Improving Provider Performance

This article in the id21 e-magazine discusses new research in Bangladesh, India, and Nigeria on strategies to improve performance associated with the informal provision of health care. The research has been done in association with the Future Health Systems Research Programme Consortium.

As described by the authors: "Poor people often use informal providers for health care. In Bangladesh formally trained workers account for only five percent of providers. The private sector comprises around 180,000 informal providers practising as village doctors and/or drug vendors. Over 70 percent of India’s population is rural yet more than 70 percent of its medical professionals practice in the urban, affluent private sector or have migrated overseas. Fewer than 50,000 doctors work in rural primary and secondary health care facilities; health care is delivered mainly by under-trained staff, often referred to as rural medical practitioners or the informal private health sector. In Nigeria, self-treatment of common illnesses using drugs purchased from patent medicine vendors (PMVs) is widespread and the most common source of malaria treatment in Nigeria. [A graph shows that patent medicine vendors and self-treatment occupy as much as 80% of health care provision.]"


Research in Bangladesh shows that rural villagers, social leaders, health care providers, and drug vendors see village doctors as an essential source of health care; but there is concern about the quality of care: "village doctors need up-to-date medical information and training opportunities. A new intervention is testing a manual and a training programme to improve informal providers’ treatment of common illnesses; ...[and] also creating a network of informal providers - Shaysthya Sena or Health Force - whose members must adhere to agreed quality standards for:

• appropriateness of treatment
• reduction in prescriptions of harmful drugs
• timely and appropriate referrals.

Compliance will be monitored by a local health watch group, composed of members of the Shastya Sena network, government administration, civil society, peers and experts."

In India, there is a call for innovative health partnerships with informal providers to improve the quality of care: "First Care Health is a social enterprise with rural medical practitioners currently being piloted by the Indian Institute of Technology’s Rural Technology and Business Incubator in Tamil Nadu. They have given rural practitioners computers and internet technology, distance learning and other support."


In Nigeria, PMVs are calling for stronger government regulation to reduce the availability of fake drugs. Nearly a quarter of PMVs called for self-regulation through professional associations. Both vendors and the government wish to involve the community in monitoring the quality of drugs, which is the basis of a project of the University of Ibadan: "The University of Ibadan is trying to increase consumer knowledge and expectations for consumer rights, including the creation of effective regulatory partnerships to ensure the quality and affordability of drug supplies." The government would like to strengthen the communication of drug policy and regulation to PMVs and develop mechanisms by which they can work together to identify and remove substandard and counterfeit drugs from the market.

In short, the authors recommend including informal providers as key sources of service by implementing mechanisms attuned to the context, capacity, and technology available. The potential benefits of linking informal providers, communities, knowledge brokers, researchers, and policymakers may include the following outcomes:

• more empowered informal providers
• better informed government actors
• more locally-devised and –owned educational tools
• stronger formal links between civil society, government, and the informal sector.