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Informal markets

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  • 1. 1 UNDERSTANDING & INTERVENING IN INFORMAL MARKETS IN HEALTH LIGHTNING TALKS FROM FUTURE HEALTH SYSTEMS RESEARCH CONSORTIUM
  • 2. 2
  • 3. 3 Understanding Informal Markets: a Framework for Analysis Gerald Bloom
  • 4. Spread of health related markets  Out-of pocket payments are a substantial proportion of health expenditure  There are a variety of suppliers of drugs and providers of health services (in terms of training, organization and relationship to formal structures)  Boundaries between public and private are blurred 4
  • 5. Simple interventions may not work  Training on good practice may have little impact if incentives are unchanged  Formal regulations may be unenforced and informal relationships are often influential  Markets for health goods and health services are inter-twined  Politics and power relationships influence outcomes 5
  • 6. Health market systems  Providers and users  Coordination and regulation by non-state actors  Knowledge intermediaries and asymmetric information  The use of government legal, financial and convening powers skills, capacities, incentives and power relationships 6
  • 7. Building institutions for improved performance  Analysis of structure and functioning of market system (incentives and formal and informal relationships)  Understand expectations and norms of behavior matter  Learning approach to the construction of legitimate institutions and a revised social contract  Importance of systematic information on what works and on unintended outcomes 7
  • 8. 8 The Underground Rural Healthcare Market: The case of Rural Medical Practitioners in India Barun Kanjilal
  • 9. Problem  Rural Medical Practitioners (RMP) – people practicing modern (allopathic) medicines without formal training - dominate the Indian outpatient market even though they are ‘illegal’.  Dilemma in policy making silence / neglect  Are market based economic interpretations the reason for policy failure? Can institution-based theories help?
  • 10. Research on RMPs in West Bengal: some key findings  More than half (60%) of rural outpatient market share  No significant difference in price / access barriers with government providers (average distance or OOPE)  Positive effects (1) high success rates in treating common diseases (2) up-to-date on latest drugs  Threats  Indiscriminate use of antibiotics  Minor / major surgeries  Gradual penetration to inpatient care market
  • 11. An Alternative Approach to Looking at Rural Outpatient Care Market Clients’ Health outcom e Drug detaile rs Private qualified providers RMPs Government providers Market factors Institutional Factors Contract monitoring
  • 12. Understanding the spread of RMPs through institutional economics: an alternative framework  Supportive informal institutions  Incomplete contract  Social and political sanctions  Tacit support from formal sector  Trust  Bounded rationality  Low transaction cost  Reduced uncertainty in transaction  User friendly negotiations  Vertical integration (consultancy + drug dispensing) 12
  • 13. 13 Knowledge, legitimacy and economic practice in informal markets for medicine: a critical review of research Jamie Cross and Hayley MacGregor Soc Science and Med 71 (2010) 1593-1600
  • 14. The problem of informal providers  The framing of informal providers as problematic  Uncertainties over a definition: who are they? people who ‘operate on the margins of legitimacy’ Pinto 2004 14
  • 15. Knowledge economies  Understandings of expertise and legitimacy  Practices of boundary making and fuzzy boundaries  Acknowledging the existence of hybrid practices 15
  • 16. Markets, medicine and morality of exchange  Expectations about how economic actors in the medical marketplace will behave  Reality of complex transactions embedded in broader social relationships  Need to rethink understandings of a ‘moral economy of care’ 16
  • 17. Conclusion  Must consider the role of informal providers in the pharmaceutical supply chain – need shift in attention upwards  Debates about regulation and responsibility for safety cannot exclude an analysis of the role of the pharmaceutical industry 17
  • 18. 18 Informal providers in low and middle income countries - A review of the effectiveness of interventions Nirali M. Shah
  • 19. Methods / Inclusion Criteria  Peer-reviewed and grey literature  Searched through PubMed, Google and Global Health Database  Published between Jan. 1993 and May 2008  Identifiable intervention  Used list of keywords for interventions  Providers “intervened upon” identified as IPP  Used list of keywords for types of IPP
  • 20. Definition of Informal Private Provider  Provide allopathic treatment and services  Without formal training in allopathic medicine, or providing services beyond level of training  Exist in health services market  Volunteers and providers affiliated with state, NGO or research study excluded  Examples: TBA, drug shop worker, unqualified doctor, CHW
  • 21. Interventions by medical condition
  • 22. Direction and type of outcome for FP/RH studies
  • 23. Percentage of provider behavior and knowledge outcomes that are positive, by type of provider
  • 24. Conclusions  Evidence base is limited; dearth of studies with strong research designs  Costs and details of intervention strategies not reported  Strategies applying market based incentives more successful than training  Successful strategy combinations included training+referral system, training+accreditation
  • 25. “LIGHTNING” RESPONSES 26 • Other ideas • Comments • “Big questions” for later discussion
  • 26. 27 Exploring the Effect of Drug Detailing on Village Doctors in Chakaria, Bangladesh M. Hafizur Rahman
  • 27. Who are the Village Doctors? 28
  • 28. Background  Informal health care providers deliver a significant proportion of health care services (40-60%) for the poor despite irrational use and over prescribing of drugs  Promotion of drugs by medical representatives (MR) is known to influence provider practices  Little is known about the influence of MR on informal providers 29
  • 29. Objectives  To describe the job characteristics of medical representatives, and differences in promotional practices  To identify the incentives offered to informal village doctors  To compare the training, knowledge and practices of medical representatives and village doctors 30
  • 30. Study sites  84 village doctors (44%) and 43 MRs (17%) of the study areas 31
  • 31. Education/Training of MR  Average length of training – 41.5 days  Refresher training - 1-2 trainings per year to several times per month  MRs learn from company literature, pamphlets, internet, and phone calls to company’s product management department 32
  • 32. Information provided by MR  For all village doctors – MRs as principal and often sole source of information  Literature vs package inserts  “The literature is in English and contains complicated words which are difficult to understand. (The meanings of which) Even the MRs don’t understand”  “(The package inserts are) Very helpful, more helpful than the literature provided by the MR” 33
  • 33.  Inaccurate information; village doctors depend on prior knowledge and experience  Describe the benefits but often miss out the harmful effects  “Chloramphenicol is not good for children but MRs do not say this. They never talk about the bad effects. In this way MRs are silent killers, they kill by omission.” 34
  • 34. Incentives offered  Grades the health care providers as A, B, C, D (A+, A++ if exceeds the expected number of prescriptions)  Incentives  Discounts/Samples –usually 2-3%.  Gifts (e.g. chair, stethoscope, mobile phone  Credits – pay back time varies from 5 days to 1-3 months. Small companies - flexible credit limits 35
  • 35. Characteristics of Medical Representatives and Village Doctors 36 N=43 N=83 Age (in years) Mean (+SD) 31.1(+4.8) 38.5(+12.4) <0.01 Family size Mean (+SD) 4.7(+2.4) 5.8(+3.2) <0.05 Monthly household expenditure Median (in Taka) 13,000 8,000 <0.001 Education n(%) n(%) Secondary (10th grade) 0(0) 19(23.2) <0.001 College (12th grade) 1(2.3) 50(61) Gradute 24(55.8) 13(15.9) Post-graduate 18(41.9) 0(0) Alternative source of income+ n(%) Selling medicine from own shops - 66(79.5) Agriculture - 26(31.3) Shrimp/Fish culture - 6(7.2) Other - 14(16.9) + Multiple responses
  • 36. Conclusions  The MRs are an important source of pharmaceutical information for village doctors.  The incentives offered by pharmaceutical companies to medical representatives encourage aggressive promotional practices that differ for informal versus formal providers.  The fact that MRs are more educated and financially better off than village doctors might strengthen their position to affect prescribing practices of village doctors.  Creative regulation to promote ethical promotional practices by pharmaceutical companies and their representatives could improve the prescribing habits of village doctors. 37
  • 37. 38 Informal Markets in Sexual and Reproductive Health Services and Commodities in Rural and Urban Bangladesh Sabina Rashid, Hilary Standing and Owasim Akram
  • 38. Background  Little attention has been paid to informal medical markets for sexual and reproductive health (SRH) services in Bangladesh  The public sector provides limited services or support for SRH; a large informal market has developed  33 percent of doctors with an MBBS degree and 51 percent of specialists who are public sector personnel are involved in private practice  > 85% of population is treated by informal providers. They include homeopaths, birth attendants, village doctors (“quacks”), unregistered pharmacists and faith healers  It is important to examine the characteristics of the informal market for SRH, showing how supply and demand mutually reinforce the development of this flourishing market, especially in the absence of high quality formal provision 39
  • 39. Characteristics of the providers  303 providers: 62% male; 38% female  Mean experience: 17.6 years  76 (25%) had institutional degrees  190 (63%) did not have any recognition  75% said that healing was their main profession, 25% practised it as a side business  33% charged a fee for their services  15% received gifts in kind  13% did not charge for consultations but charged for the costs of medicines
  • 40. Characteristics of the providers (2) 41  Formal (n=84) (Govt./Private/NGO Hospitals, clinics, Privately practicing MBBS doctors)  Independent Operators (n=191) (Village doctors, pharmacist, homeopath, birth attendants, roadside healers, kabiraj, hakim etc.)  Faith Healers (n=28) (Ojha, pir, fakir, hujur etc.) Type of Providers Formal 28% Independent Operators 63% FaithHealers 9%
  • 41. Men’s and Women’s use of the SRH Market Men Women Type of Provider Fre. % Fre. % Village Doctor 68 21.9 75 24.0 Drug seller/Pharmacy 57 18.3 24 7.7 MBBS doctor 47 15.1 79 25.3 Homeopath 31 10.0 18 5.8 Kabiraj/Hakim 22 07.0 6 1.9 Govt Health Center 11 03.5 36 11.5 Roadside Healer 3 01.0 - - Faith Healer 2 00.6 21 6.7 Private Hospital 1 00.3 7 2.2 Family Planning Worker - - 14 4.5 TBA - - 10 3.2 NGO Health Worker - - 6 1.9 NGO Clinic - - 4 1.3 Friends and Relative - - 1 0.3 Don't know 69 22.2 11 3.5 Total 311 100.0 312 100.0
  • 42. Whom did the men visit and for which concern? Concerns 1st Provider 2nd Provider 3rd Provider Short Term Sexual Intercourse (Premature Ejaculation/ ejaculation before coitus) 63 Suffered 29 received treatment MBBS Doctor (9) Drug Seller (5) Kabiraj/Hakim (4) Roadside Healer(3) Homeopath (3) Others (5) Total = 29 MBBS Doctor (5) Homeopath (2) Govt. Hospital (2) others (3) 2nd round = 12 Drug Seller (2) Kabiraj/Hakim (2) Others (3) 3rd round = 7 Burning or Pain when urinating 35 suffered 22 sought treatment Drug Seller (5) Govt. Hospital (4) MBBS Doctor (3) Kabiraj/Hakim (2) Homeopath (2) Others (6) Total = 22 MBBS Doctor (3) Drug Seller (2) Street Healer (1) Others (2) 2nd round = 8 MBBS Doctor (1) Homeopath (1) Friend (1) 3rd round = 3
  • 43. Whom did the women visit and for which concern? Type of Problems 1st Provider 2nd Provider 3rd Provider Sexual Relationship (discomfort/pain during intercourse, low sexual desire, inability to maintain arousal, unable to have complete satisfaction)[1] 46 suffered the problems. 25 received treatment Total number of women -25 Govt. health center/hospital (8) MBBS doctor (7) Kabiraj (4) Drug seller (4) Hujur (1) Homeopath (1) Total number of women -14 Govt. health center/hospital (5) MBBS doctor (3) Hujur (2) Drug seller (2) Village doctor (1) Hawker drug seller (1) Total number of women -7 MBBS doctor (3) Drug seller (2) Homeopath (1) Govt. health center/hospital (1) Itching, irritation and smelly discharge 43 suffered the problem. 26 received treatment Total number of women - 26 MBBS doctor (7) Homeopath (5) Kabiraj (4) Drug seller (3) Govt. health center/hospital (3) Village doctor (2) FP worker (1) Family member (1) Total number of women -10 MBBS doctor (4) Hujur (3) Govt. health center/hospital (2) Drug seller (1) Total number of women -6 MBBS doctor (3) Drug seller (1) Govt. health center/hospital (1) Family member (1) Prolapse 37 suffered the problem. 17 received treatment Total number of women --17 Kabiraj (6) Govt. health center/hospital (4) MBBS doctor (4) Village doctor (1) FP worker (1) Family member (1) Total number of women -7 MBBS doctor (3) Hujur (1) Village doctor (1) FP worker (1) Govt. health center/hospital (1) Total number of women -4 MBBS doctor (3) Drug seller (1)
  • 44. Money Spent for Treatment  151 men suffered; 90 (60%) sought treatment  Average money spent (for last concern): BDT 1468 (US$ 21); Average family income per month was BDT 6668 (US$ 94) per month.  273 women suffered;152 (55.7%) sought treatment  Average money spent (for last concern): 2374 taka (US$ 33); Average family income was 7105 (US$ 100) per month.
  • 45. Key Messages  Treatment is sought from a variety of providers of unclear benefit or quality  Treatment is costly–one third of income from their own income, rest taken as loans, credit, borrowed, selling assets  Many SRH concerns and anxieties, including possible sexually transmitted infections, are poorly addressed in government services; women use private providers for neglected or stigmatised SRH conditions  The market is responding to external influences, including widespread availability of over-the-counter pharmaceuticals and the rise of new sources of information  The very broad and gendered nature of the demand for SRH services suggests that ways to meet these needs may be more appropriate. Examples: quality assured provision of information on sexual health using a range of channels; support for improving the knowledge and skills of trusted providers
  • 46. Promoting improved performance of Private Medicine Vendors in providing access to appropriate drugs for malaria in Nigeria Oladimeji Oladepo
  • 47. 48 How can PMVs provide better access to effective malaria prevention & treatment services? The Central Question
  • 48. 49 Nigeria Study: Malaria Treatment  Estimated 57.5 million cases and 225,000 deaths (25% of global malaria burden)  New policy to provide ACTs as 1st and 2nd line drugs- Low access through Public Sector  Little known about Patent Medicine Vendors (PMVs), the main source of treatment
  • 49. 50 Proportion of total volume of all anti-malarials sold or distributed in the 1 week preceding survey (Source ACTWATCH, 2010)
  • 50. 51 54 Different Types of Anti-malarial Drugs Found
  • 51. 52 Percent of Patent Medical Vendor Shops with Anti-Malarial Drugs 0 10 20 30 40 50 60 70 80 90 100 ACTs Monotherapy artusenates Chloroquine Sulfadoxine- pyrimethamine Other PercentofShops
  • 52. 53 Other Key Findings  Low quality drugs cited as major problem by households, PMVs and Associations, government officials  Low confidence in government to regulate, but wide regional variation  PMVs know little about malaria policy change  Government officials knew little about PMV Associations
  • 53. 54 Nigeria: New Intervention strategies  New co-regulation with PMV Associations, citizens groups, government  Training & certification of PMVs  Quality Drug Testing for ACTs  Mobile phone support on drugs, referrals  Increasing consumer knowledge and engagement for monitoring
  • 54. 55  Expanding partnerships, relationships and alignments of players (including opposing interest groups) improves PMVs and community capability (Social capital)  Placing IT (drug testing diagnostics and mobile phones) in PMVs hands strengthens the anti-malarial medicine supply chain (decreases PMVs opportunity for inadvertent purchasing and selling counterfeit drugs, and improves timely and quality data reporting) Stimulating innovation from proposed strategies
  • 55. Outcomes  National Malaria Control Programme (NMCP) and FMOH adopted two intervention strategies (i.e. training and regulations for PMVs), and pilot testing them in a few states  NMCP appointed desk officers for PMV work  NMCP developed draft “National Guideline for Integrated Community Management of Malaria” which substantially includes PMVs 56
  • 56. Nigeria : Moving Forward  Ready to test the effectiveness of low cost diagnostics and mobile phone interventions on service delivery among Patent Medicine Vendors (PMVs)in 6 geopolitical Zones to:  take full advantage of other critical points of influence in the informal malaria treatment market  balance supply and demand side factors, and  influence national policy/program adoption  Lack of funds hampers this effort  Support needed to actualise this initiative 57
  • 57. Exploring New Health Markets: Experiences from Informal Transport Providers for Maternal Health Services in Eastern Uganda G. Pariyo, C. Mayora, O. Okui, F.Ssengooba, D. Peters, D Serwadda, H. Lucas, G. Bloom, E. Ekirapa-Kiracho 58
  • 58. Introduction & Background • Up to 75% of deaths can be averted by ensuring timely access to obstetric care and related maternal care-WHO • Access to maternal health care is hindered by distance, geographical accessibility, cost of transport and transport networks. • Yet in Uganda, transport in Uganda is privately organized-hard for poor to afford 59
  • 59. Aim  To explore alternative transport approaches that are rural-based and respond to the needs of clients seeking maternal health care services, cognizant of local operational contexts.
  • 60. Intervention: Quasi-Experimental Vouchers for transport Vouchers for maternal services Maternal & newborn health services Pregnant women & newborns in control Maternal & newborn health services Training Supervision Supplies, drugs and equipment Pregnant women & newborns in intervention
  • 61. Results-1st ANC Utilization, Kamuli District 0 500 1000 1500 2000 2500 3000 3500 4000 jan'09 feb'09 m arch'09 april'09 m ay'09 june'09 july'09 aug'09 sept'09 oct'09 N ov'09 D E C '09 JAN '10 FE B'10 M A R '10 A PR '10 M A Y'10 JU N '10 Month 1stANCvisit Intervention Control
  • 62. Institutional Deliveries-Kamuli District 0 100 200 300 400 500 600 700 jan'09 feb'09m arch'09april'09m ay'09june'09 july'09aug'09sept'09 oct'09Nov'09DEC '09JAN'10FEB'10M AR'10APR'10M AY'10JUN'10 Month Deliveries Intervention Control
  • 63. Benefits and challenges  Increased accessibility to services at affordable cost (initially $10-$12, now $5-$10 per delivery)  Mobilisation and sensitization of community especially mothers by transporters  Income generating activity for transporters (appox $150 monthly over and above operational costs-highly engaged)  However, challenges of difficulty in enforcement of regulations (traffic requirements)  Difficulty in organising informal associations to provide services especially rural settings 64
  • 64. Conclusions and Policy Implications  Transport appears to have been a major barrier to use of maternal health services, which can be overcome by affordable subsidies  Use of existing resources in innovative ways has the potential to improve maternal health outcomes (community capabilities)  Purely private health markets (transport markets) may not allow the poor to access the much needed maternal health care services  A form of Public-Private partnership framework in the health markets could overcome significant barrier to care [Uganda]65
  • 65. 66 Lessons from an intervention programme to make informal health care providers effective in rural Bangladesh Shehrin Shaila Mahmood, Abbas Bhuiya, M Iqbal, SMA Hanifi,M Shomik,Tania Wahed
  • 66. Background  Bangladesh is one of the health workforce crisis countries in the world with a shortage of over 60,000 doctors, 280,000 nurses and 483,000 technologists (BHW 2009)  The informal healthcare providers popularly known as Village Doctors dominate the health workforce occupying 95% of the share in Bangladesh  However, the quality of services provided by these Village Doctors are questionable  An intervention programme was carried out to reduce the harmful/inappropriate practices by the Village Doctors in Chakaria and to make them accountable to the villagers 67
  • 67. The Intervention  Implement a training intervention for improving treatment practices of Village Doctors in 11 commonly occurring illnesses in Chakaria: pneumonia, severe pneumonia, diarrhoea, hepatitis, malaria, tuberculosis, viral fever, obstructed labour, blood loss before labour, and blood loss after labour  Establish a membership-based-network involving trained and eligible Village Doctors branded as “Shasthya Sena” (Health Force)  Form a monitoring committee, known as local health watch to monitor practice pattern of joining members to ensure adherence to certain clinical and public health standards 6868
  • 68. Results  Number of Village Doctors offered training= 157  Number of Village Doctors joining the training programme=157  Number of Village Doctors joining the Shasthya Sena Network=117 69
  • 69. Impact 70 93.9 92.4 87.1 91.7 0 20 40 60 80 100 Shasthya Sena Non-Shasthya Sena %ofprescription Baseline Endline P<0.001 P>0.20 Figure: Proportion of prescription with inappropriate or harmful drug advice by the Shasthya Senas and the non-Shasthya Senas at baseline and endline • Inappropriate or harmful drug advice decreased more among the SS Group compared to the control group • However, the Difference- in-difference test showed this change was not significant (P>0.10)
  • 70. Impact P<0.05 Figure: Proportion of prescription with harmful drug advice by the Shasthya Senas and the non-Shasthya Senas at baseline and endline  Proportion of harmful drug advice increased among both the groups. However, the increase was lower in the SS group  Test of Difference-in- difference came out to be insignificant (P>0.10) Adherence to standard practices comes at the cost of lost profit in terms of decreased drug sell 71
  • 71. Concluding Remarks  Existing Village Doctors are enthusiastic about joining training programmes and are keen to learn  Networks like Shasthya Sena can be established to engage with the informal healthcare providers with an aim to improve their quality of service and to utilize this huge workforce in filling the void that is created in the formal healthcare system  However, the intervention package of medical training and monitoring through local watch alone seems to be not enough to bring in the desired level of change in practice pattern of the Village Doctors  Additional incentives need to be built into the system that can significantly improve their practice and ensure quality healthcare for the people in general and the poor in particular 72
  • 72. Thank You - Meet Us At www.futurehealthsystem.org 73