A version of this blog was also published on The Lancet's Global Health Blog.
In August, riot police in New Delhi used water cannons to disperse a group of young medical students. They were protesting a government proposal making service in rural India an undergraduate requirement, deploring the lack of infrastructure that rendered both personal and professional lives difficult in India’s rural heartland, home to around 70% of the country’s population.
There are simply not enough professional doctors willing to work in the rural areas of many low- and middle-income countries in Asia and Africa. But people living there fall sick and seek treatment, just like in cities and towns. Their first port of call is often an informal provider (IP)— an independent and unregulated medical practitioner variously known as village doctor, traditional healer, drug seller, quack, and dozens of other names.
In India, two-thirds of human resources and health facilities are in the private sector, and the shocking truth is that informal providers (IPs) are estimated to account for over 50% of the private health sector.
The degree of informality in other countries is not as well-documented as in India, but there is evidence that it is also common. For example, in rural Bangladesh, over 95% of private providers are informal. And a review of published literature on IPs in developing countries reveals utilization rates that range from 9% to 90% of all healthcare interactions. People patronize IPs because they work long hours, provide doorstop services and are often the nearest health providers who are accessible on foot. They are affordable and often willing to provide treatment on credit. Most importantly, they are usually a part of the communities where they work.
The irony is that IPs are typically not on the radar of those mandated with the task of increasing access to healthcare for the poor — with the exception of the pharmaceutical industry, which has developed wide distribution networks with them in some countries.
IPs are largely ignored by their own governments, donors and the World Health Organization. There is little attempt to monitor and improve their quality of services or to harness their proximity and patient relationships to deliver important public health interventions.
To advance the understanding of this neglected group, we decided to look at IPs in two areas of India — Tehri Garhwal, in the mountainous state of Uttarakhand in the north, and Guntur, on the coastal plains of Andhra Pradesh in the south. We wanted answers to such questions as: How common are IPs? How educated, trained, and organized are they? What kind of interactions do they have with qualified doctors? What is the quality of their services?
When we began our study of informal providers, we imagined that providers in the two areas would be quite similar — after all, they live and practice in the same country. In fact, our study revealed surprising differences:
We had expected to find more IPs in Uttarakhand, where road and transportation infrastructure is poor, population density is low, and professional doctors are in short supply. On the contrary, we found that IPs were more abundant in the more developed Andhra Pradesh, which also has more doctors, especially private ones.
Nearly all IPs in the southern site had worked as doctors’ assistants before setting up independent practices. They maintained links with these doctors, received commissions, and helped new doctors set up their practices.
IPs in Andhra Pradesh were highly organized. They had formed strong associations that federated to become a strong state level association that had lobbied successfully with a former Chief Minister for receiving state recognition and training. Twenty-two thousand out of an eligible 55,000 IPs had been trained in basic healthcare, and were registered with the state’s Paramedical Council.
Unlike the IPs in Uttarakhand, those in the south faced no hostility from a benevolent state or from doctors, with whom they shared win-win relationships. IPs in Uttarakhand, on the other hand, reported frequent harassment by the state health department, even though there is a desperate need for more health providers in this region.
IPs in Uttarakhand were better educated: 43% had graduated college and quite a few had diplomas and certificates in health disciplines such as pharmacy or lab technology. They worked mainly out of fixed clinics. Only 10% of the IPs in Andhra Pradesh had graduated college; the majority went on daily rounds from house to house, village to village.
Despite their differences, there was one remarkable similarity—their observed knowledge of the management of fever, diarrhea, and respiratory conditions was “reasonably high”—71% of them knew the standard disease management protocols in Uttarakhand and 73% in Andhra Pradesh.
We are convinced that the findings of this study in India, as well as previous research in other countries, offer a strong justification for more discussion about how to manage and harness IPs, if not clear answers for how to engage them. Few healthcare programs are overtly working with IPs, and even fewer governments. If we are serious about improving health systems, IPs must be acknowledged by governments, donors and the international health community — as they already are by millions of their trusting patients.
Photo: Informal dental provider with patient in Dhaka
 Report of the National Commission on Macroeconomics and Health (2005). Ministry of Health and Family Welfare, Government of India, New Delhi.
 Sudhinaraset M, et al (2013). What is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review. PLoS ONE 8(2): e:54978. Doi:10.1371/journal.pone.0054978.
 Gautham M, et al (2013). Informal rural healthcare providers in north and south India. Health Policy and Planning, accepted 3 June 2013.