,000 informal providers practising as village doctors and/or drug vendors.
Over 70 percent of India’s population is rural yet more than 70 percent of its medical professionals practice in the urban, affluent private sector or have migrated overseas. Fewer than 50,000 doctors work in rural primary and secondary health care facilities; health care is delivered mainly by under-trained staff, often referred to as rural medical practitioners or the informal private health sector.
In Nigeria, self-treatment of common illnesses using drugs purchased from patent medicine vendors (PMVs) is widespread and the most common source of malaria treatment in Nigeria.
Figure 1: Sources of treatment for malaria in three states in Nigeria (% of first treatment) (Larger version)
An International Centre for Diarrhoeal Disease Research, Bangladesh study found that villagers, social leaders, health care providers and drug vendors see village doctors as an essential source of health care. But there is concern about the quality of care: village doctors need up-to-date medical information and training opportunities. A new intervention is testing a manual and a training programme to improve informal providers’ treatment of common illnesses. ICDDR, B is also creating a network of informal providers - Shaysthya Sena or Health Force - whose members must adhere to agreed quality standards for:
- appropriateness of treatment
- reduction in prescriptions of harmful drugs
- timely and appropriate referrals.
Compliance will be monitored by a local health watch group, composed of members of the Shastya Sena network, government administration, civil society, peers and experts.
Recognising the potential of the informal sector, India’s National Rural Health Mission and the Eleventh Plan Approach Paper have called for innovative partnerships with informal providers to improve quality of care at the frontline. First Care Health is a social enterprise with rural medical practitioners currently being piloted by the Indian Institute of Technology’s Rural Technology and Business Incubator in Tamil Nadu. They have given rural practitioners computers and internet technology, distance learning and other support.
Researchers from the University of Ibadan in Nigeria found that most PMVs would like stronger government regulation to reduce the availability of fake drugs, while nearly a quarter called for self-regulation through professional associations.
Over 90 percent of vendors thought it would be good to involve community members in monitoring the quality of drugs – a view echoed by government. The University of Ibadan is trying to increase consumer knowledge and expectations for consumer rights, including the creation of effective regulatory partnerships to ensure the quality and affordability of drug supplies. The university’s research in Oyo State has drawn interest from the government which would like to strengthen the communication of drug policy and regulation to PMVs and understand the mechanisms by which they can work together to identify and remove substandard and counterfeit drugs from the market.
In India, health care in rural areas is delivered mainly by undertrained staff
All these interventions aim to understand better the potential benefits of linking informal providers, communities, knowledge brokers, researchers and policymakers. Possible outcomes include:
- more empowered informal providers
- better informed government actors
- more locally-devised and –owned educational tools
- stronger formal links between civil society, government and the informal sector.
Interventions and policies that fail to acknowledge informal providers as a potentially key source of services are less likely to succeed. Mechanisms will differ depending on context, capacity and technology. These mechanims will, however, provide evidence on the potential of non-state actors to improve access to quality health care.
Rowen Aziz, Meenakshi Gautham, Oladimeji Oladepo, Kate Hawkins
Future Health Systems Research Programme Consortium