What is known about informal private healthcare providers across the world?

When a mother seeks care at her local ayurved, what caliber of services is she receiving?

Little has been known about the care provided by informal healthcare providers, which go by more than 50 terms, including hakeem, compounder, quack, herbalist, and Ayurved.

A new PLoS One publication, What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review, provides a comprehensive look at what is known about informal providers globally.

May Sudhinaraset and colleagues at the Private Sector Healthcare Initiative at the University of California, San Francisco searched thousands of studies in the peer-reviewed and gray literature and identified 122 for closer analysis. The review was supported by the Center for Health Market Innovations.

The team created a working definition for a diverse set of providers:

  • Training: The providers studied had no formally recognized training from an institution, but often had informal training through apprenticeships or workshops.
  • Payment: Patients pay these providers for services in cash.
  • Registration and regulation: These providers are not typically registered with any government regulatory body and operate outside of the purview of regulation.
  • Professional affiliation: Professional associations, if they exist, are more focused on networking and conduct minimal self-regulation.

Key findings

Authors assessed the literature on the scope and practice, size and utilization patterns, quality, and reasons people use informal providers.

  • Utilization estimates, reported in 24 studies, ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement.
  • Quality of services delivered was unsurprisingly poor, with little adherence to clinical guidelines, gaps in knowledge and provider practice. However, the authors note that the studies found that the formal sector providers often performed poorly.
  • Reasons people use informal providers included convenience, affordability, and social and cultural rationale.
  • Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems.

The scope of informal providers

  • Drug sellers were the most frequently studied, as well as Traditional Birth Attendants, and village doctors. Authors found that “drug sellers operate beyond their legal capacity by selling prescription-only medications as well as offering diagnostic and therapeutic medical advice.” Their practices were relatively similar across the studies.
  • Village doctors and their practices presented more of a mixed bag. Authors found that “some village doctors have practices nearly indistinguishable from those of licensed allopathic physicians.”
  • Preventive care is not a focus for informal providers (IPs). According to the authors,
IPs generally practice poor preventive medicine, particularly IPs whose practice primarily consists of dispensing products or services in discrete units (e.g., drug sellers). Even those IPs who offer a more continuous and preventive brand of medicine (e.g., village doctors) might have a limited practice, centered around emergent situations, due to a general inability to pay for long-term health care in their community.

Read the study here.

Other new publications and resources are shedding light on the practices and dynamics of informal health providers:

  • Mystery patients sent with common ailments to public, private, and informal providers in northern India received many incorrect treatments, and rare correct diagnoses, according to a study published recently in Health Affairs. Yet the study found only small differences between trained and untrained doctors in some important aspects of medical practice. Read about the study here.
  • While informal providers work in markets free from regulation, they are heavily embedded in social relations and depend on formal government and private providers for referrals and training, according to another study focused on providers in Karnataka, India. Click to read an abstract.
  • The Center for Health Market Innovations, the Private Sector in Health, and Future Health Systems jointly hosted a virtual seminar about CHMI's findings on informal providers in India. Watch the presentation here!

More research and policies of engagement are needed to address inappropriate practices and harness this large health workforce. CHMI will explore this topic in future publications and share examples of programs engaging informal healthcare workers around the world. Do you know about a program that works with informal providers? Contact us to ensure CHMI captures this information in our Programs data set.