Transcript Informal providers – an overview

Informal providers – an overview
Dr. Meenakshi Gautham
Hon. Research faculty, CRENIEO, India
Research fellow, London School of Hygiene and
Tropical Medicine
Outline
• The importance of informal providers within health
systems in LMICs
• Definitional criteria
• Extent and utilization in different countries
• Issues for discussion in the agenda
• Workshop objectives and deliverables
Health systems in LMICs
• Mixed public and private healthcare financing and delivery
• Private sector as source of healthcare exceeds the public
sector
South Asia : 79.3%
Latin America : 66.3%
Sub-Saharan Africa : 50.8%
(DHS analysis of 48 countries – Montagu, 2008)
The real truth..
A recent systematic review of public and private healthcare systems:
• When the private sector included unlicensed physicians, it
was found to provide the majority of coverage for low-income
groups, but when only licensed providers were included, the
public sector was found to be the main source of healthcare
provision in low- and middle income countries.
Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D (2012) Comparative Performance of Private and Public
Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 9(6):
e1001244.doi:10.1371/journal.pmed.1001244
Informal providers – definitional criteria
Training: Not from formal sources.
Payment: Collect payment from patients served, not from
institutions. Chiefly entrepreneurs.
Registration and regulation: Typically not registered with any
government regulatory body.
Professional affiliation: Very few have any associational
membership.
-Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D (2013) What Is the Role of
Informal Healthcare Providers in Developing Countries? A Systematic Review.
PLoS ONE 8(2): e54978. doi:10.1371/journal.pone.0054978
Who are informal providers?
Drug sellers
-May operate beyond their legal capacity;
-Regulatory infringements are common.
Village doctors and traditional practitioners:
-May have practices similar to licensed allopathic physicians;
-May use combinations of biomedical and non-biomedical
medicines or only biomedical ones;
-More likely to be used by rural populations
Traditional Birth Attendants
Community Health Workers
Hidden yet pervasive
• Extent of informal providers
Bangladesh: 87% informal
Rural Chakaria: 96% informal
India : 51-55% informal
Uganda: 77% informal
-Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D (2013) What Is the Role of Informal Healthcare
Providers in Developing Countries? A Systematic Review. PLoS ONE 8(2): e54978.
doi:10.1371/journal.pone.0054978
Greater population coverage by IPs than formal providers in India
Tehri Garhwal
Ratio of IPs to general
population
=1:2299
(1:1867 – 1:2363)
Doctors to population
=1:9599
(1:3267 – 1:23040)
60
50
40
30
20
10
0
54.32
42.3
39.35
IPs per 100,000 pop
27.5
3.79
0.54
0
5.17
Private docs per
100,000 pop
3.06
Low
Medium
Highest
development development development
blocks
blocks
blocks
70
Guntur
60
Ratio of IPs to population50
40
=1:1941
30
(1:2588-1:1568)
20
Doctors to popn
10
=1:5412
0
(1:4843 – 1:16072)
Public docs per 100,000
pop
63.77
52.32
IPs per 100,000 pop
38.63
18.82
5.44
0.77
2.52
16.65
3.99
Low
Medium
High
development development development
blocks
blocks
blocks
Private docs per
100,000 pop
Public docs per
100,000 pop
-Gautham et al, HPP, 2013
Utilization
• First choice, exclusive choice or played any role in
healthcare
 Bangladesh : 60%-77%
 India (RMPs/village practitioners) : 19% - 54%
 Kenya (CHW/traditional practnr/drug seller) : 9%-33%
 Thailand (drug sellers): 55% - 77%
 Uganda (drug sellers/traditional healers) : 35%-62%
In India
• 90% of informal providers are in rural areas (DeCosta and
Diwan, Health Policy 2007)
• Frequent providers of first contact care (George et al, SSM,
2013; Gautham et al, IJMR, 2012)
• Of every 100 provider visits in rural areas, 70 -90 may be to
an informal provider (Das et al, Health Affairs, 2012;
Gautham et al, IJMR, 2012)
Questions for further discussion
• Quality and capacity building
• Drugs
• Incentives
• Regulation and licencing
• Legal issues
Workshop Objectives
• Enable an exchange of learning across
implementers, policy makers and researchers.
• Identify barriers to integration of informal providers,
and determine concrete strategies that
policymakers and implementers can employ to
harness informal providers substantially.
• Discuss and agree upon a few action points for
further collective action and advocacy by this group.
Workshop Deliverables
• Broad steps for developing a substantial and large
scale programme with IPs in one state in India.
• A joint advocacy statement that can be published
as a global health blog or an article
• Plans for 1-2 joint publications based on current
presentations.
• Identify a few areas for future research that can
support the evidence base for IPs’ integration.
• Any others?????