Thursday, April 25, 2013

Quacks, traditional healers and village doctors: Informal providers emerge as force in health care

An advertisement for a traditional healer in Zambia.
This piece was originally published on the PSI Impact Blog on April 9, 2013.
In my nine years managing social marketing programs for PSI in Africa, Asia and Latin America, I had two significant encounters with the category of health workers now known as “informal providers,” in Zambia and Bangladesh. In both cases, my PSI staffs and I decided to try to work with them because it seemed like folly not to work with them, given their numbers and their influence.

In Zambia, where I founded and managed PSI’s social marketing program, I became aware of the large and prominent role of traditional healers in the health system. They were everywhere – including where there were few or no formal providers – and were a respected part of the health landscape. Eventually, I became convinced that we should engage them in our HIV prevention condom social marketing program.

Realizing that traditional healers, like most players in the private sector, are motivated by financial gain, we recruited them as condom vendors, just as we had recruited wholesalers and retailers like pharmacies and grocery stores. Traditional healers saw condoms as a business opportunity and started out as good sales agents. Unfortunately, they were not always trustworthy business people: They insisted on buying on credit, but would not settle their accounts after making sales, so we had to terminate our relationship with them. Nonetheless, it was my first lesson in the importance of trying to engage traditional healers and other types of “informal providers” outside the formal health system, challenging though they could be.

Earlier this year, I started learning more about informal providers from the Center for Health Market Innovations (CHMI) which has supported studies of informal providers and focused a lot of attention on their contributions to health systems around the world.

In February, PLoS ONE published a systematic review supported by CHMI on the role of informal providers in developing countries. It found that people utilized informal providers in 9% to 90% all healthcare interactions, depending on the country, the disease in question and the methods of measurement. It also found that informal providers are referred to by at least 50 different terms, including village doctor, drug seller, traditional birth attendant, rural medical provider and quack.

In rural Mirzapur, Bangladesh, researchers from the International Centre for Diarrheal Disease Research working with CHMI found that informal providers outnumber formal providers by 12 to 1. They are practitioners without government-recognized training or registration and include allopathic providers such as drug sellers (also called village doctors), homeopaths, herbalist and faith healers. By some estimates, informal providers comprise close to 96% of health care workers in rural Bangladesh.

In the late 1990s, I was the PSI country representative in Bangladesh, working at the Social Marketing Company (SMC), where I learned of the vital role played by rural medical practitioners (RMPs) in our social marketing program. In 1974, when PSI started SMC, oral contraceptives were not an instant success. Waning sales of the Maya oral contraceptive pill forced PSI to reexamine its rural marketing strategy and discovered that by ignoring RMPs, they had turned RMPs against Maya.

“The RMPs were blaming everything from menstrual cramps to sprained muscles on Maya and they were advising women to stop taking the pill,” wrote Robert Ciszewski, the first PSI country representative in Bangladesh who now serves on the board of directors of DKT International. “The project decided to act to bring RMPs into our camp. A series of training classes complete with certificates of completion was planned … The reaction was quick and positive. They were an important and influential part of rural society, and should have been included from the beginning. Since that time, they have never wavered in their support of us, and have been a potent factor in the success of our rural marketing efforts.”

In 2012, SMC produced 3.65 million couple years of protection. It calls itself the largest privately managed, not-for-profit social marketing organization in the world.

Four myths about informal providers

In the course of three studies, CHMI learned several things that debunk the popular perceptions of informal providers:

They are not “quacks” flying under the radar. Popular opinion has portrayed informal providers as illegal providers keeping a low profile to avoid government regulation. However, informal providers are generally trusted and respected members of the community — often considered social elites.

They are not school drop-outs. They may not hold advanced degrees, but informal providers are far from school drop-outs with only primary levels of educations. The three studies have demonstrated that the majority are relatively well-educated, completing secondary levels of schooling and beyond. Some even hold graduate or professional degrees, though not necessarily in medicine.

They are not untrained and inexperienced. While it is true that the duration, formality and content of training undergone by informal providers vary widely, most practitioners have some form of training. Moreover, many have served as apprentices in addition to or in place of partaking in formal courses.

They are not disconnected from the formal system. Although they do operate outside of the formal system, informal providers often have well-developed ties to the formal sector for medical information, drug supplies and referrals. In fact, some of them receive gifts and commissions from formal sector providers for referring patients to their facilities.

CHMI is starting a discussion group on informal providers to create an open forum to share relevant reports, articles, tools and stories about projects and harnessing informal providers. If you are interested, you can sign up at 

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