Out of the Shadows?: New research calls for more engagement with informal health care sector
In global health discussions, quacks don’t get a lot of love.
While there’s a general awareness of the importance of informal medical providers in BoP communities, there’s often a reluctance on the part of health care advocates and policy makers to acknowledge and potentially legitimize them. This has led to widespread uncertainty about how to engage these providers.
Underlying this uncertainty is a lack of data. Because informal providers work outside of regulatory frameworks – and often in inaccessible geographic areas – it can be difficult to identify and measure them. Many governments are also unwilling to learn more about the informal sector, so concrete information on its size, utilization and quality is scarce.
Fortunately, that may be changing, as evidenced by the recent literature review published by May Sudhinaraset et al. in PLOS ONE – one of the first summaries of research on informal providers around the world. I recently spoke with May Sudhinaraset, a research specialist with the Global Health Group at the University of California, San Francisco, about what the review (which was supported by the Center for Health Market Innovations) reveals about this vitally important yet often overlooked sector.
Rose Reis: Based on these studies, do informal providers generally perform worse than their counterparts in the formal private and public sectors?
May Sudhinaraset: Our study found only five studies on clinical quality that compared the formal to the informal sector. Surprisingly, it wasn’t clear that the informal sector performed worse compared to the formal sector, as is typically assumed by the general public, researchers, and government. While three studies found that informal providers lacked the capacity to provide basic curative services, two studies found no difference between the sectors in clinical quality on measures such as knowledge, skills, and adherence to clinical guidelines. This is in line with Jishnu Das’ work in India, which also found little difference in quality of care between trained and untrained medical providers. This doesn’t mean we should be complacent about quality. As Berendes et al. recently showed, there is a very real issue with poor quality clinical care across health systems in low-income countries in general, not only in the informal sector.
RR: Because of the studies’ diversity, the rates of utilization—an attempt to figure out what proportion of providers in a given geographical region are informal—ranged wildly. How should we make sense of the results?
MS: While there is quite a range in the literature, it is clear that informal providers make up a significant portion of providers at a global level. There is tremendous geographical variability, but places like India and Bangladesh have consistently reported high utilization rates across a number of studies and data sources. There is a real issue of an absence of data, however, that limits the ability to quantify the real size of the sector. The best data is probably pulled from Demographic Health Surveys (DHS), nationally-representative datasets for a variety of maternal and child health services.
However, DHS only gives us utilization rates; therefore, this may not be a reflection of a demand for these services but rather the lack of alternative sources of care, particularly in rural areas where the poor are likely to live. We aren’t sure whether mothers go to drug vendors for malaria treatment and immunizations because they prefer to go to informal providers, or whether mothers go to informal providers because they are the only providers available in their communities.
We looked at a number of studies to explain the high utilization rates, particularly the reasons behind high usage. People go to informal providers because they are more convenient, affordable, and culturally-sensitive compared to the formal sector. Generally, the poor are more likely to use informal providers – typically because they can’t afford to go to other providers. Informal providers might set up in-kind payment systems and flexible pricing policies with no separate fee charged for consultations, while the median cost of treatment in the formal sector is typically much higher. Informal providers are entrepreneurs, and so their practice is contingent on the maintenance of good relationships with their communities. Even where public facilities exist, people may opt to go to informal providers because of perceived higher quality, shorter waiting times, and greater anonymity.
RR: The review found that informal providers practice “poor preventive medicine.” Why is this, and what kinds of incentives and programs can be used to encourage them to do more and better preventive care?
MS: Like other private providers, informal providers are part of a complex health market, influenced by a combination of consumer demand, pharmaceutical companies’ medical representatives, profit motivation and apprenticeships, among other factors. A review of different interventions revealed that simply training providers isn’t enough to change poor preventive care. More complex interventions that change incentive structures and consider market forces are needed. Promising interventions include providing financial incentives or mechanisms to improve the quality of care and referrals. Referral systems that incentivize or provide easier mechanisms to refer patients to higher levels of care can also make a difference. An example of this is in Indonesia, where traditional birth attendants receive financial incentives for referrals to trained midwives or institutions.
Establishing networks and associations for informal providers has also proven to be a powerful tool in maintaining quality standards and training. For example, in Nigeria, private patent medical vendors (PPMVs) have organized and formed an association that gives providers the opportunity to network with other PPMVs and medical personnel, to undergo an apprenticeship with an experienced PPMV, and protects members from undue harassment. Another example of establishing networks for informal providers is through social franchise programs, which link existing private providers together under a common brand, establishing clinical standards, guidelines, and procedures. Tapping in to these existing networks to promote better preventive care and provide prescription/clinical guidelines may be a possible mechanism to improve quality of care.
(Above: an informal health care provider at work.)
RR: For policy makers thinking about how to engage informal providers, can you point to any opportunities for “quick wins” – for example, diseases that informal providers could be equipped to diagnose, treat or refer?
MS: This will of course vary by disease prevalence in each country and by the type of informal provider one considers (traditional birth attendants can do things that drug vendors can’t). But as a generalization I would say that the quick wins are likely to be based on commodity sales where access and affordability are critical, and where the level of clinical skill in consultation or prescription is minimal. Working through informal providers to scale up access to ORS plus zinc could make a huge difference in reducing diarrhea-related mortality, and has no downside risk.
For illnesses and treatments where more skill is needed to diagnose an illness and more risks are associated with improper care, there is great potential to work through informal providers, but less of what I’d call a certain “quick win.” Treatments for tuberculosis, malaria or opportunistic infections from HIV all fall into this category. For these kinds of illnesses I think much more work is needed to understand exactly the role informal providers can and should play in diagnosis and treatment.
RR: Are any existing programs using informal providers to deliver better care to hard-to-reach populations? Are any of them making an impact?
MS: While there isn’t direct data to support this in terms of impact, I would guess that hard-to-reach populations are probably where informal providers are making the most impact. An example of a documented rural program is Population Services International/Myanmar’s Sun Primary Health program. This social franchise networks and trains lay people in rural communities to deliver preventive and curative services across a number of health outcomes (e.g. malaria, TB, HIV, family planning). Research at the Global Health Group at UCSF has documented that training programs with informal providers have improved clinical quality. The next set of analyses for this study will focus on the sustainability of training programs.
RR: What can local and global policy makers take away from the review?
MS: My hope is that the one thing global policy makers take from this review is that informal providers have an important role to play in existing and future health systems. While there is pushback from local policy makers on how, and how much, governments should engage with these providers, it is clear that in remote areas, the poorest populations often need these providers because alternative sources of care simply do not exist.