Gina Lagomarsino of Results for Development's Center for Health Market Innovation reflects on findings from a new book, Transforming Health Markets in Asia and Africa and adds information about recent studies in which CHMI has been involved on informal providers in Bangladesh, India and Nigeria.

1. The Role of
Informal Providers
in Healthcare
Markets
Gina Lagomarsino, October 17, 2012

2. STUDY SITES AND AUTHORS
• Global
– Literature review – May Sudhinaraset and Dominic
Montagu, UCSF
– Scan for interventions globally – Maria Belenky, R4D
• Three country study sites:
– India (AP and Uttarakhand) – Meenakshi
Gautham, Garwal Community Development and
Welfare Society
– Nigeria – Oladimeji Oladepo, University of Ibadan
– Bangladesh – Nabeel Ali and Shams
Arifeen, ICDDR,B

3. CONFIRMING WHAT’S KNOWN
• IPs are the first line of care and medicines for
many patients, particularly the poor
• IPs are used because they are
close, convenient, cheap, accommodating, frien
dly
• IPs engage in some harmful practices
(e.g., polypharmacy, over-prescription of
antibiotics, inappropriate injections, overuse of
oxytocin, etc.)
• IPs have developed lucrative business
models, and respond to market incentives and
patient demand

4. COUNTER TO CONVENTIONAL WISDOM
• Deep roots in community
– IPs are trusted and respected members of community with
long-running practices – often “social elites” who view theirs as
a “noble profession”
• Relatively well-educated
– IPs are often relatively well-educated (secondary and some
beyond)
– Most have some formal training (commercially offered courses
or community health worker training) or
apprenticeship, though duration and quality varies
– IPs are eager for more training and formalization
• Some level of knowledge about care protocols
– IPs do have some (incomplete) demonstrated knowledge of
proper protocols, and as a result do provide some level of
effective care
• Relationships with formal providers and formal markets
– IPs often have well-developed ties to the formal sector and
other parts of the health market for referrals, knowledge, and
drug supplies
• Can be quite organized and politically powerful

5. TYPES OF INTERVENTIONS FOR INFORMAL PROVIDERS
GOAL INTERVENTION
1. Organization: IPs are organized,
thereby reducing the • Provider associations
fragmentation of health care • Provider networks (franchises)
delivery
2. Education: IPs are trained to • Provider training
provide specific interventions • Standard operating procedures (clinical protocols,
checklists)
3. Certification: IPs are certified in • Accreditation/Licensing
the area of health in which they
practice
• Creation of a new cadre of workers
4. Compliance: IPs comply with set
• Regulatory/Monitoring policies and groups
procedural and quality standards
• Financial incentives (subsidies, insurance membership)
5. Diagnosis/Treatment support: • Decision-support tools (software, flipcharts, pamphlets)
IPs are well-supported to provide • Telemedicine (videoconferencing, call centers, and SMS)
quality care • Pre-packaged medications and kits
6. Referrals: IPs have access to and • Incentivized referrals
utilize referral networks for
complicated cases
• Collaboration with the formal sector

6. THANK YOU!
Gina Lagomarsino
glagomarsino@resultsfordevelopment.org

7. KEY DIFFERENCES ACROSS COUNTRIES
• Source, duration, content of training
(e.g., courses, apprenticeships)
• Source of medical/pharmaceutical knowledge
(e.g., media, journals, MRs, formal providers)
• Business model/source of revenue (e.g., consultation, drug
sales, commission for referrals, injections)
• Market composition (i.e., mix of IPs, private qualified, and
public)
• Degree of linkage with various other parts of the market
(MRs, qualified doctors)
• Referral patterns (e.g., do not refer, refer primarily to
public sector, refer based on patient income)
• Mix of allopathic and traditional methods
• Varying levels of formality (e.g., gov’t
recognition, prevalence and strength of associations) and
degree of state hostility
• Gender mix of IPs

8. OPPORTUNITIES TO INTERVENE?
• Governments/NGOs/social entrepreneurs should pay attention to and
engage IPs. Opportunity to:
– Mitigate harmful practices
– Promote positive practices such as delivering some priority interventions
• No silver bullet
– Training has its place, but needs to be supplemented with other approaches
– Need to change market incentives
– Markets are complex and dynamic, with multiple actors
• Need to address more than just IPs, but other marketplace actors
– Pharmaceutical companies and medical reps
– Consumers
– Policymakers
– Qualified doctors
• Programs need to be complex and involve multiple interventions.
Therefore, more experimentation/trial-and-error and very practical and
localized analysis will be needed

9. EXAMPLES OF INTERVENTIONS
Andhra Pradesh
• IPs organized themselves into local RMP Associations (integrated into state association) to seek
integration into the formal health system. 76% reported membership.
• State association successfully lobbied for government-sponsored training and certification
– 10 month training course established 2008 by government, seeks to formally integrate
RMPs into the state's health care system through a 10-month training course
– RMPs who pass an examination are certified as "Community Paramedics"
– Permitted to dispense a pre-defined set of medications and health services to the public
– As of October 2011, approximately 880 RMPs trained and certified
• NGO’s piloting decision-support software
Other examples
• Nigerian Patent Medicine Vendor Association
• ADDO program to certify drug shops in Tanzania and Uganda
• Shasta Sena in Bangladesh

10. FIVE WAYS TO IMPROVE HEALTH MARKETS

11. CENTER FOR HEALTH MARKET INNOVATIONS (CHMI)
VISION: For the private sector to reach its potential to deliver quality, affordable, and accessible
health care to the poor in low- and middle-income countries.
APPROACH:
CHMI promotes policies and practices that help
the private sector achieve its potential by:
ANALYZING
INFORMING CONNECTING
HIGH-
ON INNOVATIVE + FORGING
POTENTIAL
PROGRAMS* PARTNERSHIPS
INNOVATIONS
*Over 1000 programs identified in 105 countries

12. CLOSING THOUGHTS
• People in global public health first need to recognize this.
– Tendency to believe that healthcare is a top-down thing
where gov’ts or NGOs provider to people, rather than a
transaction-based system.
– Tendency to ignore this informal system
• This issue is related to a number of other issues in global
health, and ideally should be integrated into them, rather
than being thought of as the “private side”
– Human resources for health
– Universal coverage, high out-of-pocket spending
– Access to medicines
– Specific diseases, like Malaria, Diarrhea,

13. Surprises
• IPs appear to be pushing Oxytocin (often
inappropriately) in Bangladesh – though they
typically don’t deal with other “maternal issues”
• IPs in AP, India are highly linked to qualified
doctors through referrals and commissions
• IPs in Nigeria are quite well-organized and self-
regulated to some extent by the PMV Association
• Providers in Utrakhand with some formal training
had very similar knowledge levels to providers in
AP who had done apprenticeships

14. More research?
• More research needed on: • Ideas on how:
– Medical Representatives
– Pharmaceutical companies – Engage business
– Associations schools
– Margins and incentives to sell various
drugs – Identify existing
– Dynamics of market/how it is changing research
– Consumer preferences and how they
develop them pharmaceutical
– Map players and their incentives industry/market
– Interventions research s
– Role of middlemen? Access carrying
out a hh survey in AP; can we add a – Better problem-
question to figure out how the market
has changed? definition
– Commercial training institutions