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| An advertisement for a traditional healer in Zambia. |
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.
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