By Dr. Anuradha Katyal and Priya Anant
Informal providers form the undeniable yet hidden part of the health human resources in many of the low- and middle-income countries. In India, studies have confirmed that the unqualified private providers account for about 80% of all the healthcare visits. Even though people have distinct reasons to choose a particular provider, ease of access and perceived quality are often the most important factors weighed when selecting a provider. And in the absence of qualified providers in many areas, these providers form the first point of contact for many rural and urban poor patients.
Recently, the Centre for Research on New International Economic Order (CRëNIEO), gathered stakeholders from India, Rwanda, Uganda, Bangladesh and Tanzania to discuss the role of informal health providers as health human resources. We sought to identify the various aspects involved in harnessing this often-hidden resource to ensure that they do only good and do no harm.
Who are Informal Providers and what do they do?
Informal Providers (IPs) are generally men between 30 and 50 years. They are not registered or formally trained medical providers and usually do not have any professional affiliation. They receive their training from informal sources like apprenticeships, observation, family traditions etc. They collect a fee for services. They are chiefly entrepreneurs.
They may be drug sellers, village doctors, and traditional practitioners; they may have practices similar to allopathic physicians, may use bio-medical, and non-bio medical medicines, and they are more likely to be used by rural populations. In some cases they include Community Health Workers and Trained Birth Attendants.
Innovative approaches to training and monitoring informal providers
Many innovative methods have been employed to assess the quality and build the capacity of informal providers. Studies using mystery patients have demonstrated that informal providers can do a better job in diagnosing diseases vis-à-vis formally trained doctors. Yet it is a matter of concern that since these providers are not accredited by any authority the quality of healthcare provision remains largely unknown. It is also worth noting that since IPs use mixed methods of care it is challenging to assess the non-allopathic systems in which they practice.
Several people attending the Chennai consultation represented programs working with informal providers in various capacities. Minimax Uganda is a capacity building pilot led by Makerere University and the Karolinska Institutet to provide training for drug sellers—who function as IPs—around acute febrile illnesses and diarrheal disease. So far data have shown that giving these providers free rapid diagnostics, training them to assess danger signs in children with fever and diarrhea, and promoting pre-packaged drugs via social marketing led to more adherence to protocols. Similarly, in Bangladesh, Save the Children is implementing an initiative to train village doctors for correct diagnosis, treatment consistency, record keeping, management of drugs and supplies, and improved compliance for managing diarrhea and pneumonia in children. Liver Foundation in India works to convert “self-proclaimed, unqualified doctors” to enriched healthcare workers through educational, social, and cultural inputs to reduce harm and increase benefits. Operation Asha in India has developed an e-compliance device, which is a biometric mechanism to assess patients’ compliance with DOTS treatment for tuberculosis and hence impact the quality of care delivered by informal providers. They have tied financial incentives based on this impact. Five years post training there has been an improvement in their practice, even though the organization does not certify these providers.
Do incentives improve the quality of healthcare delivered by IPs?
There is no clear answer to this question. Providing training incentives may seem necessary to improve quality of care provided by these providers. Yet there have also been experiments on providing them financial incentives for compliance as well.
An experiment done in Chakaria district in Bangladesh to provide incentives for training resulted in no change in prescription behavior. World Health Partners uses multilevel incentives. The tangible incentives are financial while the intangible incentives were training and branding.
Licensing IPs and the Andhra Pradesh experience
Is licensing the IPs and mainstreaming them a good idea? Experts have different views on this and some in the medical establishment may be opposed to formalizing IPs. In Rwanda and Tanzania the governments have supported initiatives related to IPs, yet according to participants in our consultation, experience has shown that laws are difficult to modify and regulatory oversight is a must.
The state of Andhra Pradesh in India has had a slightly different experience, with the government itself taking the lead to train and certify IPs, called RMPs (rural medical providers). They have been trained by public sector doctors to prescribe over-the-counter drugs and provide first aid and supervised home care. They were registered in the Paramedical Board of Andhra Pradesh.
Advocacy and the future
Many people choose to seek care from informal providers and we must respect and acknowledge their choice. While recent studies in Bangladesh, India, and Nigeria have helped shed light on these often overlooked health human resource assets, further research could further illuminate their practices. Participants in the consultation agreed that it is absolutely necessary that findings from the available research be translated into policy and action. The Center for Health Market Innovations is currently tracking more than 50 programs that work with informal providers, but further documentation of existing initiatives must be done and gaps must be identified. Smaller experiments at block (local) level must be operationalized. The existing informal providers should be mapped and perhaps a decentralized association should be formed.
The participants' opinion was divided over certification of IPs, but all believed that it is inevitable and necessary to mainstream them considering that formal providers are a constrained resource in developing nations and informal providers generally form the first point of contact.
I would summarize the group’s sentiment as: “The task is to do what is possible without forgetting to make possible what is necessary.”
Photo (main): A rural medical provider (right) in Bihar, India
Photo (body): A presentation at the Stakeholder Consultation In Chennai, India