Background
Informal health care providers (informal providers) are the providers who engage in health activities for which they do not possess official qualification or permit [
1]. Their informality can be identified by their training, business model, registration and regulation as well as professional affiliations [
1]. In Bangladesh, the term refers to those who are not registered with any government regulatory body, therefore operate beyond government’s oversight [
2]. They comprise of a range of providers including community health workers (CHWs), informal (unqualified) allopathic providers (e.g. village doctors and drugstore sales people/ drug vendors), traditional healers, non-secular faith healers, traditional birth attendants and homeopaths [
2]. Generally, they do not receive any training from any recognized medical training institution; however, workshop, seminar, and apprenticeships are their typical learning platforms [
2]. CHWs for example, either the ones who are posted by government or non-governmental organization (NGO), commonly receive a wide range of basic preventive and curative care training provided by the government or affiliated NGOs [
2]. Informal providers’ practices are usually small and localized, and dependent on the maintenance of good networking and relationships with the communities [
2]. Whilst most unqualified allopathic providers and homeopaths provide services through drug shops, CHWs and traditional healers provide door-step services [
2]. Because their main responsibility is to deliver health promotion and education, CHWs are not supposed to provide curative care even if they are part of the formal public service delivery [
3]. Thus, when they do, their practices become that of informal providers.
Albeit their neglected role, informal providers are vital in bridging the gaps between allopathic and traditional medicine through the services they provide [
4]. They constitute a significant component of the health system in most low- and middle-income countries (LMICs), including in Bangladesh [
1,
4]. In contrast to the small number of qualified providers, it is estimated that 44% of total health workforce in Bangladesh are traditional healers, 23% are traditional birth attendants (trained and untrained), 8% are village doctors, and 8% are drug sellers [
5]. Due to this significant shortage and unequal distribution of qualified providers in the formal health system, people are often left with the option to seek care from informal providers, especially the poor and the disadvantaged [
5]. In addition, informal providers regularly serve as the first point of contact for most patients as they share common values and norms, reside close to the community, and thus more accessible and affordable [
2,
6,
7]. In rural Bangladesh, around 65% of primary health care is provided by informal allopathic providers [
8]. Similarly, the most prevalent form of health care providers in the urban and peri-urban areas appeared to be this type of providers [
9].
Clinical practice guideline is a proven tool that can improve the quality of care delivered to the patients [
10]. In limited settings like Bangladesh, it offers an aid whereby the health workers adhere to essential practices [
11]. In child health, World Health Organization (WHO) established guidelines for preventing and treating diarrhoea and pneumonia among children [
12], which have proved to be effective in improving children’s health outcomes [
13]. In similar vein, Bangladesh government with the support from WHO created a national guideline for management of hypertension cases, which has been tested and demonstrated to be useful to the primary care physician [
14]. Unfortunately, informal providers may not have access to such guideline, leading to incorrect diagnoses and treatment care which may not be appropriate [
15].
Appropriate care, defined as “
care that is effective, efficient and in line with ethical principles of fair allocation” [
16] is a concern for health systems across the world [
17‐
21]. Inappropriate care in the form of under-use, misuse and over-use of healthcare services are recognized as a barrier to quality of care that lead to poor health outcomes [
22]. In addition, rational use of medicine –
“patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community” [
23], is also a problem in Bangladesh and elsewhere, even in the formal sector [
11,
24]. Irrational use of medicine poses serious public health consequences, including treatment failure, increased adverse drug events and accelerating rates of antimicrobial resistance as well as catastrophic health expenditure [
25].
Informal providers are significant actors in Bangladesh health system and their role cannot be ignored in the effort to increase effective coverage of health care services, especially in low-income urban settings [
9]. It is important to understand their knowledge and practice - how they perceive appropriate care and rational treatment, so they can be more effectively engaged in the delivery of health care services. The current study aims to fill-in this knowledge gap, using qualitative approach undertaken in two peri-urban settings in Bangladesh. However, this is a small-scale study which provides the ground for a further exploration.
Results
A total of 13 IDIs were carried out with the informal allopathic providers, six from Kamranghirchar and seven from Savar. Among the respondents, only one female provider was interviewed. Most providers aged more than 40 years-old with more than 5 years of professional experience. In terms of education, four of them completed tertiary education, seven completed higher secondary (grade twelve) education, and the rest only had secondary education (grade ten). On an average, half of the providers consulted between ten to twelve patients per day, while two of them consulted more than twenty patients daily.
Current practices
Diagnosis practices
Nine out of the thirteen interviewed informal allopathic providers mentioned that knowing the history of the disease and understanding the presenting symptoms were the primary tools for diagnosis. One provider described the process below:
“As allopathic treatment is based on signs and symptoms, I try to identify the disease mainly based on the symptoms and from my experience. For example, in case of diarrhea, if the stool smells very bad I understand that it is due to food poisoning. Also, I consider patient’s age and the severity of the disease”. (IDI-1, Section 2.B).
Eight providers also referred to some physical measures such as blood pressure, pulse rate, and body temperature for diagnosis. According to a respondent:
“I consider few essential things in my diagnosis process and those are- first, the history of the disease and the duration of the disease, blood pressure, body temperature and any other thing that is needed for a particular problem. By this way, I try to understand the severity of the disease. Then I prescribe the necessary drug”. (IDI-2, Section 2.B).
Guidelines followed
Six interviewed providers directly confessed they did not have any guideline from the government or other institution which they followed in their practice. However, they adhered to the written and verbal guidelines and suggestions from pharmaceutical companies’ representatives, even when they did not quite understand the rationale of those suggestions. Meanwhile, four providers were aware of some existing guidelines. Nevertheless, they did not use them, as they felt confident with their ability to diagnose and provide treatment due to their long working experience. Furthermore, four providers mentioned that their ethics were their best guideline, as stated by a new provider who had been in the job for less than 5 years:
“I do not have any guideline that I can follow. To me, my ethics is my strong guideline in giving medicine and treatment to my patients, as they trust me”. (IDI-8, Section-2.C).
Prescription practice for specific health conditions
In the current study, the providers’ prescription practices were explored for three common health problems in Bangladesh. The practices are described below.
Basis for determining medication dose
The prevailing perception among providers regarding dose determination was to consider patients’ age and the anthropometric measure i.e. weight for children. However, only four providers strictly considered age or weight to determine the dose. As a respondent stated:
“Mainly it depends on both age and weight. But if the age is less than ten years-old, the weight is the main factor to consider”. (IDI-10, Section 2.A).
Besides this, three providers considered patients’ physical condition, which could be determined by observing the patients. Only one provider with less than 3 years of experience mentioned that disease’s severity along with the duration of the disease was the main factor in determining the dose, as stated:
“It depends on the age, weight and severity of the disease, but the severity of the disease is the vital factor. For instance, if it is a normal case, in terms of antibiotics, we suggest one spoon. If it is severe we suggest two spoons and if it is really severe we give three spoons, but never more than three spoons for children”. (IDI-11, Section 2.A).
Referral practice
Nine providers mentioned that they would refer patients to specialized doctors or hospital when they could not identify the disease. If the patients did not want to go to the hospital and compelled them to give treatment, which was common, they would provide basic treatment as per their knowledge. Afterwards, if the patient’s condition did not improve or even worsen after taking the treatment for around 5–6 days, they would again refer the patients to the hospital. In case of emergency, all providers would encourage the patients to go to the hospital.
“Yes, if I cannot manage, I refer to specialist doctor or hospital. When the patient’s situation is severe, I must refer. I even arrange appointments with the doctor that I know over phone sometimes”. (IDI-6, Section-3).
Underlying perception and knowledge, and source of information
Perception of appropriate treatment
Nine out of thirteen informal allopathic providers reported that correct diagnosis based on history, symptoms and signs as well as appropriate medication were the key elements of appropriate care. Referring to specialist doctors or tertiary hospitals for treatment was another important aspect mentioned, when the disease could not be identified or in case of an emergency. One provider with more than 15 years of experience said that:
“To know the disease condition correctly by listening to patient’s disease history, making diagnosis and then providing appropriate drugs is the appropriate treatment. If I cannot detect the problem, to refer to the doctor or hospital is also part of my appropriate treatment”. (IDI-4, Section-2. A).
Five providers also mentioned that identifying the exposure to the disease was the key point in providing the right treatment to patients. Moreover, one provider stated that providing accurate dose of medicine was an important part of treatment to avoid excessive drug prescription. Additionally, few providers mentioned that appropriate treatment could only be ascertained when patients recovered from their illnesses. One respondent with more than 10 years of experience stated that:
“If patient get well after getting treatment that is appropriate treatment”.
(IDI-9, Section-2).
Knowledge regarding drug (antibiotic) resistance
In the current study, different opinion regarding drug resistance were found among informal allopathic providers. The most common perception was that if a high-power antibiotic was given to a patient initially, a lower-power antibiotic would not work for that patient afterwards. Another prevailing concept was that due to specific immune system’s issue, especially among those who were addicted to recreational drugs or among chain smokers, some drugs would not work or yield good outcome. A respondent with less than 5 years of experience explained that:
“Due to the specific body’s immune system some drugs do not work, so it is resistance for them. Like, medicine does not bring optimum result for drug addict or chain smoker”. (IDI-7, Section-2. A).
However, two providers perceived a specific drug to be resistant if after 4–5 days of treatment the condition of the patient didn’t improve. Only one provider considered a sensitivity test to confirm drug resistance.
All interviewed providers in the current study obtained information regarding medication, particularly new drugs, primarily from the pharmaceutical companies’ representatives. These representatives usually provided some written information and sometimes offered seminar or workshop. Some providers established relationship with local registered medical practitioners (Bachelor of Medicine, Bachelor of Surgery/ MBBS doctors) who became their source of information. As mentioned by a respondent with less than 5 years of working experience:
“I get the information about any new drugs from medical representatives and the leaflets they provide. Moreover, I discuss with one MBBS doctor who comes to my dispensary once or twice a month to pass time with other people”. (IDI-10, Section 2.C).
Apart from this, the providers also read books and drug guideline. However, they didn’t consider them as the main resource, as most of the materials were only available in English.
Perceived barriers in appropriate use of treatment
Some common barriers to providing appropriate care and treatment were expressed by all informal allopathic providers below.
Lack of training or qualification
During the interview, it was found that all providers received training in the early stage of their career. They mostly received a six-month Local Medical Assistance and Family Planning (LMAF) training. Only one provider obtained a Diploma in Medical Faculty (DMF), a four-year course which includes an internship. These courses offer a basic training on health care and medicine. The providers considered the training as important because it gave them the only valid way to enter their profession. Furthermore, the training helped to raise their confidence in treating patients and facilitated networking with other participants. However, the providers expressed that the training duration was too short to enable them to obtain the necessary knowledge or to qualify them for more specific treatments. In addition, they complained that there were several institutions offering LMAF training which did not maintain their training quality. A provider acknowledged that:
“I am lacking the training that will give me the skill to treat patient appropriately. I also cannot give treatment for many conditions such as for pregnant women, as I did not have the specific training for this. But besides that, my degree also does not permit (to treat pregnant women)”. (IDI-3, Section 3.A).
The insufficient training that providers received has influenced negatively on their knowledge. Some providers confessed that sometimes they could not understand the pathological (diagnostic test) report and the prescription from MBBS doctors. They did not have any other way to understand the prescription without asking the medical representatives, and they could do it only if they have good relationship with them.
To provide appropriate care, the providers recognized the importance of diagnostic tools that can help them to make proper diagnosis. Nevertheless, most of them did not have the access to the required diagnostics. A provider with more than 15 years of experience pleaded:
“We need modern diagnostic equipment so we can make proper diagnosis”. (IDI-5, Section 3.A).
In addition, sometimes they also did not have the right medicine because they did not have the permit to store and sell certain drugs. A respondent said that:
“Sometimes I cannot give the drugs according to the prescriptions as I cannot (not allowed to) keep certain drugs”. (IDI-8, Section-3. A).
No systematic and efficient regulation system
In Bangladesh, there is no established regulation system to monitor informal providers’ practices, let alone their quality of service. For most providers, no one ever checked their qualification and their license. Only two providers mentioned they faced a mobile court once in the course of their profession, which was more than 10 years ago. One respondent mentioned:
“I never see any kind of monitoring body to supervise our work or check whether our license is valid or not during the time that I have worked”. (IDI-9, Section-3. A).
However, another provider argued that penalizing them for running their practice was not an effective way to address the issue of appropriate treatment, as agreed by another provider:
“Indeed, there is no gain to take any kind of hard step against informal providers. Rather, giving motivation is important to increase our capability for providing proper treatment”. (IDI-9, Section-3. A).
Patient pressure to provide specific medicine
Eight providers stated that it was common for the patients to demand some medicine according to their choice. Since going to a specialist doctor would require a lot of money for the diagnostic tests and consultation fees, many patients urged the providers to treat them instead. In addition, the patients usually wanted to get well quickly, thus they requested for antibiotics from the beginning, and sometimes even for a higher dose. A provider with less than 15 years of experience explained that:
“Few patients asked for antibiotics as they believe that by taking antibiotic the recovery will be quick; they sometimes even mentioned the name of a specific antibiotic. In such cases, it is tough for us to resist patient’s request, although we know this might not be good for their health”. (IDI-13, Section 2.C).
Because of their business orientation, the providers did not want to lose any patient. Therefore, two of them usually complied with patient’s request. Nonetheless, two providers mentioned they also tried to convince patients to trust them with the diagnosis and treatment. Fortunately, one provider mentioned that patients’ tendency to give them pressure was decreasing day by day.
Suggested ways to overcome existing barriers
Enforcing regulation and monitoring
Five providers believed in the importance of regulation enforcement to make them more accountable. They suggested to establish a strong regulation system with regular monitoring activities, so that uncertified and unlicensed providers could be disciplined. They also argued that similar regulation and monitoring should be applied to pharmaceutical companies as well. They indicated that many pharmaceutical companies operate outside of the regulation system. A provider with between 15 to 30 years of experience explained that:
“It is really tough to overcome many existing problems. There are many pharmaceutical companies which are established and operate without maintaining the rules and regulation”. (IDI-1, Section 3.B).
Comprehensive training and refresher training
The providers recommended that area-based training by a skilled health professional known to the providers, preferably an MBBS doctor, could be a way to improve their knowledge and skill. This area-based training was suggested because it would be more acceptable to the providers, especially in terms of accessibility. The same respondent who has between fifteen to 30 years of experience suggested:
“It would be better to arrange area-based training by skillful persons like MBBS doctors”. (IDI-1, Section 3.B).
The providers also urged LMAF program to update training curriculum and to increase training duration. Two providers mentioned that many patients visited them for pregnancy-related care. However, they could not offer the service because of their lack of knowledge. Therefore, they requested for a special training that can help them to meet these demands in the future.
Recognition by the health system and the authority
A common expectation expressed by the providers was a proper recognition and acknowledgement of their important role in the health system. They realized that they serve a large proportion of the population without imposing expensive user charges. The current situation which did not recognize them as an integral part of the system made them feel unsettled and unmotivated to improve their capacity and practice. A respondent pleaded:
“Do not exclude us because we are village doctor. Rather consider us as important helpers who are trying to give the right treatment to patients. Please create some good policy for us where we can get the recognition”. (IDI- 2, Section 3.B).
They proposed that establishing an effective informal allopathic providers association in collaboration with government body could be a good approach to ensure their accountability. As voiced by one provider with less than 5 years of experience:
“Establish effective informal providers association in collaboration with government body, and include all informal providers for ensuring accountability”. (IDI-10, Section-3. B).
Making the literatures and guidelines available in Bangla
The providers revealed that language was a barrier to access the information and other written materials provided by pharmaceutical companies. They suggested the materials to be offered in Bangla, so they can understand properly how the medicine works, the appropriate use and dose, as well as the side effects. They also recommended that the material can be designed in a way that is easier to understand, so the providers would not hesitate to refer to them when necessary. One respondent argued that:
“It would be more effective for us if we get all the clinical guideline in Bangla (language) and in an easier form so that we can consider these materials as a useful resource in our profession”. (IDI-2, Section- 3.B).
The informal allopathic providers mentioned that maintaining the ethical aspect during treatment was important for appropriate care and treatment. Due to their business orientation, sometimes the providers prescribed medicine that was not needed and even harmful to the patient. In their opinion, this tendency could only be avoided if ones followed ethical principles. One provider with less than 15 years’ experience mentioned that:
“...However most important factor is our own ethical concern to stop wrong treatment and misuse of medicine”. (IDI-13, Section 2.C).
Educating patient
Two providers highlighted the vital role of patients to choose which provider to go to for their treatment. They considered it to be beneficial for the patients to understand the performance of different providers, so they can trust the treatment of the provider of their choice. For the providers themselves, being identified as a good provider would give them the encouragement to treat their patients more effectively and efficiently. Another respondent with less than 15 years’ experience mentioned that:
“I think it is equally important to educate patient on the appropriate treatment and inform them regarding the side effect of antibiotic if it is not necessary, as many patients insist to receive antibiotic from the first day, even if it is not required.” (IDI-3, Section- 3.B).
Acknowledgements
The authors would like to thank all the respondents who participated in the study and generously shared their insights. We would like to thank our Summative Learning Project team members: Afzal Aftab, Diwas Acharya, Elizabeth Wangari, Nazia Haque Oni, Tanha Zahidi and Zunayed Al Azdi, who contributed their time and energy in designing the study and collecting the data. We are grateful to James P. Grant School of Public Health, BRAC University and its faculties who provided guidance and support, including the funding for conducting the study as a requirement for the partial fulfillment of the MPH degree.
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