n n o v a t i o n in Informal Health Market in Bangladesh Innovations in informal health market in Bangladesh

Outline Who constitute healthcare providers Health seeking behavior Quality of services Challenges and opportunities

Who constitute healthcare providers

Health seeking behavior

Quality of services

Challenges and opportunities

Data Sources ICDDR,B study in 2006-07 in Chakaria, a sub-district Bangladesh Health Watch survey (nation wide) in 2007

ICDDR,B study in 2006-07 in Chakaria, a sub-district

Bangladesh Health Watch survey

(nation wide) in 2007

Health Care Providers in Chakaria, Bangladesh, 2006 TBA Spiritual Healer Village Doctor Homeopath Formal sector Kabiraj Population (560,000) Per 10,000 Formal (4%) 2.00 Qualified Physician (Regular) 39 .70 Qualified Physician (Guest) 20 .36 Sub-Assistant Community Medical Officer (SACMO-Paramedics) 7 .13 Family Welfare Visitor 13 .23 Midwife (ICDDR,B Trained) 12 .21 Family Welfare Assistant (Trained on midwifery by government) 13 .23 Nurse 8 .14 Informal (96%) 43.64 Village doctor (Allopathic) 328 5.86 Village doctor (Homeopathy) 174 3.11 Kabiraj (Traditional) 289 5.16 Religious/spiritual healer 694 12.39 Traditional birth attendant 959 17.13

Prevalence of Illness, Chakaria, 2007 43.5% of the 6,162 individuals included in the community survey reported suffering from some kind of illness during the 14 days preceding the survey . Wave of Viral Fever

43.5% of the 6,162 individuals included in the community survey reported suffering from some kind of illness during the 14 days preceding the survey .

Sources of First Line of Care, Chakaria, 2007 * SACMO=Sub assistant community medical officer Source of healthcare % Village doctors/Pharmacy 50.3 Home remedy 23.3 MBBS 10.6 Homeopath 8.1 SACMO* 4.7 Spiritual healers 1.1 Others 1.9

Use of Physicians and Village Doctors by Poor and Better Off, Chakaria, 2007

Circumstances Preferring Physicians and Village Doctors, Chakaria, 2007 MBBS doctors for perceived severe conditions Villager doctors for not so severe conditions

MBBS doctors for perceived severe conditions

Villager doctors for not so severe conditions

Reasons for Choosing Village Doctors, Chakaria, 2007 Multiple responses recorded Reasons for choosing the health care provider (n=340) % Quality of treatment is good 69.5 Nearest health care provider 42.5 Low treatment cost 17.3 Well behaved health care provider 17.3 Treatment cost on credit 14.6 No other health care facility available nearby 5.8 Health care provider is a family member or a relative or a known person 5.6 Advised by the neighbors or others 0.4

Why are the Village Doctors So Popular? Chakaria, 2007 They are always available In case of emergency they go to the patient’s house They charge lower consultancy fee They refer patients to other doctors if and when needed Patients can get medicines according to the money they have

They are always available

In case of emergency they go to the patient’s house

They charge lower consultancy fee

They refer patients to other doctors if and when needed

Patients can get medicines according to the money they have

Use of Drug for Treating Diarrhoea, Fever, and ARI by the Village Doctors, Chakaria, 2006 Inappropriate 75% Appropriate 18% Harmful 7%

Shortage of physician, nurse and technologist, Bangladesh, 2007 Gap between the need as per WHO recommendation and existing numbers Source: Bangladesh Health Watch 2008

Summary Situation Village doctors are the most dominant group practicing modern medicine Village doctors are popular among patients from all socioeconomic strata Patients seek care from village doctors with the belief that they are receiving quality care The quality of services provided by the village doctors are questionable Increasing the number of MBBS doctors in the immediate future does not seem feasible.

Village doctors are the most dominant group practicing modern medicine

Village doctors are popular among patients from all socioeconomic strata

Patients seek care from village doctors with the belief that they are receiving quality care

The quality of services provided by the village doctors are questionable

Increasing the number of MBBS doctors in the immediate future does not seem feasible.

A Few Questions??? What are the possible solutions for immediate future? Who do we resort back to in order to ensure health care for the rural people? Can we make use of the vast army of village doctors? How?

What are the possible solutions for immediate future?

Who do we resort back to in order to ensure health care for the rural people?

Can we make use of the vast army of village doctors? How?

Working with the Village Doctors to Make Health Systems Work for the Poor in Bangladesh

Why Village Doctor? Has been in existence for long Dominant first line healthcare provider 62% of the service providers using modern medicine are Village Doctors Majority villagers contact them first for treatment Live in the rural area Acute shortage of formally trained providers Unlikely to have enough number of trained provider in the foreseeable future Can work as a link between the formal sector and the villagers Has the potential to bridge the transition from informal system to formal

Has been in existence for long

Dominant first line healthcare provider

62% of the service providers using modern medicine are Village Doctors

Majority villagers contact them first for treatment

Live in the rural area

Acute shortage of formally trained providers

Unlikely to have enough number of trained provider in the foreseeable future

Can work as a link between the formal sector and the villagers

Has the potential to bridge the transition from informal system to formal

Challenges Quality of services Accountability Need for a Model

Quality of services

Accountability

In Search of a Model - Interventions Component Activity Quality of service Training Accountability Watch Reward, consolidation, promotion Branding/Franchising

Quality of Services - Training Content of training DOs and DON’Ts for managing: Pneumonia, diarrhea, viral fever, malaria, hepatitis, APH, Obstructed labour, PPH DOs and DON’Ts in using Antibiotics and Steroids Referral and information about referral Cover page of the booklet

Content of training

DOs and DON’Ts for managing:

Pneumonia, diarrhea,

viral fever, malaria, hepatitis,

APH, Obstructed labour, PPH

DOs and DON’Ts in using Antibiotics and Steroids

Referral and information about referral

Cover page of the booklet

Accountability – Union Health Watch Composition Elected representatives Social leaders Representative of Village Doctors Activity Orientation of healthcare system, drug, major health problems, monitoring techniques Monitoring performance of Village Doctors Meeting once a quarter Provide feedback

Composition

Elected representatives

Social leaders

Representative of Village Doctors

Activity

Orientation of healthcare system, drug, major health problems, monitoring techniques

Monitoring performance of Village Doctors

Meeting once a quarter

Provide feedback

Branding – Shysthya Sena Network of Village Doctors – Shysthya Sena Membership criteria Adherence to desired agreed practices Maintenance of records Physical facility Yearly assessment by oversight committee Public recognition Badge, stationery, logo, sign etc. Committee and its function Village Doctors, Health and Administration, local government, civil society Quarterly meeting Decide guidelines for operation and assessment Oversight of the quality of services Awarding of reward

Network of Village Doctors –

Shysthya Sena

Membership criteria

Adherence to desired agreed practices

Maintenance of records

Physical facility

Yearly assessment by oversight committee

Public recognition

Badge, stationery, logo, sign etc.

Committee and its function

Village Doctors, Health and Administration, local government, civil society

Quarterly meeting

Decide guidelines for operation and assessment

Oversight of the quality of services

Awarding of reward

Phases of Activities Phase I – Pilot (Ongoing) Phase II – Impact evaluation (2009 +) Phase III – Scale Up

Phase I – Pilot (Ongoing)

Phase II – Impact evaluation (2009 +)

Phase III – Scale Up

Thank You