1. 'Tackling the shortage of HRH :Are Informal Health Providers the solution?' Examples of health sector engagement with informal providers. 14:00-16:00. Organized by NHRHO Asma ElSony Modified from Prof S Bertel “Bertie” Squire Feb 2013 Presentation on Triage-Plus Dissemination Meeting, NHRHO Khartoum, and personal experience

2. Overview 1.Experience with engagement of informal providers in health care prior to Triage-Plus People the asset for Investment S Africa Kenya Malawi 2.Recent systematic review on the role of informal providers in developing countries 3.Conclusions

3. European Union Total FDI: 52% of world total USA (Total FDI: 21% of world total Japan (Total FDI: 5% of world total Concentration of global FDI Source: based on data in UNCTAD, 2001

4. Diversity of total FDI inflows within the developing world Source: United Nations Conference on Trade and Development (UNCTAD) Online Databases, Feb. 2006

5. WB Report 1993Health Health is essential for growth and economic development and access to sustainable development The remarkable improvement in health in E Asian countries & miracle on health Performance indicators, was due to the accumulation of Human Capital Through education info and K and investing in Health. Addressing health policy, issues of health as an inclusive right is not limited to the provision of appropriate health care in a timely manner, but also to provide underlying determinants of health, to ensure the active participation, in economy & development.

6. From a TB Unit to …The STOP TB Partnership The STOP TB Partnership with the aim to improve global tuberculosis (TB) control through expanding access to the Union’s model of directly observed treatment short course (DOTS) strategy. Advocated the approach of 'Engaging all Care Providers in the EDS.

7. Figure 1: Age distribution in health institutions Asma ElSony, MD, DTCD PhD,1& Gunnar Bjune, M.D., PhD,

8. Figure 2: Case finding in health facilities Asma ElSony, MD, DTCD PhD,1& Gunnar Bjune, M.D., PhD

9. Asma ElSony, MD, DTCD PhD,1& Gunnar Bjune, M.D., PhD Figure 3: Trend in location of diagnosis in women

10. Asma ElSony, MD, DTCD PhD,1& Gunnar Bjune, M.D PhDs., Figure 4: Age distribution in PHC facilitie (1997-2000)

11. Hlabisa 1991-1995 Formal Sector health workers least effective supervisors (79% completion) Laypeople (85%), CHWs (88%) or Storekeepers (84%)(p=0.0008) South Africa – who observes TB treatment (DOT supporters)

12. Kenya – improving malaria home treatment Over the C

13. 3 districts Kenya–: random allocation to the Intervention (Training Private AM sellers): improving malaria home treatment

14. PMV Practice Pre & Post Intervention for simple and Complicated Malaria, simulate visits 2003, 2004

15. Poverty indicators/area – Lilongwe (Malawi)

16. n=179 patients Poverty measured against Integrated Household Survey (IHS) - 72% poor Patient costs for TB diagnosis (US$) [Urban] When a woman or when the poor are sick, the opportunity costs faced by their households are greater. On average, patients spent 13 US$ or 18 days’ income; lost 22 days from work while accessing a TB diagnosis. For non-poor patients, the total costs amounted to 129% of total monthly income, or 184% after food expenditures. For the poor, this cost rose to 248% of monthly income or 574% after food.

17. Patients made multiple visits to store-keepers

18. Terms for Informal Providers Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D (2013) What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review. PLoS ONE 8(2): e54978. doi:10.1371/journal.pone.0054978 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0054978

19. Conclusions 1.Informal providers can provide a bridge between poor patients and formal health services for a variety of health care issues 2.More work needed to build consensus on definition of informal provider and understanding of most effective role in health care provision 3.Growing momentum to use robust, randomised intervention designs to further develop and test effectiveness and cost- effectiveness of engaging informal providers

20. Thank you