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
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
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
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
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)
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.
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
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