Defining a role for the informal sector in health care provision in Bangladesh and Mali

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Defining a role for the informal sector in
health care provision in Bangladesh and Mali
MAS Conference 2008 Primary Health Care and
Social Equity Illusion or Reality?

• Peter Winch
• Johns Hopkins University
• pwinch_at_jhsph.edu

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What is needed to fully implement Primary Health
Care?
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Lead role for the State in PHC

• The International Conference on Primary Health
  Care (PHC) in Almaty in 1978
• Declared health to be a fundamental human right
• Defined a lead role for the State, in statements
  such as All governments should formulate
  national policies, strategies and plans of action
  to launch and sustain primary health care.

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How to make care accessible?

• Improve transport and communications
• Roads
• Cell phones
• First-level health care facilities
• Build more so no one is far from one
• Provide high-quality care referral
• Community-level providers
• One or more per community

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First-level health care facilities

• Functional network and high levels of utilization
  in some countries e.g. Sri Lanka
• In many other countries, difficulty making them
  fully functional
• Too few or too concentrated in one area
• Shortages of health workers
• Poor health worker performance
• Violence against female health workers

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The alternative Community providers

• Private physicians
• Traditional healers
• Traditional birth attendants
• Community health workers
• Informal sector providers

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Traditional healers

• Typical strengths
• Deep roots in the community, respected
• Communicate with locally-understood terms and
  concepts
• See serious and stigmatized conditions
• Distributed throughout the community

• Typical weaknesses
• Diversity, role sometimes must be defined on
  case-by-case basis
• Esoteric knowledge, may be hesitant to share
  information
• Treatments of varying efficacy, difficult to
  fully assess their value

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Community health workers

• Typical strengths
• Selected by community
• Younger, literate
• Standardized skills and services
• Functionally integrated with government or NGO
  health services and referral system

• Typical weaknesses
• Motivation and incentives
• High attrition rates in many programs, CHW work
  stepping stone to other work
• Limited range of services treatments relative
  to other providers

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CHW and village oversight committee
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Informal sector providers

• Provide modern medications and/or play diagnostic
  role in areas where physicians are unavailable or
  too expensive
• Take many different forms
• Shop, unlicensed pharmacy
• Ambulatory vendor
• Village doctor (Bangladesh)
• Often given pejorative titles e.g. quack

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Informal sector providers

• Understudied by anthropologists
• Traditional healers have been subject of numerous
  anthropological studies, some studies of CHWs,
  very few studies of informal sector providers

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Informal sector providers

• Typical strengths
• Recognized source of modern medication in the
  community
• Financially self-sufficient
• Innovative, eager to adopt new ideas

• Typical weaknesses
• Uncertain quality of medication
• Uneven quality of care, limited counseling
• Treating conditions beyond their level of
  expertise
• Illegal nature of their practice

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Bangladesh
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Bangladesh

• Types of informal sector providers
• Shops, unlicensed pharmacies
• Village doctors (gram daktar)
• Sources of medications
• Pharmaceutical companies
• Medical representatives of companies
• Who Primarily men

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Role of pharmaceutical companies

• National pharmaceutical companies significant
  source of employment in Bangladesh
• Village doctors seen as additional channel of
  distribution, actively supported by
  pharmaceutical companies
• Regular visits by medical representatives

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Role of pharmaceutical companies

• Next two slides from 2005 study by Nazneen
  Akhtar, Azharul I. Khan, Lauren S. Blum, Halim
  Miah, Rafiqul Islam and Charles Larson of ICDDR,B
  in Bangladesh
• Exploring Interactions Between Pharmaceutical
  Representatives and Health Care Providers in
  Bangladesh

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Frequency and Intensity of Interactions with
Medical Representatives
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Notes from visit of Medical Representative to a
Village Doctor

• Seeing the MR getting off from the motorbike the
  village doctor walks to him, welcomes him inside
  while shaking hands. He says, Bhai, you are
  like a family member to me. Please come have
  tea and offers a seat.
• The MR sits, opens his bag and brings out the
  first product. The village doctor immediately
  indicates that he prescribes this medicine. The
  MR says, "thank you . After tea the MR continues
  to describe a variety of products, often drawing
  a diagram to explain the biomedical process and
  function of the drug. He gives the practitioner
  literature on each drug and offers small gifts.
  When finished, he leaves samples of all drugs
  discussed.
• The practitioner accompanies the MR to the
  road. He says, Bhai, dont worry, I always
  prescribe your drugs. He then reaches out to
  shake the MRs hand. The visit lasted 20 minutes.

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Sources of care for sick children in household
survey in 16 sub-districts of Bangladesh, 2005
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Sources of care for children with rapid breathing
in household survey in 16 sub-districts of
Bangladesh, 2005
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Quality of care for children with rapid breathing
in household survey in 16 sub-districts of
Bangladesh, 2005

• Typically expect quality of care in informal
  sector to be much worse than formal sector
• BUT Few differences in quality of care between
  formal and informal sector providers observed
• Qualified doctors and village doctors providing
  better quality care than paramedics and drug
  sellers

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Case management tasks by providers for children
with respiratory symptoms, Bangladesh, 2006
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Geographic variation in quality

• Large variations in quality by region of
  Bangladesh
• Where quality is higher, it tends to be higher
  for all providers
• This is evidence for interaction between
  providers, no wall between formal and informal
  sectors

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Quality Scores of Providers by Division of
Bangladesh
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Public health interventions dont decrease use of
village doctors

• Levels of utilization of village doctors fairly
  stable, despite improvements made in care from
  health facilities or from community health
  workers
• Example Careseeking in Matlab, Bangladesh during
  the Multi-County Evaluation of IMCI (Integrated
  Management of Childhood Illnesses)

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Care seeking from service providers for perceived
pneumonia in IMCI study in Matlab, Bangladesh
Under-five children ill in the last two weeks in
the IMCI area
Data source MCE-IMCI household coverage
survey Slide courtesy of Shams El Arifeen,
ICDDR,B, Bangladesh
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Why are Village Doctors at a competitive
advantage vis-à-vis other providers?

• Village doctors have wide variety of drugs in
  stock various antibiotics, various formulations
  (syrup, tablet, injection)
• Village doctors can treat any illness, if people
  unsure of diagnosis, may seem better to visit
  village doctor
• Health facilities and CHWs experience stock-outs
  of essential medications
• Care from other providers is not of appreciably
  better quality than that of village doctors

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Attitude of government

• Informal sector increasingly seen as important
  partner, necessary for achieving targets for
  health
• Informal sector included in some national plans
  e.g. national scale-up of IMCI
• Support from pharmaceutical companies reinforces
  their position

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Mali
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Mali

• Types of informal sector providers
• Market stalls, shops
• Ambulatory vendors, drugs in bucket
• Sources of medications
• Drugs smuggled in across border
• Expired drugs from health facilities
• Drugs diverted from health facilities
• Who Men, women and children

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Variety of medications at market stall
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Sources of Care for sick children Survey
conducted in Bougouni District, Mali, April 2004,
n228
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Sources of antibiotics, 159 sick children
receiving antibiotics, Bougouni, Mali

Market and health center or maternity
center Slide courtesy of Kate Gilroy
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Attitude of government

• Informal sector described in highly negative
  terms
• La vente abusive de médicaments
• Government not receptive to suggestions to
  collaborate with informal sector, as has been
  done in Nigeria, Uganda, Kenya etc.
• Viewed as a law enforcement problem

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Comparison of informal sector providers Mali and
Bangladesh
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Common features of informal sector Bangladesh
and Mali

• High level of utilization, greater than formal
  sector
• Utilization by all wealth quintiles
• Despite for-profit orientation, may be best
  option for reaching the poor
• Secular trend to increasing use of informal
  sector, respond to deficiencies of government
  health services

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Intervention models to improve quality of care in
private sector

• Increasing quality of care in pharmacies ?
  Accredited Drug Dispensing Outlets
• www.msh.org/seam/country_programs/3.1.4b.htm
• Vendor-to-vendor interventions
• www.malariajournal.com/content/2/1/10
• Negotiation (contracts) with private providers
  to change behavior
• Trop Med Int Health. 2002 Mar7(3)210-9
• Health Policy Plan. 2000 Dec15(4)400-7.

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Research agenda for anthropology Informal sector

• Relationships and flow of information between
  informal sector providers, formal sector
  providers, customers and pharmaceutical companies
• Current and potential service to underserved
  groups Men, elderly, disabled
• Patterns of pharmaceutical sale
• Intended and unintended effects of interventions
  in informal sector