In rural Mirzapur, one of Bangladesh’s 500 upazilas—or sub-districts—accessing a formal health provider is a tall order. Public facilities such as the Upazila-level Health Complexes are often ill-equipped and overcrowded and formal private practitioners are few and very far between. This is a scenario that plays out across Bangladesh, a country that suffers from a medical human resource shortage in the hundreds of thousands. Who fills the gap? By and large, the task falls to informal providers. These are practitioners without government-recognized training or registration and include allopathic providers such as drug seller (also called village doctors), homeopaths, herbalist and faith healers. In fact, it is estimated that drug sellers/village doctors outnumber formal providers in the country twelve to one.
On a recent trip to Bangladesh, my colleagues and I visited a drug seller at the Pakulla Bazar, an hour or so outside of Dhaka. The outlet was tidy and appeared fully stocked. The owner smiled in front of colorful product labels and introduced us to his nephew, who is serving as his apprentice. In lieu of formal training, medical knowledge is often passed down from relative to relative in the form of apprenticeships. The shop had basic diagnostic equipment—stethoscope, thermometer, weighing machine—but these are rarely used in practice. Most patients are diagnosed through a verbal description of symptoms. And herein lies the larger problem: should drug sellers, even if formally trained and registered in the practice, be offering consultations and medical advice?
At right: Woman visiting the Katora Community Health Center, Bangladesh.
This visit was part of a three-day long meeting convened by the Results for Development Institute and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) to review findings from three studies on the role of informal providers in healthcare delivery. Commissioned a year earlier as part of the Center for Health Market Innovations (CHMI), the studies looked at the dynamics of informal provider interactions within the broader health marketplace in Bangladesh, India and Nigeria. As the analysis wraps up, the findings are beginning to debunk some of the most common claims about informal provider practices:
- Informal providers are not 'quacks' flying under the radar. Popular opinion has colored informal practitioners as quacks, illegal providers of care who aim to maintain a low profile in order to sidestep government regulation. The reality, however, is quite different. In fact, informal providers appear to be trusted and respected members of the community—often considered to be “social elites” who view theirs as a “noble profession”.
- Informal providers are not school dropouts. Informal providers may not hold advanced degrees, but they also appear to be far from school drop-outs with only primary levels of educations. The three studies have demonstrated that the majority of practitioners operating informally are relatively well-educated, completing secondary levels of schooling and beyond. Some even hold graduate or professional degrees, though not necessarily in their field of practice.
- Informal providers are not untrained and inexperienced. While it is true that the duration, formality, and content of health training undergone by many informal providers varies widely, most practitioners do have some form of training, including commercially offered courses and public training for community health workers. Moreover, many have served as apprentices in addition to or in place of partaking in formal courses.
- Informal providers are not disconnected from the 'formal' system. While they do, by definition, operate outside of the formal health system, informal providers often have well-developed ties to the formal sector and other parts of the health market for medical information, drug supplies, and referrals. In fact, some informal practitioners receive gifts and commission from formal sector providers for referring patients to their facilities.
Of course, many of the study findings also support commonly-held views regarding informal provider operations. They are clearly the first line of care for patients, particularly the poor, and have developed lucrative business models that respond to market incentives and patient demand. Furthermore, provider roles are often fluid, with drug sellers offering medical consultations and health providers dispensing medication when these services are demanded and it is profitable to do so. And although additional research on care quality is needed, it is also evident that they engage in some harmful medical practices, including inadequate testing before diagnosis, inappropriate injections, and over-prescription of antibiotics and other medications.
On the first day of the Informal Provider meeting, ICDDR,B launched a new book, “Doctoring Village Doctors: Giving Attention Where it is Due," which recounts their experience with Shasthya Sena in Bangladesh.
Recognizing that informal providers serve many people in developing countries, the question then becomes: what do we do about it? Meeting participants aimed to tackle this issue on the final day of the workshop, offering a list of stakeholders whose engagement is essential to achieving meaningful change. This includes the informal providers themselves, but also consumers, policymakers, medical representatives, pharmaceutical companies, professional associations and formal sector providers, among others. Specific recommendations ranged from harnessing patent medical vendors (drug sellers) in Nigeria to promote preventative behavior by educating the community on malaria-prevention and selling insecticide spray and bed nets, to formalizing ties between the rural medical providers and their formal counterparts in India in a mentorship-style program.
Much remains to be researched and debated, but we are undoubtedly getting closer to understanding the complex role that informal providers play in the healthcare marketplace—an essential step in potentially harnessing their capacity to improve the reach of the formal health system for the benefit of the underserved.