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Harnessing informal providers for health systems improvement: Lessons from Indiamal providers webinar


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    • 1. informal providers for health systems improvement: Lessons from India An initiative of the Private Sector in Health Symposium
    • 2. 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
    • 3. 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 theSydney meeting and to ensure that those who may not be attending the Symposium have the opportunity to participate in debates about strategies for improving theperformance of health markets in meeting the needs of the poor.
    • 4. Harnessing informal providers forhealth 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?
    • 5. Future Health Systems’ work oninformal 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
    • 6. 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
    • 7. Gina
    • 8. Growing Knowledge about the Role of Informal Providers within Health Systems Gina Lagomarsino Results for DevelopmentHarnessing Informal Providers for Health Systems February 5, 2013Improvement: Lessons from India
    • 9. 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 Group met two times:  Gina Lagomarsino, R4D • Sept. 2010 – Washington, DC  Kim Longfield, PSI • March 2012 – Dhaka  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
    • 10. WHO ARE INFORMAL PROVIDERS (IPS)?Definition of Informal Providers The following definition was developed by UCSF Global Health Group with input and agreement from the CHMI Informal Provider Working Group: • Chiefly entrepreneurs Business • Collect payment from patients, not institutions Model • Payment is often undocumented and tendered in cash • Possess little or no officially recognized training Training from formal bodies such as a government, NGO, or academic institution • Operate outside of effective regulation of Registration government and independent regulatory / Regulation organizations
    • 11. 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
    • 12. LEARNING MORE ABOUT THE DYNAMICS OF INFORMALMARKETSCHMI Commissioned studies in Bangladesh, India and Nigeria Research Lead Study Site IP Studied Bangladesh Nabeel Ashraf Ali, Shams El Arifeen Tangail district Sunamgang district Village Doctors/ ICDDR,B; James P Grant School of Public Rangpur district Drug Sellers Health-BRAC University Cox Bazar Dr. Meenakshi Gautham Centre for Research on New Rural Medical India International Economic Order (CReNIEO); Guntur district, Andhra Pradesh Tehri district, Utarrakhand Practitioners Garhwal Community Development and (RMPs) Welfare Society; London School of Hygiene and Tropical Medicine Professor Oladimeji Oladepo 10 Local Government Areas, Nigeria Oyo State Patent Medicine Faculty of Public Health-College of 10 Local Government Areas, Vendors (PMVs) Medicine, University of Ibadan Nasarawa State
    • 13. 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
    • 14. 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
    • 15. 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
    • 16. 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
    • 17. 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
    • 18. POTENTIAL INTERVENTIONS WITH INFORMAL PROVIDERS Goal Intervention1. Organization: IPs are organized,  Provider Associations thereby reducing the fragmentation  Provider Networks of health care delivery2. Education: IPs are trained to provide  Provider Training specific interventions  Standard Operating Procedures3. Certification: IPs are certified in the  Accreditation/Licensing area of health in which they practice  Aggressive Enforcement/Forced Shutdown4. Compliance: IPs comply with set  Regulatory/Monitoring Policies and Groups procedural and quality standards  Financial Incentives/subsidies5. Job support: IPs are well-equipped to  On-site support: (E.g., job aids, decision-support software) provide quality care  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  Incentivized referrals utilize referral networks for  Collaboration with the formal sector complicated cases  Rural postings for formal providers
    • 19. IPS ARE RELEVANT FOR MANY BROAD HEALTH SYSTEMCHALLENGESNecessary 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
    • 20. 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
    • 21. 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.
    • 22. THANK YOU!
    • 23. A study of informalproviders in two districts ofIndia Dr. Meenakshi Gautham Centre for Research in New International Economic Order (CReNIEO), Chennai Garwhal Community Development and Welfare Society (GCDWS), Tehri Garhwal Research Fellow LSHTM
    • 24. ContentsBackgroundOur studyResults
    • 25. Background
    • 26. The demand side: providers of first contactProviders of first contact, AP (a previous study) Allopathic practitioner (94.8%) Private Public (3.2%) (91.6%) Same or Same ornearby village Town (22.1%) nearby village Town (2.0%) (69.5%) (1.2 %) 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
    • 27. BiharFirst contact health providers in rural Bihar (previous study) 100% 90% 90% 80% Village practitioner 70% 60% qualified private doctor 50% govt. facility 40% 30% Homeopathic/ayur/ unani 20% 10% 0% Source: Dror et al. Household survey in rural Bihar -1000 households. Erasmus University, NL, and Micro Insurance Academy, India. May-June 2010
    • 28. Different mix of frontline health workers across different rural locations45.00%40.00%35.00% Village practitioner30.00% Traditional healer25.00% Govt. facility20.00% Govt. health worker15.00% Ayurvedic/homeo./unani10.00% Private doctor 5.00% 0.00% First contact health providers in rural Orissa 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
    • 29. Our study
    • 30. Study locations• District Tehri Garhwal, Uttarakhand state• District Guntur Andhra Pradesh state
    • 31. Tehri was more rural with lower population density, higher literacy but higher IMR, no medical collegesKey features Tehri GunturPopulation 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 82.4% 1.45%population size ≤ 500% of adults literate 75.10% 67.99%Monthly per capita Na 599.11expenditure (UT=901) (AP=816)Infant mortality rate 64 49No. of medical colleges 0 3
    • 32. 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
    • 33. Study samples and processes1. Block selectionGuntur, 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
    • 34. Study processes..contdStudy objectives/key Study ProcessesvariablesProvider enumeration Provider identification through key village contacts, group discussions with community members, and snowballing technique. Surveyed market places and facilities. Structured questionnaire for interviewing IPsEducation and training Interviews with all mapped IPs (368 in Guntur; 263 in Tehri)Practice Interviews with all mapped IPs.characteristicsKnowledge 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 In-depth interviews with sampled IPs, their associations,formal sector professional doctors, health administrators
    • 35. Knowledge and performance assessments Conditions Protocols Knowledge Performance • Fever • Adapted • Scores • Same • Diarrhoea from WHO based on conditions • Respiratory guidelines number of and problems by 3 correct protocols physicians responses • Observed for each first 3 question consenting patients for each condition • Total 9 patients per provider
    • 36. Example of knowledge and performance itemsKnowledge question (interviewed) Performance item (observed)What physical examination will you perform on a Checks for dehydrationdiarrhea patient? -skin pinch for adults or -abdomen pinch/sunken eyes/lethargy/ inability to eat orCheck for dehydration drink for children-skin pinch for adults or- abdomen pinch/sunken eyes/lethargy/ inability to 1=Yes; 0=Noeat or drink for childrenCheck fever (pulse or thermometer) Checks fever (pulse or thermometer)Check BP 1=Yes; 0=NoDo nothingAny other (please write verbatim) Checks BP 1=Yes; 0=No0 =Incorrect (‘d’, or any other incorrect response) Any other examination (write verbatim)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
    • 37. Results
    • 38. Greater population coverage by IPs than formal providers; greater in AP than UTGreater population coverage by IPs than formal providers, greater in AP than UT 60 53.56 Tehri Garhwal 50 42.3 Ratio of IPs to popn 39.35 40 IPs per 100,000 pop =1:2299 27.5 30 Doctors to popn 20 Private docs per 10 3.79 5.17 3.06 100,000 pop =1:9599 0.54 0 0 Public docs per 100,000 Low Medium Highest pop development development development blocks blocks blocks Guntur 70 63.77 Ratio of IPs to popn 60 52.32 =1:1941 50 38.63 IPs per 100,000 pop 40 Doctors to popn 30 18.82 16.65 =1:5412 20 Private docs per 10 5.44 2.52 3.99 100,000 pop 0.77 0 Public docs per Low Medium High 100,000 pop development development development blocks blocks blocks
    • 39. Differences in education and types of trainingIP’s education and training Tehri Guntur (N=263) (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 55% 100%independent practiceWorked under a qualified doctor (with MBBS or MD 40% 91%degrees)Average number of years of apprenticeship 4 years 7 yearsMean number of years of independent practice in 10.5 years 13 yearsthe present location
    • 40. 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 18.70% 41.00% not in the same block) Born in the same state (but not 10.30% 5.70% in the same district) Born in another state 19.50% 0.30%
    • 41. Door step services in AP; clinic based in UT;the key is proximityIP characteristics Tehri GunturType of practiceMainly clinic 99.00% 31.25%Mainly mobile 0.50% 39.40%Clinic and mobile 0.50% 29.35%Clinic locationClinic at IPs’ residence 29.00% 37%Mean distance of clinic from residence 2.3kms 1.3kmsClinic operating hoursOpen 7 days a week 90.00% 95.00%Mean number of hours 9.4 hours 11.0 hoursMobile provider characteristicsMean hours of travel/day - 6.6hoursMean distance covered - 2.1 kms
    • 42. ‘I go from villageto village, houseto house ringingmy bell….’
    • 43. AP: More prescribers, more ‘allopathic’ medicinesUT: 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%
    • 44. No significant difference in the knowledge levels82.00% 79.60%80.00%78.00% 76.43%76.00%74.00% 72.79% 71.42%72.00% 69.88% 69.67%70.00% 68.50% Tehri 67.70%68.00% Guntur66.00%64.00%62.00%60.00% Diarrhea Fever Respiratory Combined conditions
    • 45. Guntur IPs performed marginally but significantly better; overall knowledge lower than performance80.00% 72.82%70.00% 65.79%60.00% 55.57% 56.27% 53.22% 50.66%50.00% 43.41% 40.47%40.00% Tehri30.00% Guntur20.00%10.00% 0.00% diarrhea** fever respiratory * combined
    • 46. Biggest difference – injections and medicines Injections/ antibiotics Tehri Guntur received by patients % of patients that 13% 71% received an injection Mean number of 0.94 1.19 antibiotics received % of patients that 19% 30% received 2 or more antibiotics
    • 47. Relationships with the formal sector Qualified doctors were the main source of new knowledge for more than half of Guntur IPs 60 54 50 40 34 Medical reps 30 Qualified doctors Medical journals 20 17 17 Mass media 10 8.1 4 0 0.5 0 Tehri IPs Guntur IPs
    • 48. Relationships with the formal sectorWin-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 swordHostility 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.
    • 49. The AP initiativeRegistration with the State Paramedical Board / Act of 2006
    • 50. Flexible One Year Training1 year, bi-weekly sessions at nearby health facilities
    • 51. Barriers and supporting factorsBarriers• 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
    • 52. 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
    • 53. Acknowledgements Centre for Research in New Garhwal Community Development International Economic and Welfare Society, Tehri Order, Chennai, India Garhwal, India Dr. K.M Shyamprasad Dr. Rajesh Singh Dr. S. Srinivasan Ms. Rajkumari Singh Ms. Anshi Zachariah Mr. Manoj Kumar Ms. Premila Vijayraghavan Field research team Dr. Lalitha & the field team All hospital staff Mr. Christopher Singh Crenieo training centre staff Contact:
    • 54. Questions?