1. Informal providers – an overview Dr. Meenakshi Gautham Hon. Research faculty, CRENIEO, India Research fellow, London School of Hygiene and Tropical Medicine

2. Outline The importance of informal providers within health systems in LMICs Definitional criteria Extent and utilization in different countries Issues for discussion in the agenda Workshop objectives and deliverables

3. Health systems in LMICs Mixed public and private healthcare financing and delivery Private sector as source of healthcare exceeds the public sector South Asia : 79.3% Latin America : 66.3% Sub-Saharan Africa : 50.8% (DHS analysis of 48 countries – Montagu, 2008)

4. The real truth.. A recent systematic review of public and private healthcare systems: When the private sector included unlicensed physicians, it was found to provide the majority of coverage for low-income groups, but when only licensed providers were included, the public sector was found to be the main source of healthcare provision in low- and middle income countries. Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D (2012) Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 9(6): e1001244.doi:10.1371/journal.pmed.1001244

5. Informal providers – definitional criteria Training: Not from formal sources. Payment: Collect payment from patients served, not from institutions. Chiefly entrepreneurs. Registration and regulation: Typically not registered with any government regulatory body. Professional affiliation: Very few have any associational membership. -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

6. Who are informal providers? Drug sellers -May operate beyond their legal capacity; -Regulatory infringements are common. Village doctors and traditional practitioners: -May have practices similar to licensed allopathic physicians; -May use combinations of biomedical and non-biomedical medicines or only biomedical ones; -More likely to be used by rural populations Traditional Birth Attendants Community Health Workers

7. Hidden yet pervasive Extent of informal providers Bangladesh: 87% informal Rural Chakaria: 96% informal India : 51-55% informal Uganda: 77% informal - 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

8. Greater population coverage by IPs than formal providers in India Tehri Garhwal Ratio of IPs to general population =1:2299 (1:1867 – 1:2363) Doctors to population =1:9599 (1:3267 – 1:23040) Guntur Ratio of IPs to population =1:1941 (1:2588-1:1568) Doctors to popn =1:5412 (1:4843 – 1:16072) -Gautham et al, HPP, 2013

9. Utilization First choice, exclusive choice or played any role in healthcare  Bangladesh : 60%-77%  India (RMPs/village practitioners) : 19% - 54%  Kenya (CHW/traditional practnr/drug seller) : 9%-33%  Thailand (drug sellers): 55% - 77%  Uganda (drug sellers/traditional healers) : 35%-62%

10. In India 90% of informal providers are in rural areas (DeCosta and Diwan, Health Policy 2007) Frequent providers of first contact care (George et al, SSM, 2013; Gautham et al, IJMR, 2012) Of every 100 provider visits in rural areas, 70 -90 may be to an informal provider (Das et al, Health Affairs, 2012; Gautham et al, IJMR, 2012)

11. Questions for further discussion Quality and capacity building Drugs Incentives Regulation and licencing Legal issues

12. Workshop Objectives Enable an exchange of learning across implementers, policy makers and researchers. Identify barriers to integration of informal providers, and determine concrete strategies that policymakers and implementers can employ to harness informal providers substantially. Discuss and agree upon a few action points for further collective action and advocacy by this group.

13. Workshop Deliverables Broad steps for developing a substantial and large scale programme with IPs in one state in India. A joint advocacy statement that can be published as a global health blog or an article Plans for 1-2 joint publications based on current presentations. Identify a few areas for future research that can support the evidence base for IPs’ integration. Any others?????