Can informal health entrepreneurs help increase access to health services in rural areas?


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New approaches to medical care can improve health outcomes (Credit: World Bank, Flickr)

In many poor countries, a large proportion of health services is provided by the private sector, including services to the poor. However, the private sector is highly fragmented and the quality of services varies widely. Private health markets consist of providers with very diverse levels of qualification, ranging from formally trained doctors with medical degrees to informal practitioners without any formal medical training. According to Jishnu Das, in rural Madhya Pradesh— one of the poorest states in India, households can access on average 7.5 private providers, 0.6 public providers and 3.04 public paramedical staff. Of those identified as doctors, 65% had no formal medical training and of every 100 visits to healthcare providers, eight were to the public sector and 70 to untrained private sector providers.

Often this reality has led health regulators to focus on “weeding out the quacks” and ensuring that only qualified providers are able to practice. However, as Jishnu’s research has shown, low effort among qualified providers can often reduce quality of care to the levels of untrained providers. Therefore, strict enforcement of regulation stipulating that only qualified providers may practice could lead to acceptance of low quality care, while pushing out good quality care. In this sense, a better approach might be to engage all providers and connect informal practitioners to qualified health professionals.

Last week we hosted an event with World Health Partners (WHP), an international NGO which identifies existing resources available outside the public sector. WHP helps supplement healthcare delivery to marginalized and rural communities, which constitute up to three-fourths of the population in developing countries, by creating an operational framework where providers can deliver care themselves or, when not properly equipped to do so, can serve as a conduit to higher-skilled providers and earn a commission in the process. Such a strategy is important since it makes it possible to creatively use informal providers who serve as the first point of contact for rural communities. The framework enables these providers to connect electronically with general practitioners and specialists concentrated in urban areas, thereby combining local social networks with remote technical skills and extending the frontiers of service delivery.  

Technologies and business networking are important ingredients to this framework. Opportunities to deliver curative care—the primary interest of the private sector – come bundled with the mandate to deliver preventative services. Scale is not only needed to address the extensive need but also to generate volume, which reduces costs and makes services more affordable for the rural poor. WHP’s largest project is currently being implemented in Bihar, India’s poorest state with a population of 104 million, where curative and preventive care is delivered through a network of 6,000 rural centers. The network will grow to 18,000 centers over the next 18 months with support from the Gates Foundation.

This approach is bound to be controversial and while it’s not without risks, it seems worthy of exploring given its potential impact. In particular, the type of approach pioneered by WHP could be replicated if an independent evaluation sheds light on the demand for these services; how often unqualified providers rely on the network’s technology as opposed to business as usual; the cost compared to more traditional approaches such as sending qualified providers to rural villages; and, most importantly, the impact on health outcomes.

As we advance towards a “science of delivery,” it will be critical to have a better understanding how markets for healthcare function and how they can work better for the poor. Understanding how to leverage existing providers, even when they lack formal qualifications, will inevitably be a key part of the puzzle.



Join the Conversation

Jorge Coarasa
June 13, 2013

Rob: thanks for your question. I don't think there is a one-size-fits-all answer as context will play a key role. These informal entrepreneurs currently exist, provide care and get paid by fees collected from users which as we know has important equity implications. One of the mechanisms being tested by WHP is having formal practitioners paying commisions for referrals while training and support is subsidized by the networking organization through support from the Gates Foundation. The equitly, quality and sustainability implications of this have not been evaluated and that is one of the aspects that would need to be better understood before replicating elsewhere. Training, recognizing and certifying these providers would open the door for them to be financed by mechanisms alternative to user fees. One other interesting experience is that of Accredited Drug Dispensing Outlets (ADDO) in Tanzania.

June 17, 2013

Hi, Congratulations for the wonderful article. I am a doctor and worked in Rural parts of UP (most populous) state of India. There is plethora of Private practitioners without formal medical training. They mainly practice in periphery so that government cannot raid them and can continue to practice & earn money. Their primary intention is to make money. Sometimes they will ill treat patient to such an extent and then refer them at the terminal stage. They treat patients with high costing antibiotics without knowing the proper indications of usage. lack of anti septic knowledge makes the patients vulnerable to injection abscess, which is very common.
On a positive side they are the boon for the rural people as the govt facilities are useless, may be due to lack of manpower, lack of drugs & lack of compassion and care. They tender to the people as they are easily accessible. And going to long distance to a good facility is difficult due poor infrastructure and roads.
Its would be a big challenge to tap these existing manpower and improve the quality of care as they might see it as a threat rather than opportunity. there also can be many more issues and challenges to tap into the network.
The question still remains..

Jorge Coarasa
June 17, 2013

Manan: Thanks for your comment. The issues you raise are very good examples of why the staus quo is not acceptable. You are right, engaging informal health entrpreneurs will be a huge challenge and we don't have good answers to many questions yet. Tackling this will require inputs from both trained doctors like you who understand the situation on the ground as well as the informal providers themselves and the patients they treat.

Rob Yates
June 14, 2013

A route away from UHC?
You are absolutely right Jorge, in flagging the inequities associated with point-of-service fees. The President of the World Bank had a lot to say about this in his speech to the World Health Assembly last month when he said:
“The issue of point-of-service fees is critical. Anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can drastically reduce their use of needed services. This is both unjust and unnecessary. Countries can replace point-of-service fees with a variety of forms of sustainable financing that don’t risk putting poor people in this potentially fatal bind. Elimination or sharp reduction of point-of-service payments is a common feature of all systems that have successfully achieved universal health coverage”
As the intention appears to be to scale up this project and therefore increase the role of point-of-service fees, how is this approach compatible with President Kim’s statement above?
Also aren’t you concerned that commission payments for these “informal health entrepreneurs” are likely to lead to supplier induced demand, resulting in poor people receiving unnecessary investigations and expensive treatments. I trust the commissions will not be based on a percentage of the final bill presented to the patient by the formal provider. Even with flat-rate commission there must be a danger that vulnerable people will be exploited by these incentives.
In your reply, you say that the equity aspects of this approach have not been evaluated yet. Might I suggest that you get on with this pretty quickly, because I fear that a health system based on this approach will take countries away from UHC.

Jorge Coarasa
June 14, 2013

Dear Rob: all excellent points that highlight the premise of the post: while engaging informal providers will be key, we need to evaluate current approaches before they are scaled up or replicated. WHP is an independent NGO that came to the WBG to present what they are doing, it is not a WBG or WBG supported program. The link to their web page is on the post, you may feel free to contact them directly.

Rob Yates
June 12, 2013

One question springs to mind Jorge - How and by whom will these informal health entrepreneurs by financed?