nnovationin Informal Health Market in Bangladesh

Innovations in informal health market in Bangladesh

Outline

• Who constitute healthcare providers• Health seeking behavior• Quality of services • Challenges and opportunities

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Data Sources• ICDDR,B study in 2006-07 in Chakaria, a sub-district • Bangladesh Health Watch survey

(nation wide) in 2007

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Health Care Providers in Chakaria, Bangladesh, 2006

Population (560,000) Per 10,000

Formal (4%) 2.00

Qualified Physician (Regular) 39 .70Qualified Physician (Guest) 20 .36Sub-Assistant Community Medical Officer (SACMO-Paramedics) 7

.13

Family Welfare Visitor 13 .23Midwife (ICDDR,B Trained) 12 .21Family Welfare Assistant (Trained on midwifery by government) 13

.23

Nurse 8 .14Informal (96%) 43.64

Village doctor (Allopathic) 328 5.86Village doctor (Homeopathy) 174 3.11Kabiraj (Traditional) 289 5.16Religious/spiritual healer 694 12.39

Traditional birth attendant 959 17.13

TBASpiritual Healer

Village Doctor

Homeopath

Formal sector

Kabiraj

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Prevalence of Illness, Chakaria, 2007

43.5% of the 6,162 individuals included in the community survey reported suffering from some kind of illness during the 14 days preceding the

survey. Wave of Viral Fever

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Sources of First Line of Care, Chakaria, 2007

Source of healthcare %

Village doctors/Pharmacy 50.3

Home remedy 23.3

MBBS 10.6

Homeopath 8.1

SACMO* 4.7

Spiritual healers 1.1

Others 1.9

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* SACMO=Sub assistant community medical officer

Use of Physicians and Village Doctors by Poor and Better Off, Chakaria, 2007

0

20

40

60

80

100

MBBS Village Doctors

%

Lowest quintile2nd3rd4thHighest quintile

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Circumstances Preferring Physicians and Village Doctors, Chakaria, 2007

• MBBS doctors for perceived severe conditions

• Villager doctors for not so severe conditions

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Reasons for Choosing Village Doctors, Chakaria, 2007

Reasons for choosing the health care provider (n=340) %

Quality of treatment is good 69.5Nearest health care provider 42.5Low treatment cost 17.3Well behaved health care provider 17.3Treatment cost on credit 14.6No other health care facility available nearby 5.8Health care provider is a family member or a relative or a known person

5.6

Advised by the neighbors or others 0.4

Multiple responses recorded

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Why are the Village Doctors So Popular?Chakaria, 2007

 • They are always available• In case of emergency they go to the patient’s

house• They charge lower consultancy fee • They refer patients to other doctors if and when

needed• Patients can get medicines according to the

money they have

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Use of Drug for Treating Diarrhoea, Fever, and ARI by the Village Doctors, Chakaria, 2006

Inappropriate 75%

Appropriate 18%Harmful

7%

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Shortage of physician, nurse and technologist, Bangladesh, 2007

Gap between the need as per WHO recommendation and existing numbers

Source: Bangladesh Health Watch 2008

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Summary Situation

• Village doctors are the most dominant group practicing modern medicine

• Village doctors are popular among patients from all socioeconomic strata

• Patients seek care from village doctors with the belief that they are receiving quality care

• The quality of services provided by the village doctors are questionable

• Increasing the number of MBBS doctors in the immediate future does not seem feasible.

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A Few Questions???

• What are the possible solutions for immediate future?

• Who do we resort back to in order to ensure health care for the rural people?

• Can we make use of the vast army of village doctors? How?

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Working with the Village Doctors to Make Health Systems Work for

the Poor in Bangladesh

Why Village Doctor?• Has been in existence for long• Dominant first line healthcare provider

– 62% of the service providers using modern medicine are Village Doctors

– Majority villagers contact them first for treatment

• Live in the rural area• Acute shortage of formally trained providers• Unlikely to have enough number of trained provider in the

foreseeable future• Can work as a link between the formal sector and the

villagers• Has the potential to bridge the transition from informal

system to formal

Challenges

• Quality of services • Accountability

Need for a Model

In Search of a Model - Interventions

Component ActivityQuality of service Training

Accountability Watch

Reward, consolidation, promotion

Branding/Franchising

Quality of Services - Training

Content of training• DOs and DON’Ts for managing:

Pneumonia, diarrhea, viral fever, malaria, hepatitis,APH, Obstructed labour, PPH

• DOs and DON’Ts in using Antibiotics and Steroids

• Referral and information about referral

Cover page of the booklet

Accountability – Union Health Watch

Composition• Elected representatives• Social leaders• Representative of Village

Doctors

Activity• Orientation of healthcare

system, drug, major health problems, monitoring techniques

• Monitoring performance of Village Doctors

• Meeting once a quarter• Provide feedback

Branding – Shysthya Sena

Network of Village Doctors –

Shysthya Sena

• Membership criteria– Adherence to desired

agreed practices– Maintenance of records– Physical facility

• Yearly assessment by oversight committee

• Public recognition• Badge, stationery, logo,

sign etc.

Committee and its function

• Village Doctors, Health and Administration, local government, civil society

• Quarterly meeting• Decide guidelines for

operation and assessment• Oversight of the quality of

services• Awarding of reward

Phases of Activities

• Phase I – Pilot (Ongoing)• Phase II – Impact evaluation (2009 +)• Phase III – Scale Up

Thank You