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

1. 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 pwinch@jhsph.edu

2. What is needed to fully implement Primary Health Care?

3. 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…”.

4. 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

5. 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

6. The alternative: Community providers • Private physicians • Traditional healers • Traditional birth attendants • Community health workers • Informal sector providers

7. 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 Traditional healers

8. 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 Community health workers

9. CHW and village oversight committee

10. 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

11. 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

12. 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 Informal sector providers

13. Bangladesh

14. 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

15. 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

16. 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”

17. Frequency and Intensity of Interactions with Medical Representatives

18. 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.

19. Sources of care for sick children in household survey in 16 sub-districts of Bangladesh, 2005

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

21. 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

22. Case management tasks by providers for children with respiratory symptoms, Bangladesh, 2006

23. 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

24. Quality Scores of Providers by Division of Bangladesh

25. 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)

26. 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

27. 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

28. 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

29. Mali

30. 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

31. Variety of medications at market stall

32. Sources of Care for sick children Survey conducted in Bougouni District, Mali, April 2004, n=228

33. Sources of antibiotics, 159 sick children receiving antibiotics, Bougouni, Mali * *Market and health center or maternity center Slide courtesy of Kate Gilroy

37. 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

38. Comparison of informal sector providers: Mali and Bangladesh

39. 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

40. 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.

41. 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