As low, middle, and high income countries increasingly turn to solutions to achieve universal health coverage, there is a corresponding excitement for the potential of community-based care as one answer, ranging from community health workers to informal providers. On November 3, participants at the Second Global Symposium on Health Systems Research gathered for a panel discussion on Extending Service Delivery through Traditional and Informal Providers, drawing on the diverse experiences of three continents. In each setting, there was some attempt by the formal sector to engage with the informal to address chronic disease, tuberculosis, MNCH health priorities, highlighting the potential power of such human resources but also existing constraints and challenges.
Incorporating informal providers in the India’s national TB strategy
In India, Dr. Garima Pathak of the Public Health Foundation of India shared how the national government has incorporated informal providers into the national TB strategy. The stark reality of addressing the access to TB care through extended service delivery is clear, with India contributing ¼ of the global disease burden. This has translated into a massive financial burden at an estimated $23.7 billion direct and indirect costs to the country annually. India committed to universal access to care for all TB patients, offering free diagnostic and treatment services since 2006, but was challenged with the need to improve the program’s reach and impact.
From Dr. Pathak’s perspective, the rationale for incorporating informal providers into the national strategy was straightforward. Health care in India is primarily sought from the private sector, with informal providers often acting as the first line of care. Dr. Pathak described the group as key informants with an enriched understanding of the practices and beliefs of the community: “It is assuming the role of an important service provider, especially in remote and hard to reach areas.” This is particularly true for marginalized populations who often seek care from informal providers even when offered free or subsidized services through the public sector. In response, informal providers have been trained as Community DOT providers, watching as the patient swallow anti-TB medicines in their presence.
While this is one step towards achieving universal coverage for TB care, results from a social assessment study suggest that informal providers still lack the right incentive structure to fully participate in the program; others aren’t aware of the program and how to participate. The government has identified some solutions to these challenges, including the involvement of village health and sanitation committees in rural settings to raise awareness, introducing the concept of “TB free villages”, the provision of mobile technologies to informal providers, and the launch of a help line to guide informal providers in diagnosing TB.
The role of traditional medicine providers in Kerala’s good health outcomes
Kerala, a southern state in India, was selected as a case study in both the 1985 and 2012 Good Health at Low Cost report as a result of its dramatic improvements in infant mortality and life expectancy despite severe economic constraints. In fact, a number of studies have pointed to Kerala as a model health system characterized by better access and affordability; increased health awareness; and successful control of major infectious diseases.
However, Unnikrishnan Payyappallimana of the UN University in Japan encouraged participants to take a closer look at why Kerala is able to produce health outcomes far above the national average. “There’s a long list of studies on good health in Kerala,” Unnikrishnan shared, “But the role of traditional systems in producing good health is nearly absent in the literature.”
Today, the diversity of medical systems in India is represented in the utilization of allopathic (45%), ayuverdic (35%), and homeopathic (20%) health institutions. Could the broadened choice of healthcare options, including a very active traditional medicine sector, result in better access and improved health outcomes?
The question had no definitive answers, but was an area identified for further research, particularly as countries move towards universal health coverage. “In countries like India, the significance of traditional and informal providers is huge – but definitions of UHC are based on a highly biomedical paradigm. We need to better understand the specific contributions of traditional medicine to health.”
Achieving MNCH goals through Community Health Workers in Tanzania
Community health workers are often touted as a catchall solution to human resource constraints in low-income countries. However, in Tanzania a study on the use of community health agents as part of national MNCH goals is generating early evidence that these health workers have the potential to impact neonatal survival.
Fatuma Manzi of the Ifakara Health Insitute (IHI) shared how the primary health care policy has incorporated community health agents into its newborn survival package of interventions.
Tanzania has “a long history of community volunteers, but,” as Fatuma pointed out, “it’s characterized by patchy implementation and a lack of central support.” Fatuma’s group has been leading an evaluation of this pilot, looking at the impact and cost of the scalable package of interventions at a community level.
Female volunteer counselors undergo 5 days of training and are supervised by local health facility staff. They then make 3 home visits during a woman’s pregnancy, 2 post-partum, and additional visits for low-birth weight babies.
Survey results are encouraging, with some evidence that coverage is increasing – during pregnancy, 78% of pregnant women in the pilot district received at least one visit; and soon after delivery, 48% of women received a fourth visit. This indicates that key behaviors on the part of the community health workers have started to change, and further studies will focus on the impact on newborn survival.
In all of these scenarios, the formal and informal sectors were able to agree that understanding the depth and role of community-based providers could ultimately provide better care for vulnerable populations across multiple countries.
Some questions remain as to how to assure that good quality services are being delivered at the community level. But with all the advantages--such as trust, community engagement, and proximity--community-based care is a rich and fertile field worthy to push forward.