Transcript Defining a role for the informal sector in health care

MAS Conference 2008
Primary Health Care and Social
Equity – Illusion or Reality?
Defining a role for the informal
sector in health care provision
in Bangladesh and Mali
Peter Winch
Johns Hopkins University
[email protected]
What is needed to fully implement
Primary Health Care?
Address
Promote
determinants preventive
of poor health interventions
Make care
accessible,
affordable and
of high quality
Water
Education
Agriculture
Community
governance
Environmental
stewardship
Management of
acute and
chronic illnesses
Maternal care
Surgical care
Mental health
Etc.
Immunization
Micronutrients
Mosquito nets
Family planning
Handwashing
Latrine use
Etc.
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…”.
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
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
The alternative:
Community providers
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Private physicians
Traditional healers
Traditional birth attendants
Community health workers
Informal sector providers
Traditional healers
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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-bycase basis
 Esoteric knowledge,
may be hesitant to
share information
 Treatments of varying
efficacy, difficult to
fully assess their value
Community health workers

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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
CHW and village oversight committee
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
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
Informal sector providers
Typical strengths
 Recognized source of
modern medication in
the community
 Financially selfsufficient
 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
Bangladesh
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
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
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”
Frequency and Intensity of Interactions
with Medical Representatives
Number of visits per
week to the same
provider
Minutes per visit
Number of products
promoted during
each visit
Visits to
formal sector
providers
3-6
Visits to
informal sector
providers
1-2
4-6
10-15
6-8
10-12
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,
don’t worry, I always prescribe your drugs.” He then reaches
out to shake the MRs hand. The visit lasted 20 minutes.
Sources of care for sick children in household
survey in 16 sub-districts of Bangladesh, 2005
# caretakers interviewed
1665
# (%) U-5 children sick in previous two weeks of survey
957 (58%)
# (%) went outside of home for treatment
450 (47%)
Formal sector
Qualified doctor
20.8 % (105)
Paramedic/FWV/Nurse
4.2%
(21)
Depot holder/community health worker
0.8%
(4)
Informal/ traditional sector
Village doctor
41.9% (212)
Drug sellers
17.8%
(90)
Homeopath
13.2%
(67)
1.4%
(7)
Traditional healer
Sources of care for children with rapid
breathing in household survey in 16 subdistricts of Bangladesh, 2005
Source
Formal sector
Qualified doctor
Paramedic/FWV/Nurse
Depot Holders
% (N=69)
23%
7%
0%
(16)
(5)
(0)
41%
20%
9%
(28)
(14)
(6)
Informal/ traditional sector
Village doctor
Drug sellers
Homeopath
Quality of care for children with rapid
breathing in household survey in 16 subdistricts 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
Case management tasks by providers for children with
respiratory symptoms, Bangladesh, 2006
Qualified Paramedics/
doctor
Nurse
N=105
N= 21
Drug
sellers
N=90
Village
doctors
N=212
Counted respiratory rate
62%
43%
32%
48%
Listened to the chest with a
stethoscope
66%
43%
38%
50%
Told what was wrong with
the child
62%
43%
36%
62%
Explained the danger signs
64%
29%
55%
52%
Asked whether the caretaker
understood everything he
said
67%
57%
49%
69%
Asked whether the caretaker
had any questions)
28%
24%
13%
29%
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
Quality Scores of Providers
by Division of Bangladesh
4.18
4.1
3.57
3.25
2.36
2.1
2.29
2.09
2.55
1.73
1.33
0.67
Qualified
doctor
Paramedic
Drug seller Village doctor
Chittagong
Dhaka
Rajshahi
Public health interventions don’t
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)
Care seeking from service providers for perceived
pneumonia in IMCI study in Matlab, Bangladesh
First level GoB
Other untrained
Other trained
No care
Village doctors
Village health workers
53%
51%
46%
29%
32%
35%
34%
22%
41%
38%
26%
24%
26%
21%
16%
43%
21%
19%
16%
8%
5%
3%
Jul'02- Jun'03
Jul'03- Jun'04
5%
2%
2%
0%
Jul'04- Jun'05
Jul'05- Jun'06
Jul'06- Jun'07
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
2%
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
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
Mali
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
Variety of medications at market stall
Sources of Care for sick children
Survey conducted in Bougouni District, Mali, April 2004, n=228
Appropriate sources of modern medications/care 99 (43.4%)
Community health centre
68 (29.8%)
District referral hospital
2 (0.9%)
Community health worker operating a drug kit
27 (11.8%)
Maternity/nurse’s aide
19 (8.3%)
Unauthorized sources of modern medications
124 (54.4%)
Vendors in the market
92 (40.4%)
Small shop/ambulatory vendor
43 (18.9%)
Pharmacy
5 (2.2%)
Traditional sources of care
170 (74.6%)
Traditional healer
53 (23.3%)
Old “wise” woman
59 (29.9%)
Traditional medications prepared by family
94 (41.2%)
Sources of antibiotics, 159 sick children
receiving antibiotics, Bougouni, Mali
Market vendors, shops,
or itinerant vendor
60%
Two sources*
7%
Community/ Referral
health center
22%
Pharmacy
2%
Informal maternity or
nurse’s aid
9%
*Market and health center or maternity center
Slide courtesy of Kate Gilroy
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
Comparison of informal sector
providers: Mali and Bangladesh
Mali
Site of work
Bangladesh
Market stall,
Shop with
sheet on ground concrete walls
Minimal
Extensive
Support from
pharmaceutical
companies
Packaging of
Often
drug
unpackaged
Attitude of
Highly negative
government
Usually packaged
Mixed, but
increasingly
positive
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
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 Mar;7(3):210-9
– Health Policy Plan. 2000 Dec;15(4):400-7.
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