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A focus on informal providers

posted Feb 12, 2013, 8:29 AM by Jeff Knezovich   [ updated Feb 14, 2013, 11:01 PM by Kate Hawkins ]
Last Tuesday, the Private Sector in Health launched webinar series with a session on informal providers in India, which was co-hosted by the Future Health Systems Consortium (FHS) and the Center for Health Market Innovations (CHMI). The webinar was well attended with participants spanning five continents, helping to achieve the goal of the webinar series of widening the discussion on key issues facing the private sector and health in the run up to the symposium in July.

For this first webinar, speakers from the UK (Gerry Bloom), the US (Gina Lagomarsino) and India (Meenakshi Gautham) provided an overview of the importance of informal providers to health service provision and provided convincing arguments as to why governments and donors should pay more attention to this neglected group when formulating health-related regulation and considering how we might further the cause of universal access.

An overview
Drawing on CHMI sponsored studies from Bangladesh, India and Nigeria and a literature review conducted by the Global Health Group at the University of California, Gina explained that informal providers are not an easy group to define – they can be drug sellers, traditional birth attendants, village doctors, and traditional healers. CHMI used three characteristics to narrow down their field of study: that they were mainly an entrepreneur who is paid by patients, not by an institutions, usually in cash; that they had little or no officially recognized training and; that they operated largely outside of effective oversight or regulation by government or other independent bodies.

They found that informal providers represented a significant portion of the healthcare system in a number of countries and that the poor are most likely to seek their care. The quality of their services is highly variable (although there is little evidence on this). Despite this, they are popular due to convenience (location, operating hours), affordability and culture. The country studies confirmed that informal providers had strong ties to their local communities, that they were trusted and that they are often considered social elites with levels of schooling beyond the national average. So, while the global health world might view them as ‘quacks’ this is not how they are considered locally. 

Most of the informal providers had some medical training or had taken commercial courses. For example, in Nigeria 85.5% of Patent Medicine Vendors studied had previous training on diseases such as malaria, diarrhea and pharmaceutical products. Some had been apprentices to formal providers, and many were eager to learn more. 

Informal providers did, however, engage in incorrect and potentially harmful practices. For example inadequate testing before diagnosis (as in the case of malaria in Nigeria), rampant over-prescription of antibiotics in some markets (particularly apparent in Bangladesh, where most patients receive one or more antibiotic) and, inappropriate injections (particularly pronounced in some parts of India). However they did demonstrate some knowledge of appropriate protocols. Gina urged further partnerships for research and also to get some of the findings of the studies taken up in policy and practice and to gather more insights into how to minimize harm and maximize potential. 

A focus on India
Meenakshi provided more detail on the Indian country study which was conducted in two states, Uttarakhand and Andhra Pradesh. The aim of the study was to identify and count informal and formal providers in the study areas and to get a better sense of their levels of education and training, skills, services and costs. They found that in both states there was a greater population coverage of informal providers compared to qualified doctors. In both settings they had very strong local roots, but they provided their services in different ways. In Tehri (UT state) they were mainly clinic based, but in Guntur (AP state) they mainly went door-to-door but most were open seven days a week.

The relationship between informal providers and qualified doctors was particularly interesting. In Guntur 40.5% informal providers received referral commissions from private doctors and 7% received gifts, for example medical equipment and sample medicines. The Government doctors were the informal providers’ trainers in the state training program, and there were no signs of overt hostility. However they were considered competitors. In Tehri there was hostility between the two groups. With only five private doctors within the district, informal provider referrals were directed equally towards public facilities and private facilities, including in nearby towns outside the district. The informal providers recounted how they had had bitter experiences with health department officials, who demanded certificates and diplomas and sometimes bribes. This study dispels the myth that they are lone operators, in fact there were interactions with other informal providers and also with formal sector.

Meenakshi concluded by reflecting that informal provider markets have evolved in different ways in response to different contextual influences and that they are likely to play a role in the provision of health related goods and services for quite some time.

What’s next?
A recording of the webinar is available for those of you who want to delve into more of the details of all presentations. We want to extend out thanks to Future Health Systems and CHMI for all their efforts to make this webinar a success. We hope that you will join us for the next session in the series which will be held in March and will explore the Bellagio Statement on the Future of Health Markets.