Harnessing informal providers for health systems improvement: Lessons from

India

An initiative of the Private Sector in Health Symposium

http://www.pshealth.org/ https://twitter.com/psinhealth

Symposium: Sydney 6 July 2013

• Since 2009 a group of researchers and policy analysts working on health markets in low and middle-income countries have organised a pre-congress symposium at the biennial conferences of the International Health Economics Association

• The aim has been to encourage and disseminate high quality research on the performance of these markets and on practical strategies for improving access to safe and effective services by the poor

• The Future Health Systems Consortium is responsible for organising the 2013 symposium with financial support from the Gates and Rockefeller Foundations and SHOPS

www.pshealth.org

Webinar series

• Facilitated by the Future Health Systems Consortium

• Organised by a number of institutes

• Publicised widely to involve a wide audience

• The next webinar will be held on 7 March 2013 entitled, ‘Shaping the future of health markets: Reflections from a meeting in Bellagio’. Registration will open soon!

Providing opportunities to set the scene well before the Sydney meeting and to ensure that those who may not be

attending the Symposium have the opportunity to participate in debates about strategies for improving the performance

of health markets in meeting the needs of the poor.

Harnessing informal providers for health systems improvement

• Important sources of advice and drugs for poor people in many low and middle-income countries

• Growing body of evidence on who uses them and the services they provide

• A variety of innovators and social entrepreneurs are testing strategies for improving their performance

• Governments are gradually recognising the importance of these providers

Engaging with informal providers: an opportunity for governments to increase access to effective and

affordable services?

Future Health Systems’ work on informal providers

• Case studies in India, Bangladesh, Nigeria and China

• Transforming Health Markets in Asia and Africa: Improving Quality and Access for the poor

• Collaboration with CHMI programme of work on informal providers

• Meeting in Bellagio and production of a briefing note: Future Health Markets: a meeting statement from Bellagio

• Building networks and testing interventions

http://www.futurehealthsystems.org

Organisation of webinar

• Presentations by Gina Lagomarsino and Meenakshi Gautham

• On the side of the screen you should see a control panel with a chat function. Participants are invited to send written questions or comments to the meeting organiser via Instant Message. If you send your questions to the entire audience they will be public. We will remove any duplications and select questions to pose to each presenter

• We are recording the webinar and so your questions may be made public

• The aim of the webinar is to stimulate discussion and debate about the role of informal providers and strategies for improving their performance

• Help us to improve the organisation of webinars by completing an evaluation form

Gina

Growing Knowledge about the Role of Informal Providers within Health Systems

Gina Lagomarsino Results for Development

Harnessing Informal Providers for Health Systems Improvement: Lessons from India

February 5, 2013

CHMI CONVENED GROUP ON INFORMAL PROVIDERSMembers of Working Group of researchers and practitioners

Sofi Bergkvist, AccessHealth Peter Berman, Harvard Abbas Bhuiya, ICDDR,B Gerry Bloom, IDS Bill Brieger, Johns Hopkins Annapurna Chavali, AccessHealth Birger Forsberg, Karolinska Gopi Gopalakrishnan, World Health Partners Mohammad Iqbal, ICDDR,B Gina Lagomarsino, R4D Kim Longfield, PSI Bruce Mackay, HLSP Dominic Montagu, UCSF Stefan Nachuk, Rockefeller Foundation Gael O’Sullivan, Abt Associates Karen Pak Oppenheimer, World Health Partners David Peters, Johns Hopkins Edumund Rutta, MSH Nirali Shah, PSI Guy Stallworthy, Gates Foundation Hongwen Zhao, WHO

Group met two times:• Sept. 2010 – Washington, DC• March 2012 – Dhaka

WHO ARE INFORMAL PROVIDERS (IPS)?Definition of Informal Providers

Business Model

• Chiefly entrepreneurs• Collect payment from patients, not institutions• Payment is often undocumented and tendered in

cash

Training• Possess little or no officially recognized training

from formal bodies such as a government, NGO, or academic institution

Registration/

Regulation

• Operate outside of effective regulation of government and independent regulatory organizations

The following definition was developed by UCSF Global Health Group with input and agreement from the CHMI Informal Provider Working Group:

WHAT DO WE KNOW ABOUT INFORMAL PROVIDERS?Literature review findings

In 2011, CHMI, in collaboration with May Sudhinaraset and Dominic Montagu at the Global Health Group at the University of California, San Francisco (UCSF), completed a literature review on IPs to determine what is known on the topic.

Size: IPs make up a significant portion of the health sector—ranging from 51-55% in India to 96% in rural Chakaria, Bangladesh.

Scope: IPs are used in day-to-day healthcare and function across the continuum of care.

Quality: Information is limited; the quality of care delivered by IPs appears variable.

Reasons for use: IPs are used because of their convenience, low price and for cultural/social reasons.

Study published in PLoS-ONE on Feb. 6 2013

LEARNING MORE ABOUT THE DYNAMICS OF INFORMAL MARKETSCHMI Commissioned studies in Bangladesh, India and Nigeria

Research Lead Study Site IP StudiedBangladesh

Nabeel Ashraf Ali, Shams El Arifeen

ICDDR,B; James P Grant School of Public Health-BRAC University

Tangail district Sunamgang district Rangpur district Cox Bazar

Village Doctors/Drug Sellers

India

Dr. Meenakshi Gautham

Centre for Research on New International Economic Order (CReNIEO); Garhwal Community Development and Welfare Society; London School of Hygiene and Tropical Medicine

Guntur district, Andhra Pradesh Tehri district, Utarrakhand

Rural Medical Practitioners (RMPs)

Nigeria

Professor Oladimeji Oladepo

Faculty of Public Health-College of Medicine, University of Ibadan

10 Local Government Areas, Oyo State

10 Local Government Areas, Nasarawa State

Patent Medicine Vendors (PMVs)

FINDINGS FROM 3-COUNTRY STUDYTheme 1: IPs’ relationship to their communities

IPs and their communities

• IPs have local roots and have well-established, long-running, practices

• IPs are often the first point of care for patients

• IPs have developed lucrative businesses

• They appear to be well-regarded and trusted members of the community

• IPs are relatively well educated compared to their clients, which contributes to their high profile in the community

FINDINGS FROM 3-COUNTRY STUDYTheme 2: Education and Training

Education and training received by IPs

• Most informal providers appear to have some form of health training

• The duration, formality, and content of health training varies widely

• Training can comprise commercially offered courses, public training for community health workers, or apprenticeship

FINDINGS FROM 3-COUNTRY STUDYTheme 3: Quality of care

Quality of care delivered by IPs

• IPs engage in some incorrect and potentially harmful practices

• IPs exhibit some appropriate knowledge regarding basic conditions and standards of care

• Also evident that knowledge does not always translate into practice, with polypharmacy and irrational use of drugs a common problem

FINDINGS FROM 3-COUNTRY STUDYTheme 4: Relationship with the formal sector

Relationship between IPs and the formal healthcare sector

• IPs function within a complex health market and have established some ties to other parts of the market

• Many have some ties to the formal health sector for new medical information, drug supplies, and referrals

• IPs also operate in reaction to demand from consumers

FINDINGS FROM 3-COUNTRY STUDYTheme 5: Organization of IPs

Organization and recognition of IPs

• Can range from little coherent organization and government hostility to nation-wide organization and government recognition

• Examples exist of well-organized and strong informal provider associations acting on behalf of the members’ interest

POTENTIAL INTERVENTIONS WITH INFORMAL PROVIDERS

Goal Intervention1. Organization: IPs are organized,

thereby reducing the fragmentation of health care delivery

Provider Associations Provider Networks

2. Education: IPs are trained to provide specific interventions

Provider Training Standard Operating Procedures

3. Certification: IPs are certified in the area of health in which they practice

Accreditation/Licensing Aggressive Enforcement/Forced Shutdown

4. Compliance: IPs comply with set procedural and quality standards

Regulatory/Monitoring Policies and Groups Financial Incentives/subsidies

5. Job support: IPs are well-equipped to provide quality care

On-site support: (E.g., job aids, decision-support software) Remote support: (E.g., call centers, telemedicine) Supply-chain improvements: (E.g., pre-packaged medications,

pooled procurement of drugs)

6. Referrals: IPs have access to and utilize referral networks for complicated cases

Incentivized referrals Collaboration with the formal sector Rural postings for formal providers

IPS ARE RELEVANT FOR MANY BROAD HEALTH SYSTEM CHALLENGESNecessary to consider IPs if we are to address a number of related issues

Convergence between IPs and other health systems issues include:

Health human resource shortages, including frontline/community health workers

Poor quality of medicines, irrational drug use, and inadequate access to essential medicines

High out-of-pocket spending

Lack of universal health coverage

POTENTIAL NEXT STEPS

Research to be completed• Country papers published• Three-country study synthesis paper published

Potential action steps• Policymaker engagement in select countries• Convene community of practitioners working with IPs in

different countries to share promising practices• Engage with global Human Resources for Health and Frontline

Health Workers/Community Health Workers communities

OTHER RELEVANT WORK ON INFORMAL PROVIDERSRecent Publications

Transforming Health Markets in Asia and Africa: Improving Quality Access for the Poor, Bloom, G., Kanjilal, B., Lucas, H. and Peters, D.

In Urban And Rural India, A Standardized Patient Study Showed Low Levels Of Provider Training And Huge Quality Gaps, Health Affairs, Das, j. et al.

Developing World: Bringing order to unregulated health markets, Commentary in Nature, Peters, D. and Bloom, G.

Mapping Health Care Markets in Rural Cambodia: A Survey of formal and Informal providers, Presentation at the Health Systems Research Symposium, Beijing, Özaltin, E.

THANK YOU!

glagomarsino@resultsfordevelopment.org

www.healthmarketinnovations.org

A study of informal providers in two districts of India

Dr. Meenakshi GauthamCentre for Research in New International

Economic Order (CReNIEO), ChennaiGarwhal Community Development and Welfare

Society (GCDWS), Tehri GarhwalResearch Fellow LSHTM

Contents

Background

Our study

Results

Background

The demand side: providers of first contact

Allopathic practitioner

(94.8%)

Private

(91.6%)

Same or nearby village

(69.5%) Town (22.1%)

Public (3.2%)

Same or nearby village

(1.2 %) Town (2.0%)

Source: Gautham et al. First we go to the small doctor: First contact for curative healthcare sought by rural communities in AP and Orissa, India. Indian J Med Res 134, November 2011, pp 627-638

Providers of first contact, AP (a previous study)

Bihar

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%90%

Village practitioner

qualified private doctor

govt. facility

Homeopathic/ayur/unani

Source: Dror et al. Household survey in rural Bihar -1000 households. Erasmus University, NL, and Micro Insurance Academy, India. May-June 2010

First contact health providers in rural Bihar (previous study)

Different mix of frontline health workers across different rural locations

Source: Gautham et al. First we go to the small doctor: First contact for curative healthcare sought by rural communities in AP and Orissa, India. Indian J Med Res 134, November 2011, pp 627-638

First contact health providers in rural Orissa0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Village practitionerTraditional healerGovt. facilityGovt. health workerAyurvedic/homeo./unaniPrivate doctor

Our study

Study locations

• District Tehri Garhwal, Uttarakhand state

• District Guntur Andhra Pradesh state

Tehri was more rural with lower population density, higher literacy but higher IMR, no medical colleges

Key features Tehri Guntur

Population density (sq km) 139.43 429.43

% of rural population 86.63% 66.11%

No. of inhabited villages 1,752 1,047

% of villages with population size ≤ 500

82.4% 1.45%

% of adults literate 75.10% 67.99%

Monthly per capita expenditure

Na(UT=901)

599.11 (AP=816)

Infant mortality rate 64 49

No. of medical colleges 0 3

Study objectives

• Identify and enumerate informal and formal providers in the study areas

• Document IPs’ levels of education and training, physical set up, mobility, practice characteristics, and costs of services

• Assess knowledge and skills/performance

• Explore relationships with the formal health system/providers

• Analyse barriers and facilitating factors in the process of integrating IPs

Guntur, 9 out of 57 blocks were selected by:

• Stratification into 3 clusters by level of development (low, medium, high)

• Proportional sampling from each cluster (3 from low, 5 from medium, 1 from high)

Tehri• All 9 blocks were included

• Blocks also categorised into low (2), medium (5), and high (2) using same criteria

Study samples and processes

1. Block selection

Study processes..contd

Study objectives/key variables

Study Processes

Provider enumeration Provider identification through key village contacts, group discussions with community members, and snowballing technique. Surveyed market places and facilities.

Structured questionnaire for interviewing IPs

Education and training Interviews with all mapped IPs (368 in Guntur; 263 in Tehri)

Practice characteristics

Interviews with all mapped IPs.

Knowledge Interviews with a sample of IPs:100 in AP and 90 in Tehri.

Skills/Performance Patient-provider observations using an Observation tool with the sampled IPs. (Description slide follows).

Relationships with formal sector

In-depth interviews with sampled IPs, their associations, professional doctors, health administrators

Knowledge and performance assessments

Conditions

• Fever• Diarrhoea• Respiratory

problems

Protocols

• Adapted from WHO guidelines by 3 physicians

Knowledge

• Scores based on number of correct responses for each question

Performance

• Same conditions and protocols

• Observed first 3 consenting patients for each condition

• Total 9 patients per provider

Example of knowledge and performance items

Knowledge question (interviewed) Performance item (observed)

What physical examination will you perform on a diarrhea patient? Check for dehydration -skin pinch for adults or - abdomen pinch/sunken eyes/lethargy/ inability to eat or drink for childrenCheck fever (pulse or thermometer) Check BP Do nothing Any other (please write verbatim) 0 =Incorrect (‘d’, or any other incorrect response)1 = mentions any one of ‘a’, ‘b’ or ‘c’2 = mentions any two of ‘a’, ‘b’ or ‘c’3 = mentions any three of ‘a’, ‘b’ or ‘c’90 =no response/doesn’t know

Checks for dehydration -skin pinch for adults or -abdomen pinch/sunken eyes/lethargy/ inability to eat or drink for children

1=Yes; 0=No

Checks fever (pulse or thermometer) 1=Yes; 0=No

Checks BP 1=Yes; 0=No

Any other examination (write verbatim)

Results

Greater population coverage by IPs than formal providers; greater in AP than UT

Tehri Garhwal

Ratio of IPs to popn

=1:2299

Doctors to popn

=1:9599

Guntur

Ratio of IPs to popn

=1:1941

Doctors to popn

=1:5412

0204060

42.3 39.3553.56

0.54 0 3.063.79 5.17

27.5

IPs per 100,000 popPrivate docs per 100,000 popPublic docs per 100,000 pop

0204060

63.7752.32

38.63

0.770000000000013

18.82 16.655.44 2.52 3.99

IPs per 100,000 popPrivate docs per 100,000 pop Public docs per 100,000 pop

Greater population coverage by IPs than formal providers, greater in AP than UT

Differences in education and types of training

IP’s education and training Tehri (N=263)

Guntur (N=368)

Studied up to class 11 in school 94% 41%

Graduates 43% 10%

Held a health related diploma or certificate 93% 35.6%

Worked as compounder / assistant before starting independent practice

55% 100%

Worked under a qualified doctor (with MBBS or MD degrees)

40% 91%

Average number of years of apprenticeship 4 years 7 years

Mean number of years of independent practice in the present location

10.5 years 13 years

IPs had strong local roots in both districts

Nativity and origin of the IPs Tehri Guntur

Born in the same block 51.50% 53.00%

Born in the same district (but not in the same block)

18.70% 41.00%

Born in the same state (but not in the same district)

10.30% 5.70%

Born in another state 19.50% 0.30%

Door step services in AP; clinic based in UT;the key is proximity

IP characteristics Tehri Guntur

Type of practice

Mainly clinic 99.00% 31.25%

Mainly mobile 0.50% 39.40%

Clinic and mobile 0.50% 29.35%

Clinic location

Clinic at IPs’ residence 29.00% 37%

Mean distance of clinic from residence 2.3kms 1.3kms

Clinic operating hours

Open 7 days a week 90.00% 95.00%

Mean number of hours 9.4 hours 11.0 hours

Mobile provider characteristics

Mean hours of travel/day - 6.6hours

Mean distance covered - 2.1 kms

‘I go from village to village, house to house ringing my bell….’

AP: More prescribers, more ‘allopathic’ medicines UT: More dispensers, more blended medicines

IP characteristics Tehri Guntur

Clientele

Average number of patients /day 14 17

Mean number of client households 367 604

Medical system followed

Treats only with allopathic medicines 33.00% 99.00%

Treats only with non-allopathic medicines 9.00% 0.50%

Treats with allopathic and non-allopathic 58.00% 0.50%

Provision of medicines

Only dispenses 42.00% 17.00%

Only prescribes 7.00% 48.00%

Mostly dispenses but also prescribes 49.00% 25.00%

Mostly prescribes but also dispenses 3.00% 10.00%

No significant difference in the knowledge levels

Diarrhea Fever Respiratory conditions

Combined60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

76.43%

69.88%

67.70%

71.42%

79.60%

68.50%69.67%

72.79%

TehriGuntur

Guntur IPs performed marginally but significantly better; overall knowledge lower than performance

diarrhea** fever respiratory * combined0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

65.79%

43.41%

50.66%53.22%

72.82%

40.47%

55.57% 56.27%

TehriGuntur

Biggest difference – injections and medicines

Injections/ antibiotics received by patients

Tehri Guntur

% of patients that received an injection

13% 71%

Mean number of antibiotics received

0.94 1.19

% of patients that received 2 or more antibiotics

19% 30%

Relationships with the formal sector

Tehri IPs Guntur IPs0

10

20

30

40

50

60

17

0.50

54

34

8.1

17

4

Medical repsQualified doctorsMedical journalsMass media

Qualified doctors were the main source of new knowledge for more than half of Guntur IPs

Relationships with the formal sector

Win-win relationships in Guntur• 40.5% IPs received referral commissions from private doctors

• 7% received gifts -small medical equipment and sample medicines

• IPs’ confidence and faith in private doctors due to their perceived technical skills and

their interpersonal bonds

• Government doctors were IPs’ trainers in the state training programme, no signs of

overt hostility

• But IPs also perceived doctors as their biggest competitors; thus a double edged

sword

Hostility and lack of interaction in Tehri• With only 5 private doctors within the district, IP referrals were directed equally towards

public facilities and private facilities, including in nearby towns outside the district

• Bitter experiences with health department officials, who demanded certificates and

diplomas and sometimes bribes.

The AP initiative

Registration with the State Paramedical Board / Act of 2006

Flexible One Year Training

1 year, bi-weekly sessions at nearby health facilities

Barriers and supporting factors

Barriers

• Legal obstacles and periodic court orders against ‘quacks’

• IPs not united or organised, not seen as a political force

• Weak support by local governments or political leaders

• Opposition/ambivalence of the formal medical fraternity

• Insufficient knowledge about IPs and their role, and what interventions?

Supporting Factors

• United and organised IPs have become a political strength in AP

• Strong political will displayed by AP’s former Chief Minister

• Win-win partnerships with the formal sector, especially private sector

• State level certification initiatives as in AP have set a useful example

• Increasing body of knowledge, support and pressure from local and international

health community

Conclusions and recommendations

• IPs on the margins of institutional frameworks, but their role is firmly institutionalized

• IP markets have evolved in different ways in response to different contextual influences

• IPs will continue to play this role for quite a long time

• Dispels the myth that IPs are solo providers. The have interactions amongst themselves and with other formal sector providers

• Role of the apprenticeship model needs to be examined closely

• Interventions need to move beyond training now

• Universal health coverage provides a good framework, as it includes issues of equity, quality, and calls for immediate as well long term strategies

Acknowledgements

Centre for Research in New International Economic Order, Chennai, India

Garhwal Community Development and Welfare Society, Tehri Garhwal, India

Dr. K.M ShyamprasadDr. S. SrinivasanMs. Anshi ZachariahMs. Premila VijayraghavanDr. Lalitha & the field teamMr. Christopher SinghCrenieo training centre staff

Dr. Rajesh SinghMs. Rajkumari SinghMr. Manoj KumarField research teamAll hospital staff

Contact:Meenakshi.gautham@lshtm.ac.ukGautham.meenakshi@gmail.com

Questions?