Improving provider performance: innovative strategies in Bangladesh, India and Nigeria

Poor quality and high costs are associated with the informal provision of health care. This has led to a search for innovative strategies to improve performance. New research on interventions in Bangladesh, India and Nigeria provides learning about different ways to achieve this goal.

Poor people often use informalproviders for health care. In Bangladesh formally trained workers account foronly five percent of providers. The private sector comprises around 180,000informal providers practising modern medicine as village doctors and/or drugvendors.

More than 70 percent of India’spopulation is rural yet more than 70 percent of its medical professionalspractice in the urban and affluent private sector, or have migrated overseas. Fewerthan 50,000 doctors work in rural primary and secondary health care facilities.Health care in rural areas is delivered mainly by under-trained staff, oftenreferred to as rural medical practitioners or the informal private healthsector.

In Nigeria, self-treatment of commonillnesses using drugs purchased from patent medicine vendors (PMVs) iswidespread and is the most common sourceof malaria treatment in Nigeria.

An ICDDR,Bstudy in Bangladesh found that villagers, social leaders, health care providersand drug vendors perceived village doctors to be an essential source of healthcare in poor rural areas. However, there was some concern about the quality ofcare. Village doctors need better access to up-to-date medical information andtraining opportunities. As a result ICDDR,B have put in place an interventionthat is testing a manual and a training programme to try to improve informalprovider’s treatment of common illnesses. They are also working to create anetwork of informal providers - Shaysthya Sena or Health Force - whose members are expected to adhereto agreed quality standards for:

appropriatenessof treatment

reduction inprescriptions of harmful drugs

timely and appropriate referrals.

Compliance will be monitored bya local health watch group, composed of members of the ShastyaSena network, government administration, civilsociety, peers and experts.

Recognising the potential of theinformal sector, India's National Rural Health Mission and the Eleventh PlanApproach Paper have called for innovative partnerships with informal providersto improve quality of care at the frontline. First Care Health is a socialenterprise with rural medical practitioners which is currently being piloted bythe Indian Institute of Technology’s Rural Technology and Business Incubator inrural Tamil Nadu. They have given rural practitioners computers and internettechnology as well as distance learning and other support.

Researchers from the University of Ibadan in Nigeria found that most PMVs would like stronger governmentregulation to reduce the availability of fake drugs, while nearly a quartercalled for self-regulation through professional associations.

Over 90 percent of vendorsthought it was a good idea to involve community members in monitoring thequality of drugs – a view echoed by government. University of Ibadan is working in Oyo State to try and increase consumer knowledgeand expectations for consumer rights, including the creation of effectiveregulatory partnerships for ensuring the quality and affordability of drugsupplies. Their research has drawn interest from government who would like tostrengthen the communication of drug policy and regulation to PMVs andunderstand the mechanisms by which they can work together to identify andremove substandard and counterfeit drugs from the market.

Theseinterventions have adopted a learning approach to try and better understand thepotential positive benefits of linking informal providers, communities,knowledge brokers, researchers and policy makers. Potential outcomes of theseinterventions in Bangladesh, India and Nigeria include:

moreempowered informal providers

betterinformed government actors

morerelevant locally devised and owned educational tools

strongerand formalised links between civil society, government and the informal sector.

Interventionsand policies to strengthen health systems that fail to acknowledge informalproviders as a potentially key source of services for poor people seem destinedto be less than optimal. Mechanisms for improving performance, like thosementioned above, will differ depending on context and existing capacity and technology. However they will provideuseful evidence on the potential of non state actors to improve access tobetter quality health care.