informal markets
TRANSCRIPT
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UNDERSTANDING & INTERVENING IN INFORMAL
MARKETS IN HEALTH
LIGHTNING TALKS FROMFUTURE HEALTH SYSTEMS RESEARCH CONSORTIUM
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Understanding Informal Markets: a Framework for Analysis
Gerald Bloom
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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
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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
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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
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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
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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
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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)
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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
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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
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Knowledge economies
Understandings of expertise and legitimacy
Practices of boundary making and fuzzy boundaries
Acknowledging the existence of hybrid practices
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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’
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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
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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
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“LIGHTNING” RESPONSES
• Other ideas• Comments• “Big questions” for later discussion
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Exploring the Effect of Drug Detailing on Village Doctors in Chakaria, Bangladesh
M. Hafizur Rahman
Who are the Village Doctors?
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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
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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
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Study sites
84 village doctors (44%) and 43 MRs (17%) of the study areas
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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
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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”
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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.”
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Incentives offered Grades the health care providers as A, B,
C, D (A+, A++ if exceeds the expected number of prescriptions)
IncentivesDiscounts/Samples –usually 2-3%. Gifts (e.g. chair, stethoscope, mobile phoneCredits – pay back time varies from 5 days to
1-3 months. Small companies - flexible credit limits
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Characteristics of Medical Representatives and Village Doctors
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N=43 N=83Age (in years) Mean (+SD) 31.1(+4.8) 38.5(+12.4) <0.01Family size Mean (+SD) 4.7(+2.4) 5.8(+3.2) <0.05Monthly household expenditure Median (in Taka) 13,000 8,000 <0.001Education 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.
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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
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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)
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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
Formal28%
Independent Operators
63%
Faith Healers9%
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 Suffered29 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 suffered22 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 -25Govt. healthcenter/hospital (8)MBBS doctor (7)Kabiraj (4)Drug seller (4)Hujur (1)Homeopath (1)
Total number of women -14Govt. health center/hospital (5)MBBS doctor (3)Hujur (2)Drug seller (2)Village doctor (1)Hawker drug seller (1)
Total number of women -7MBBS doctor (3)Drug seller (2)Homeopath (1)Govt. health center/hospital (1)
Itching, irritation and smelly discharge43 suffered the problem. 26 received treatment
Total number of women - 26MBBS doctor (7)Homeopath (5)Kabiraj (4)Drug seller (3)Govt. health center/hospital (3)Village doctor (2)FP worker (1)Family member (1)
Total number of women -10MBBS doctor (4)Hujur (3)Govt. health center/hospital (2)Drug seller (1)
Total number of women -6MBBS doctor (3)Drug seller (1)Govt. health center/hospital (1)Family member (1)
Prolapse37 suffered the problem. 17 received treatment
Total number of women --17Kabiraj (6)Govt. health center/hospital (4)MBBS doctor (4)Village doctor (1)FP worker (1)Family member (1)
Total number of women -7MBBS doctor (3)Hujur (1)Village doctor (1)FP worker (1)Govt. health center/hospital (1)
Total number of women -4MBBS 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
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How can PMVs provide better access to effective malaria prevention & treatment services?
The Central Question
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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
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Proportion of total volume of all anti-malarials sold or distributed in the 1 week preceding survey
(Source ACTWATCH, 2010)
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54 Different Types of Anti-malarial Drugs Found
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Percent of Patent Medical Vendor Shops with Anti-Malarial Drugs
0
10
20
30
40
50
60
70
80
90
100
ACTs Monotherapyartusenates
Chloroquine Sulfadoxine-pyrimethamine
Other
Perc
ent o
f Sho
ps
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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
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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
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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
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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
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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
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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
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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
0500
1000150020002500300035004000
Month
1st A
NC v
isit
Intervention Control
Institutional Deliveries-Kamuli District
0100200300400500600700
Month
Del
iver
ies
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
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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
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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
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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
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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
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Impact
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93.9 92.487.1 91.7
0
20
40
60
80
100
Shasthya Sena Non-Shasthya Sena
% o
f pre
scrip
tion
BaselineEndline
P<0.001P>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 O Proportion of harmful
drug advice increased among both the groups. However, the increase was lower in the SS group
O 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
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Concluding Remarks O Existing Village Doctors are enthusiastic about joining training
programmes and are keen to learn
O 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
O 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
O 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
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