Informal markets

1
UNDERSTANDING &
INTERVENING IN INFORMAL
MARKETS IN HEALTH
LIGHTNING TALKS FROM
FUTURE HEALTH SYSTEMS
RESEARCH CONSORTIUM

3
Understanding Informal Markets: a
Framework for Analysis
Gerald Bloom

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

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

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

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
The Underground Rural Healthcare
Market: The case of Rural Medical
Practitioners in India
Barun Kanjilal

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?

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

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

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
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

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

Knowledge economies
 Understandings of expertise and
legitimacy
 Practices of boundary making and
fuzzy boundaries
 Acknowledging the existence of
hybrid practices
15

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

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
Informal providers in low and middle
income countries - A review of the
effectiveness of interventions
Nirali M. Shah

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

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

Interventions by medical condition

Direction and type of outcome for FP/RH studies

Percentage of provider behavior and knowledge outcomes that
are positive, by type of provider

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

“LIGHTNING” RESPONSES
26
• Other ideas
• Comments
• “Big questions” for later discussion

27
Exploring the Effect of Drug Detailing on
Village Doctors in Chakaria, Bangladesh
M. Hafizur Rahman

Who are the Village Doctors?
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

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

Study sites
 84 village doctors (44%) and 43
MRs (17%) of the study areas
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

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

 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

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

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

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

38
Informal Markets in Sexual and Reproductive
Health Services and Commodities in Rural and
Urban Bangladesh
Sabina Rashid, Hilary Standing and Owasim
Akram

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

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

Characteristics of the providers (2)
41
 Formal (n=84)
(Govt./Private/NGO Hospitals,
clinics, Privately practicing MBBS
doctors)
 Independent Operators
(n=191)
(Village doctors, pharmacist,
homeopath, birth attendants,
roadside healers, kabiraj, hakim
etc.)
 Faith Healers (n=28)
(Ojha, pir, fakir, hujur etc.) Type of Providers
Formal
28%
Independent
Operators
63%
FaithHealers
9%

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

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

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)
Govt. health center/hospital
(5)
MBBS doctor (3)
Hujur (2)
Drug seller (2)
Village doctor (1)
Hawker drug seller (1)
MBBS doctor (3)
Drug seller (2)
Homeopath (1)
(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)
(3)
Village doctor (2)
FP worker (1)
Family member (1)
MBBS doctor (4)
Hujur (3)
(2)
Drug seller (1)
MBBS doctor (3)
Drug seller (1)
(1)
Family member (1)
Prolapse
37 suffered the problem. 17
received treatment
Total number of women --17
Kabiraj (6)
(4)
MBBS doctor (4)
Village doctor (1)
FP worker (1)
Family member (1)
MBBS doctor (3)
Hujur (1)
Village doctor (1)
FP worker (1)
(1)
MBBS doctor (3)
Drug seller (1)

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.

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

Promoting improved performance of Private
Medicine Vendors in providing access to
appropriate drugs for malaria in Nigeria
Oladimeji Oladepo

48
How can
PMVs
provide
better
access to
effective
malaria
prevention
& treatment
services?
The Central Question

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

50
Proportion of total volume of all anti-malarials
sold or distributed in the 1 week preceding
survey
(Source ACTWATCH, 2010)

51
54 Different Types of Anti-malarial
Drugs Found

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

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

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

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

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

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

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

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

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.

Intervention: Quasi-Experimental
Vouchers
for
transport
Vouchers
for
maternal
services
Maternal & newborn
health services
Pregnant
women &
newborns
in control
Maternal & newborn
health services
Training
Supervision
Supplies,
drugs and
equipment
Pregnant
women &
newborns in
intervention

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

Institutional Deliveries-Kamuli District
0
100
200
300
400
500
600
700
jan'09
feb'09m
arch'09april'09m
ay'09june'09
july'09aug'09sept'09
oct'09Nov'09DEC
'09JAN'10FEB'10M
AR'10APR'10M
AY'10JUN'10
Month
Deliveries
Intervention Control

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

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

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

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

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

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

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)

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

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

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73

Informal markets

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