Standardized patients methodology used to assess clinical skills Relationships with Interviews with a sample of formal providers and key formal system informants. FGDs with community members. Barriers/facilitators FGDs with community members and key informants. for integration Interviews with formal providers and policy makers. Key findings 1. Provider enumeration and characteristics 2. Education and training 3. Practice characteristics 4. Knowledge and skills 5. Relationships with formal system 6. Barriers and facilitators for integration 1. Provider enumeration and characteristics Tehri (263 IPs) Guntur (368 IPs)

1. http://www.pshealth.org/ https://twitter.com/psinhealth
Harnessing informal providers for health
systems improvement: Lessons from
India
An initiative of the Private Sector in
Health Symposium

2. Symposium: Sydney 6 July 2013
• Since 2009 a group of researchers and policy analysts
working on health markets in low and middle-income
countries have organised a pre-congress symposium
at the biennial conferences of the International Health
Economics Association
• The aim has been to encourage and disseminate high
quality research on the performance of these markets
and on practical strategies for improving access to
safe and effective services by the poor
• The Future Health Systems Consortium is responsible
for organising the 2013 symposium with financial
support from the Gates and Rockefeller Foundations
and SHOPS
www.pshealth.org

3. Webinar series
• Facilitated by the Future Health Systems Consortium
• Organised by a number of institutes
• Publicised widely to involve a wide audience
• The next webinar will be held on 7 March 2013
entitled, ‘Shaping the future of health markets:
Reflections from a meeting in Bellagio’. Registration will
open soon!
Providing opportunities to set the scene well before the
Sydney meeting and to ensure that those who may not be
attending the Symposium have the opportunity to
participate in debates about strategies for improving the
performance of health markets in meeting the needs of the
poor.

4. Harnessing informal providers for
health systems improvement
• Important sources of advice and drugs for poor
people in many low and middle-income countries
• Growing body of evidence on who uses them and
the services they provide
• A variety of innovators and social entrepreneurs are
testing strategies for improving their performance
• Governments are gradually recognising the
importance of these providers
Engaging with informal providers: an opportunity for
governments to increase access to effective and
affordable services?

5. Future Health Systems’ work on
informal providers
• Case studies in
India, Bangladesh, Nigeria and
China
• Transforming Health Markets in
Asia and Africa: Improving Quality
and Access for the poor
• Collaboration with CHMI
programme of work on informal
providers
• Meeting in Bellagio and production
of a briefing note: Future Health
Markets: a meeting statement
from Bellagio
• Building networks and testing
interventions

6. Organisation of webinar
• Presentations by Gina Lagomarsino and Meenakshi
Gautham
• On the side of the screen you should see a control panel with
a chat function. Participants are invited to send written
questions or comments to the meeting organiser via Instant
Message. If you send your questions to the entire audience
they will be public. We will remove any duplications and select
questions to pose to each presenter
• We are recording the webinar and so your questions may be
made public
• The aim of the webinar is to stimulate discussion and debate
about the role of informal providers and strategies for
improving their performance
• Help us to improve the organisation of webinars by
completing an evaluation form

7. Gina

8. Growing Knowledge
about the Role of
Informal Providers
within Health Systems
Gina Lagomarsino Results for Development
Harnessing Informal Providers for Health Systems February 5, 2013
Improvement: Lessons from India

9. CHMI CONVENED GROUP ON INFORMAL PROVIDERS
Members of Working Group of researchers and practitioners
 Sofi Bergkvist, AccessHealth
 Peter Berman, Harvard
 Abbas Bhuiya, ICDDR,B
 Gerry Bloom, IDS
 Bill Brieger, Johns Hopkins
 Annapurna Chavali, AccessHealth
 Birger Forsberg, Karolinska
 Gopi Gopalakrishnan, World Health Partners
 Mohammad Iqbal, ICDDR,B Group met two times:
 Gina Lagomarsino, R4D • Sept. 2010 – Washington, DC
 Kim Longfield, PSI • March 2012 – Dhaka
 Bruce Mackay, HLSP
 Dominic Montagu, UCSF
 Stefan Nachuk, Rockefeller Foundation
 Gael O’Sullivan, Abt Associates
 Karen Pak Oppenheimer, World Health Partners
 David Peters, Johns Hopkins
 Edumund Rutta, MSH
 Nirali Shah, PSI
 Guy Stallworthy, Gates Foundation
 Hongwen Zhao, WHO

10. WHO ARE INFORMAL PROVIDERS (IPS)?
Definition of Informal Providers
The following definition was developed by UCSF Global Health Group with input and
agreement from the CHMI Informal Provider Working Group:
• Chiefly entrepreneurs
Business • Collect payment from patients, not institutions
Model • Payment is often undocumented and tendered in
cash
• Possess little or no officially recognized training
Training from formal bodies such as a government, NGO,
or academic institution
• Operate outside of effective regulation of
Registration
government and independent regulatory
/ Regulation organizations

11. WHAT DO WE KNOW ABOUT INFORMAL PROVIDERS?
Literature review findings
In 2011, CHMI, in collaboration with May
Sudhinaraset and Dominic Montagu at the Global
Health Group at the University of California, San
Francisco (UCSF), completed a literature review on
IPs to determine what is known on the topic.
 Size: IPs make up a significant portion of the
health sector—ranging from 51-55% in India to
96% in rural Chakaria, Bangladesh.
 Scope: IPs are used in day-to-day healthcare
and function across the continuum of care.
 Quality: Information is limited; the quality of
care delivered by IPs appears variable.
 Reasons for use: IPs are used because of
their convenience, low price and for
cultural/social reasons.
Study published in PLoS-ONE on Feb. 6 2013

12. LEARNING MORE ABOUT THE DYNAMICS OF INFORMAL
MARKETS
CHMI Commissioned studies in Bangladesh, India and Nigeria
Research Lead Study Site IP Studied
Bangladesh
Nabeel Ashraf Ali, Shams El Arifeen Tangail district
Sunamgang district Village Doctors/
ICDDR,B; James P Grant School of Public Rangpur district Drug Sellers
Health-BRAC University Cox Bazar
Dr. Meenakshi Gautham
Centre for Research on New Rural Medical
India
International Economic Order (CReNIEO); Guntur district, Andhra Pradesh
Tehri district, Utarrakhand Practitioners
Garhwal Community Development and (RMPs)
Welfare Society; London School of
Hygiene and Tropical Medicine
Professor Oladimeji Oladepo 10 Local Government Areas,
Nigeria
Oyo State Patent Medicine
Faculty of Public Health-College of 10 Local Government Areas, Vendors (PMVs)
Medicine, University of Ibadan Nasarawa State

13. FINDINGS FROM 3-COUNTRY STUDY
Theme 1: IPs’ relationship to their communities
IPs and their communities
• IPs have local roots and have well-
established, long-running, practices
• IPs are often the first point of care for patients
• IPs have developed lucrative businesses
• They appear to be well-regarded and trusted
members of the community
• IPs are relatively well educated compared to
their clients, which contributes to their high
profile in the community

14. FINDINGS FROM 3-COUNTRY STUDY
Theme 2: Education and Training
Education and training received by IPs
• Most informal providers appear to have some
form of health training
• The duration, formality, and content of health
training varies widely
• Training can comprise commercially offered
courses, public training for community health
workers, or apprenticeship

15. FINDINGS FROM 3-COUNTRY STUDY
Theme 3: Quality of care
Quality of care delivered by IPs
• IPs engage in some incorrect and
potentially harmful practices
• IPs exhibit some appropriate
knowledge regarding basic conditions
and standards of care
• Also evident that knowledge does not
always translate into practice, with
polypharmacy and irrational use of
drugs a common problem

16. FINDINGS FROM 3-COUNTRY STUDY
Theme 4: Relationship with the formal sector
Relationship between IPs and the
formal healthcare sector
• IPs function within a complex health
market and have established some ties
to other parts of the market
• Many have some ties to the formal
health sector for new medical
information, drug supplies, and
referrals
• IPs also operate in reaction to demand
from consumers

17. FINDINGS FROM 3-COUNTRY STUDY
Theme 5: Organization of IPs
Organization and recognition of IPs
• Can range from little coherent
organization and government hostility
to nation-wide organization and
government recognition
• Examples exist of well-organized and
strong informal provider associations
acting on behalf of the members’
interest

18. POTENTIAL INTERVENTIONS WITH INFORMAL PROVIDERS
Goal Intervention
1. Organization: IPs are organized,  Provider Associations
thereby reducing the fragmentation  Provider Networks
of health care delivery
2. Education: IPs are trained to provide  Provider Training
specific interventions  Standard Operating Procedures
3. Certification: IPs are certified in the  Accreditation/Licensing
area of health in which they practice  Aggressive Enforcement/Forced Shutdown
4. Compliance: IPs comply with set  Regulatory/Monitoring Policies and Groups
procedural and quality standards  Financial Incentives/subsidies
5. Job support: IPs are well-equipped to  On-site support: (E.g., job aids, decision-support software)
provide quality care  Remote support: (E.g., call centers, telemedicine)
 Supply-chain improvements: (E.g., pre-packaged medications,
pooled procurement of drugs)
6. Referrals: IPs have access to and  Incentivized referrals
utilize referral networks for  Collaboration with the formal sector
complicated cases  Rural postings for formal providers

19. IPS ARE RELEVANT FOR MANY BROAD HEALTH SYSTEM
CHALLENGES
Necessary to consider IPs if we are to address a number of related issues
Convergence between IPs and other health
systems issues include:
 Health human resource
shortages, including
frontline/community health
workers
 Poor quality of medicines,
irrational drug use, and
inadequate access to essential
medicines
 High out-of-pocket spending
 Lack of universal health
coverage

20. POTENTIAL NEXT STEPS
Research to be completed
• Country papers published
• Three-country study synthesis paper published
Potential action steps
• Policymaker engagement in select countries
• Convene community of practitioners working with IPs in
different countries to share promising practices
• Engage with global Human Resources for Health and Frontline
Health Workers/Community Health Workers communities

21. OTHER RELEVANT WORK ON INFORMAL PROVIDERS
Recent Publications
Transforming Health Markets in Asia and Africa:
Improving Quality Access for the
Poor, Bloom, G., Kanjilal, B., Lucas, H. and
Peters, D.
In Urban And Rural India, A Standardized
Patient Study Showed Low Levels Of Provider
Training And Huge Quality Gaps, Health
Affairs, Das, j. et al.
Developing World: Bringing order to
unregulated health markets, Commentary in
Nature, Peters, D. and Bloom, G.
Mapping Health Care Markets in Rural
Cambodia: A Survey of formal and Informal
providers, Presentation at the Health Systems
Research Symposium, Beijing, Özaltin, E.

22. THANK YOU!
glagomarsino@resultsfordevelopment.org
www.healthmarketinnovations.org

23. A study of informal
providers in two districts of
India
Dr. Meenakshi Gautham
Centre for Research in New International
Economic Order (CReNIEO), Chennai
Garwhal Community Development and Welfare
Society (GCDWS), Tehri Garhwal
Research Fellow LSHTM

24. Contents
Background
Our study
Results

25. Background

26. The demand side: providers of first contact
Providers of first contact, AP (a previous study)
Allopathic
practitioner
(94.8%)
Private
Public (3.2%)
(91.6%)
Same or Same or
nearby village Town (22.1%) nearby village Town (2.0%)
(69.5%) (1.2 %)
Source: Gautham et al. First we go to the small doctor: First contact for curative healthcare sought by rural
communities in AP and Orissa, India. Indian J Med Res 134, November 2011, pp 627-638

27. Bihar
First contact health providers in rural Bihar (previous study)
100%
90%
90%
80%
Village practitioner
70%
60% qualified private
doctor
50%
govt. facility
40%
30% Homeopathic/ayur/
unani
20%
10%
0%
Source: Dror et al. Household survey in rural Bihar -1000 households. Erasmus University, NL, and Micro Insurance
Academy, India. May-June 2010

28. Different mix of frontline health workers across different rural
locations
45.00%
40.00%
35.00%
Village practitioner
30.00%
Traditional healer
25.00%
Govt. facility
20.00%
Govt. health worker
15.00%
Ayurvedic/homeo./unani
10.00%
Private doctor
5.00%
0.00%
First contact health providers in rural Orissa
Source: Gautham et al. First we go to the small doctor: First contact for curative healthcare sought by rural
communities in AP and Orissa, India. Indian J Med Res 134, November 2011, pp 627-638

29. Our study

30. Study locations
• District Tehri Garhwal,
Uttarakhand state
• District Guntur
Andhra Pradesh state

31. Tehri was more rural with lower population density,
higher literacy but higher IMR, no medical colleges
Key features Tehri Guntur
Population density (sq km) 139.43 429.43
% of rural population 86.63% 66.11%
No. of inhabited villages 1,752 1,047
% of villages with 82.4% 1.45%
population size ≤ 500
% of adults literate 75.10% 67.99%
Monthly per capita Na 599.11
expenditure (UT=901) (AP=816)
Infant mortality rate 64 49
No. of medical colleges 0 3

32. Study objectives
• Identify and enumerate informal and formal
providers in the study areas
• Document IPs’ levels of education and training,
physical set up, mobility, practice characteristics,
and costs of services
• Assess knowledge and skills/performance
• Explore relationships with the formal health
system/providers
• Analyse barriers and facilitating factors in the
process of integrating IPs

33. Study samples and processes
1. Block selection
Guntur, 9 out of 57 blocks were selected by:
• Stratification into 3 clusters by level of development (low,
medium, high)
• Proportional sampling from each cluster (3 from low, 5 from
medium, 1 from high)
Tehri
• All 9 blocks were included
• Blocks also categorised into low (2), medium (5), and high (2)
using same criteria

34. Study processes..contd
Study objectives/key Study Processes
variables
Provider enumeration Provider identification through key village contacts, group
discussions with community members, and snowballing
technique. Surveyed market places and facilities.
Structured questionnaire for interviewing IPs
Education and training Interviews with all mapped IPs (368 in Guntur; 263 in Tehri)
Practice Interviews with all mapped IPs.
characteristics
Knowledge Interviews with a sample of IPs:100 in AP and 90 in Tehri.
Skills/Performance Patient-provider observations using an Observation tool with
the sampled IPs. (Description slide follows).
Relationships with In-depth interviews with sampled IPs, their associations,
formal sector professional doctors, health administrators

35. Knowledge and performance assessments
Conditions Protocols Knowledge Performance
• Fever • Adapted • Scores • Same
• Diarrhoea from WHO based on conditions
• Respiratory guidelines number of and
problems by 3 correct protocols
physicians responses • Observed
for each first 3
question consenting
patients for
each
condition
• Total 9
patients
per
provider

36. Example of knowledge and performance items
Knowledge question (interviewed) Performance item (observed)
What physical examination will you perform on a Checks for dehydration
diarrhea patient? -skin pinch for adults or
-abdomen pinch/sunken eyes/lethargy/ inability to eat or
Check for dehydration drink for children
-skin pinch for adults or
- abdomen pinch/sunken eyes/lethargy/ inability to 1=Yes; 0=No
eat or drink for children
Check fever (pulse or thermometer) Checks fever (pulse or thermometer)
Check BP 1=Yes; 0=No
Do nothing
Any other (please write verbatim) Checks BP
1=Yes; 0=No
0 =Incorrect (‘d’, or any other incorrect response) Any other examination (write verbatim)
1 = mentions any one of ‘a’, ‘b’ or ‘c’
2 = mentions any two of ‘a’, ‘b’ or ‘c’
3 = mentions any three of ‘a’, ‘b’ or ‘c’
90 =no response/doesn’t know

37. Results

38. Greater population coverage by IPs than formal
providers; greater in AP than UT
Greater population coverage by IPs than formal providers, greater in AP than UT
60 53.56
Tehri Garhwal
50 42.3
Ratio of IPs to popn 39.35
40 IPs per 100,000 pop
=1:2299 27.5
30
Doctors to popn 20 Private docs per
10 3.79 5.17 3.06 100,000 pop
=1:9599 0.54 0
0 Public docs per 100,000
Low Medium Highest pop
development development development
blocks blocks blocks
Guntur
70 63.77
Ratio of IPs to popn 60 52.32
=1:1941 50 38.63 IPs per 100,000 pop
40
Doctors to popn 30 18.82 16.65
=1:5412 20 Private docs per
10 5.44 2.52 3.99 100,000 pop
0.77
0 Public docs per
Low Medium High 100,000 pop
development development development
blocks blocks blocks

39. Differences in education and types of training
IP’s education and training Tehri Guntur
(N=263) (N=368)
Studied up to class 11 in school 94% 41%
Graduates 43% 10%
Held a health related diploma or certificate 93% 35.6%
Worked as compounder / assistant before starting 55% 100%
independent practice
Worked under a qualified doctor (with MBBS or MD 40% 91%
degrees)
Average number of years of apprenticeship 4 years 7 years
Mean number of years of independent practice in 10.5 years 13 years
the present location

40. IPs had strong local roots in both districts
Nativity and origin of the IPs Tehri Guntur
Born in the same block 51.50% 53.00%
Born in the same district (but 18.70% 41.00%
not in the same block)
Born in the same state (but not 10.30% 5.70%
in the same district)
Born in another state 19.50% 0.30%

41. Door step services in AP; clinic based in UT;
the key is proximity
IP characteristics Tehri Guntur
Type of practice
Mainly clinic 99.00% 31.25%
Mainly mobile 0.50% 39.40%
Clinic and mobile 0.50% 29.35%
Clinic location
Clinic at IPs’ residence 29.00% 37%
Mean distance of clinic from residence 2.3kms 1.3kms
Clinic operating hours
Open 7 days a week 90.00% 95.00%
Mean number of hours 9.4 hours 11.0 hours
Mobile provider characteristics
Mean hours of travel/day - 6.6hours
Mean distance covered - 2.1 kms

42. ‘I go from village
to village, house
to house ringing
my bell….’

43. AP: More prescribers, more ‘allopathic’ medicines
UT: More dispensers, more blended medicines
IP characteristics Tehri Guntur
Clientele
Average number of patients /day 14 17
Mean number of client households 367 604
Medical system followed
Treats only with allopathic medicines 33.00% 99.00%
Treats only with non-allopathic medicines 9.00% 0.50%
Treats with allopathic and non-allopathic 58.00% 0.50%
Provision of medicines
Only dispenses 42.00% 17.00%
Only prescribes 7.00% 48.00%
Mostly dispenses but also prescribes 49.00% 25.00%
Mostly prescribes but also dispenses 3.00% 10.00%

44. No significant difference in the knowledge levels
82.00%
79.60%
80.00%
78.00% 76.43%
76.00%
74.00% 72.79%
71.42%
72.00%
69.88% 69.67%
70.00% 68.50% Tehri
67.70%
68.00%
Guntur
66.00%
64.00%
62.00%
60.00%
Diarrhea Fever Respiratory Combined
conditions

45. Guntur IPs performed marginally but significantly
better; overall knowledge lower than performance
80.00%
72.82%
70.00% 65.79%
60.00% 55.57% 56.27%
53.22%
50.66%
50.00% 43.41%
40.47%
40.00% Tehri
30.00% Guntur
20.00%
10.00%
0.00%
diarrhea** fever respiratory * combined

46. Biggest difference – injections and medicines
Injections/ antibiotics Tehri Guntur
received by patients
% of patients that 13% 71%
received an injection
Mean number of 0.94 1.19
antibiotics received
% of patients that 19% 30%
received 2 or more
antibiotics

47. Relationships with the formal sector
Qualified doctors were the main source of new knowledge for more than
half of Guntur IPs
60
54
50
40
34 Medical reps
30 Qualified doctors
Medical journals
20 17 17
Mass media
10 8.1
4
0 0.5
0
Tehri IPs Guntur IPs

48. Relationships with the formal sector
Win-win relationships in Guntur
• 40.5% IPs received referral commissions from private doctors
• 7% received gifts -small medical equipment and sample medicines
• IPs’ confidence and faith in private doctors due to their perceived technical skills and
their interpersonal bonds
• Government doctors were IPs’ trainers in the state training programme, no signs of
overt hostility
• But IPs also perceived doctors as their biggest competitors; thus a double edged
sword
Hostility and lack of interaction in Tehri
• With only 5 private doctors within the district, IP referrals were directed equally towards
public facilities and private facilities, including in nearby towns outside the district
• Bitter experiences with health department officials, who demanded certificates and
diplomas and sometimes bribes.

49. The AP initiative
Registration with the State Paramedical Board / Act of 2006

50. Flexible One Year Training
1 year, bi-weekly sessions at nearby health facilities

51. Barriers and supporting factors
Barriers
• Legal obstacles and periodic court orders against ‘quacks’
• IPs not united or organised, not seen as a political force
• Weak support by local governments or political leaders
• Opposition/ambivalence of the formal medical fraternity
• Insufficient knowledge about IPs and their role, and what interventions?
Supporting Factors
• United and organised IPs have become a political strength in AP
• Strong political will displayed by AP’s former Chief Minister
• Win-win partnerships with the formal sector, especially private sector
• State level certification initiatives as in AP have set a useful example
• Increasing body of knowledge, support and pressure from local and international
health community

52. Conclusions and recommendations
• IPs on the margins of institutional frameworks, but their role is firmly
institutionalized
• IP markets have evolved in different ways in response to different contextual
influences
• IPs will continue to play this role for quite a long time
• Dispels the myth that IPs are solo providers. The have interactions
amongst themselves and with other formal sector providers
• Role of the apprenticeship model needs to be examined closely
• Interventions need to move beyond training now
• Universal health coverage provides a good framework, as it includes issues
of equity, quality, and calls for immediate as well long term strategies

53. Acknowledgements
Centre for Research in New Garhwal Community Development
International Economic and Welfare Society, Tehri
Order, Chennai, India Garhwal, India
Dr. K.M Shyamprasad Dr. Rajesh Singh
Dr. S. Srinivasan Ms. Rajkumari Singh
Ms. Anshi Zachariah Mr. Manoj Kumar
Ms. Premila Vijayraghavan Field research team
Dr. Lalitha & the field team All hospital staff
Mr. Christopher Singh
Crenieo training centre staff
Contact:
Meenakshi.gautham@lshtm.ac.uk
Gautham.meenakshi@gmail.com

54. Questions?