Informal Providers: More Harm than Good? Insights from the HSR Debate

This October the Third Global Symposium on Health Systems Research convened in Cape Town, South Africa to launch a global discussion on the science and practice of people-centered health systems.  Researchers, funders, policy-makers and implementers from a wide range of backgrounds and countries gathered to discuss pressing challenges in strengthening health systems. A major topic of discussion: how can we leverage the private sector to improve health systems?

In collaboration with the Private Sector Working Group of Health Systems Global, the Center for Health Market Innovations (CHMI) and the Center for Research on New International Economic Order (CRëNIEO) organized a debate to discuss the benefit and harm of informal providers (IPs).  Informal providers are individuals who provide health care without government-recognized training/and or registration.  

The panel of speakers included six experts who have either worked closely with informal providers, or studied the health effects of informal providers in depth.  Dr. Phyllis Awor presented her research on IPs in Uganda which found that only 10% of IPs provided appropriate care for fever, 16% for pneumonia, and 14% for diarrhea.[i]  Following an intervention, in which prepackaged drugs and diagnostics were introduced, appropriate treatment rates significantly improved. Nearly 90% of children with fever were tested with rapid diagnostic tests for malaria, and the treatment of pneumonia symptoms and diarrhea was 3 to 12 times better in the intervention area compared to the non-intervention area.[ii]

Dr. Meenakshi Gautham, the lead panelist, noted that while IPs are often unqualified, they are not necessarily uneducated.  In India, where Dr. Gautham has conducted extensive research and interviews with informal providers, she noted that IPs often have university levels of education, and may have apprenticed for health care providers previously.  IPs are also highly trusted in their communities, having often been born and raised there. Even when public facilities are available, families frequently bypass these to be attended by their local IPs.

In Tanzania, the Accredited Drug Dispensing Outlets (ADDO) program organizes and trains drug vendors, who are often the first point of contact for common medical problems such as diarrhea and malaria.  Panelist Jafari Liani presented the effects of training, licensing and accrediting these drug vendors on the quality of care they provide. While baseline data showed 39% of shopkeepers recommended incorrect antibiotics for upper respiratory tract infection, only 14% of shopkeepers who participated in ADDO trainings did.[iii] 

Photo Left: Mwanahawa shows off the certificate of accreditation from ADDO. ©2012 CHMI





The debate engaged the audience with a vote on what the international community should do with IPs, presenting three options,

  1. Attempt to regulate IPs out of existence;
  2. Focus on developing competitive public and/or formalized private providers such that people no longer wish to visit IPs;
  3. Consider IPs as part of the health workforce, and therefore work to harness their capacity by formalizing them or otherwise influencing their activities.

Gathering these experts together to share their experiences with IPs demonstrated that while IPs can be harmful, they do increase access to healthcare, and option 1 was generally unpopular to the audience.  Programs and policies can be put in place to improve the quality of care which IPs provide, and even shift them into a more formal sphere, as evidenced by the experience of the ADDO program. Overwhelmingly, the audience voted for the 3rd option - to harness the capacity of IPs by formalizing them. Other audience members suggested that it be merged with option 2 - focusing on developing public and/or formalized private competition.

For more information on Informal Providers visit the recently launched CHMI topics page, where information key documents and the latest news and resources for programs that work with IPs is gathered..



[i] Awor, Phyllis, et al. "Private sector drug shops in integrated community case management of malaria, pneumonia, and diarrhea in children in Uganda." The American journal of tropical medicine and hygiene 87.5 Suppl (2012): 92-96.

[ii] ibid

[iii] “Accredited Drug Dispensing Outlets in Tanzania Strategies for Enhancing Access to Medicines Program, Final Report,” Available 10/15/2014,


Above Photo: Panelists at the Global Symposium on Health Systems Research - Informal Providers Debate.