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The role of informal providers in health markets

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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.

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The role of informal providers in health markets

  1. 1. The Role of Informal Providers in Healthcare MarketsGina Lagomarsino, October 17, 2012
  2. 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. 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. 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. 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. 6. THANK YOU! Gina Lagomarsino glagomarsino@resultsfordevelopment.org
  7. 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. 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. 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 states 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. 10. FIVE WAYS TO IMPROVE HEALTH MARKETS
  11. 11. CENTER FOR HEALTH MARKET INNOVATIONS (CHMI)VISION: For the private sector to reach its potential to deliver quality, affordable, and accessiblehealth 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. 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. 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. 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

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