Defining a role for the informal sector in health care provision

in Bangladesh and Mali

Peter WinchJohns Hopkins University

pwinch@jhsph.edu

MAS Conference 2008

Primary Health Care and Social Equity – Illusion or

Reality?

What is needed to fully implement Primary Health

Care?Address determinants of poor health

Promote preventive interventions

Make care accessible, affordable and of high quality

WaterEducationAgricultureCommunity governanceEnvironmental stewardship

ImmunizationMicronutrientsMosquito netsFamily planningHandwashingLatrine useEtc.

Management of acute and chronic illnessesMaternal careSurgical careMental healthEtc.

Lead role for the State in PHC

The International Conference on ‘Primary Health Care’ (PHC) in Almaty in 1978 – Declared health to be a fundamental

human right – Defined a lead role for the State, in

statements such as “All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care…”.

How to make care accessible?

Improve transport and communications– Roads– Cell phones

First-level health care facilities– Build more so no one is far from one – Provide high-quality care & referral

Community-level providers– One or more per community

First-level health care facilities

Functional network and high levels of utilization in some countries e.g. Sri Lanka

In many other countries, difficulty making them fully functional– Too few or too concentrated in one area– Shortages of health workers– Poor health worker performance– Violence against female health workers

The alternative: Community providers

Private physicians Traditional healers Traditional birth attendants Community health workers Informal sector providers

Traditional healers

Typical strengths Deep roots in the

community, respected

Communicate with locally-understood terms and concepts

See serious and stigmatized conditions

Distributed throughout the community

Typical weaknesses Diversity, role

sometimes must be defined on case-by-case basis

Esoteric knowledge, may be hesitant to share information

Treatments of varying efficacy, difficult to fully assess their value

Community health workers

Typical strengths Selected by

community Younger, literate Standardized skills

and services Functionally

integrated with government or NGO health services and referral system

Typical weaknesses Motivation and

incentives High attrition rates

in many programs, CHW work stepping stone to other work

Limited range of services & treatments relative to other providers

CHW and village oversight committee

Informal sector providers

Provide modern medications and/or play diagnostic role in areas where physicians are unavailable or too expensive

Take many different forms– Shop, unlicensed pharmacy– Ambulatory vendor– Village doctor (Bangladesh)

Often given pejorative titles e.g. quack

Informal sector providers

Understudied by anthropologists Traditional healers have been subject

of numerous anthropological studies, some studies of CHWs, very few studies of informal sector providers

Informal sector providers

Typical strengths Recognized source

of modern medication in the community

Financially self-sufficient

Innovative, eager to adopt new ideas

Typical weaknesses Uncertain quality of

medication Uneven quality of

care, limited counseling

Treating conditions beyond their level of expertise

“Illegal” nature of their practice

Bangladesh

Bangladesh

Types of informal sector providers– Shops, unlicensed pharmacies– Village doctors (gram daktar)

Sources of medications– Pharmaceutical companies– Medical representatives of

companies Who: Primarily men

Role of pharmaceutical companies

National pharmaceutical companies significant source of employment in Bangladesh

Village doctors seen as additional channel of distribution, actively supported by pharmaceutical companies

Regular visits by medical representatives

Role of pharmaceutical companies

Next two slides from 2005 study by Nazneen Akhtar, Azharul I. Khan, Lauren S. Blum, Halim Miah, Rafiqul Islam and Charles Larson of ICDDR,B in Bangladesh– “Exploring Interactions Between

Pharmaceutical Representatives and Health Care Providers in Bangladesh”

Frequency and Intensity of Interactions

with Medical Representatives

Visits to formal sector

providers

Visits to informal sector

providers

Number of visits per week to the same provider

3-6 1-2

Minutes per visit 4-6 10-15

Number of products promoted during each visit

6-8 10-12

Notes from visit of Medical Representative to a Village Doctor

Seeing the MR getting off from the motorbike the village doctor walks to him, welcomes him inside while shaking hands. He says, “Bhai, you are like a family member to me. Please come have tea” and offers a seat.

The MR sits, opens his bag and brings out the first product. The village doctor immediately indicates that he prescribes this medicine. The MR says, "thank you” . After tea the MR continues to describe a variety of products, often drawing a diagram to explain the biomedical process and function of the drug. He gives the practitioner literature on each drug and offers small gifts. When finished, he leaves samples of all drugs discussed.

The practitioner accompanies the MR to the road. He says, “Bhai, don’t worry, I always prescribe your drugs.” He then reaches out to shake the MRs hand. The visit lasted 20 minutes.

Sources of care for sick children in household survey in 16 sub-districts of

Bangladesh, 2005

# caretakers interviewed 1665

# (%) U-5 children sick in previous two weeks of survey

957 (58%)

# (%) went outside of home for treatment 450 (47%)

Formal sector

Qualified doctor 20.8 % (105)

Paramedic/FWV/Nurse 4.2% (21)

Depot holder/community health worker 0.8% (4)

Informal/ traditional sector

Village doctor 41.9% (212)

Drug sellers 17.8% (90)

Homeopath 13.2% (67)

Traditional healer 1.4% (7)

Sources of care for children with rapid breathing in household survey in 16 sub-

districts of Bangladesh, 2005

Source % (N=69)

Formal sector

Qualified doctor 23% (16)

Paramedic/FWV/Nurse 7% (5)

Depot Holders 0% (0)

Informal/ traditional sector

Village doctor 41% (28)

Drug sellers 20% (14)

Homeopath 9% (6)

Quality of care for children with rapid breathing in household survey in 16 sub-

districts of Bangladesh, 2005

Typically expect quality of care in informal sector to be much worse than formal sector

BUT: Few differences in quality of care between formal and informal sector providers observed

Qualified doctors and village doctors providing better quality care than paramedics and drug sellers

Case management tasks by providers for children with respiratory symptoms, Bangladesh, 2006

Qualified

doctorN=105

Paramedics/ NurseN= 21

Drug sellersN=90

Village doctor

s N=21

2

Counted respiratory rate 62% 43% 32% 48%

Listened to the chest with a stethoscope

66% 43% 38% 50%

Told what was wrong with the child

62% 43% 36% 62%

Explained the danger signs

64% 29% 55% 52%

Asked whether the caretaker understood everything he said

67% 57% 49% 69%

Asked whether the caretaker had any questions)

28% 24% 13% 29%

Geographic variation in quality

Large variations in quality by region of Bangladesh

Where quality is higher, it tends to be higher for all providers

This is evidence for interaction between providers, no wall between formal and informal sectors

Quality Scores of Providers by Division of Bangladesh

3.57

1.73

4.1

2.092.36 2.29

2.1

0.67

1.33

2.55

4.18

3.25

Qualifieddoctor

Paramedic Drug seller Village doctor

ChittagongDhakaRajshahi

Public health interventions don’t decrease use of village

doctors Levels of utilization of village doctors

fairly stable, despite improvements made in care from health facilities or from community health workers

Example: Careseeking in Matlab, Bangladesh during the Multi-County Evaluation of IMCI (Integrated Management of Childhood Illnesses)

Care seeking from service providers for perceived pneumonia in IMCI study in

Matlab, Bangladesh

Data source: MCE-IMCI household coverage survey

Slide courtesy of Shams El Arifeen, ICDDR,B, Bangladesh

Under-five children ill in the last two weeks in the IMCI area

5%3% 2%

5%2%

16%

8%

0%

16%

2%

34%

24%

38%

53%

43%

26%

19%21%21%

35%

22%

29%

41%

26%

46%

51%

32%

J ul'02- Jun'03 Jul'03- Jun'04 Jul'04- Jun'05 Jul'05- Jun'06 Jul'06- Jun'07

First level GoB Other trained Village doctors

Other untrained No care Village health workers

Why are Village Doctors at a competitive advantage

vis-à-vis other providers? Village doctors have wide variety of drugs in

stock: various antibiotics, various formulations (syrup, tablet, injection)

Village doctors can treat any illness, if people unsure of diagnosis, may seem better to visit village doctor

Health facilities and CHWs experience stock-outs of essential medications

Care from other providers is not of appreciably better quality than that of village doctors

Attitude of government

Informal sector increasingly seen as important partner, necessary for achieving targets for health

Informal sector included in some national plans e.g. national scale-up of IMCI

Support from pharmaceutical companies reinforces their position

Mali

Mali

Types of informal sector providers– Market stalls, shops– Ambulatory vendors, drugs in bucket

Sources of medications– Drugs smuggled in across border– Expired drugs from health facilities– Drugs diverted from health facilities

Who: Men, women and children

Variety of medications at market stall

Sources of Care for sick children Survey conducted in Bougouni District,

Mali, April 2004, n=228

Appropriate sources of modern medications/care

99 (43.4%)

Community health centre 68 (29.8%)

District referral hospital 2 (0.9%)

Community health worker operating a drug kit

27 (11.8%)

Maternity/nurse’s aide 19 (8.3%)

Unauthorized sources of modern medications

124 (54.4%)

Vendors in the market 92 (40.4%)

Small shop/ambulatory vendor 43 (18.9%)

Pharmacy 5 (2.2%)

Traditional sources of care 170 (74.6%)

Traditional healer 53 (23.3%)

Old “wise” woman 59 (29.9%)

Traditional medications prepared by family

94 (41.2%)

Sources of antibiotics, 159 sick children receiving antibiotics,

Bougouni, Mali

*

*Market and health center or maternity center

Slide courtesy of Kate Gilroy

Attitude of government

Informal sector described in highly negative terms– “La vente abusive de

médicaments” Government not receptive to

suggestions to collaborate with informal sector, as has been done in Nigeria, Uganda, Kenya etc.

Viewed as a law enforcement problem

Comparison of informal sector providers: Mali and Bangladesh

Mali Bangladesh

Site of work Market stall, sheet on ground

Shop with concrete walls

Support from pharmaceutical companies

Minimal Extensive

Packaging of drug

Often unpackaged

Usually packaged

Attitude of government

Highly negative

Mixed, but increasingly positive

Common features of informal sector: Bangladesh and Mali

High level of utilization, greater than formal sector

Utilization by all wealth quintiles– Despite for-profit orientation, may be

best option for reaching the poor Secular trend to increasing use of

informal sector, respond to deficiencies of government health services

Intervention models to improve quality of care in private sector Increasing quality of care in pharmacies

Accredited Drug Dispensing Outlets– www.msh.org/seam/

country_programs/3.1.4b.htm Vendor-to-vendor interventions

– www.malariajournal.com/content/2/1/10 Negotiation (“contracts”) with private

providers to change behavior– Trop Med Int Health. 2002 Mar;7(3):210-9 – Health Policy Plan. 2000 Dec;15(4):400-7.

Research agenda for anthropology: Informal sector

Relationships and flow of information between informal sector providers, formal sector providers, customers and pharmaceutical companies

Current and potential service to underserved groups: Men, elderly, disabled

Patterns of pharmaceutical sale Intended and unintended effects of

interventions in informal sector