What to do with informal health providers?

While writing my term paper, which was about water and hygiene (who would've guessed that I'd pick that topic, right?), a theme that kept coming up in review publications was the role of informal water providers. Populations in urban areas that don't have access to a well or improved water source will sometimes rely upon informal water providers to meet their needs. Informal water providers can be mobile or have established distribution points, and may not be subject to any form of quality or pricing regulation. As urban population density continues to increase, it is expected that reliance on these sources will increase as well (1). This is an obvious example of a private enterprises filling in gaps in the public sector's ability to distribute water to urban citizens. While this is necessary for people to gain access to water in some urban areas, there are some potentially negative outcomes of small-scale, private distribution. For example, plastic waste generated from sachet (safety-sealed, plastic bags of water for sale) usage contributes to the physical waste issues experienced in many urban areas. By filling canals and gutters, discarded sachets increase localized flooding and transmission of waterborne diseases during heavy rain events (2). Another example, Informal providers are not necessarily regulated for pricing or quality and there is no guarantee of continual distribution, they can move locations or fold operations at any time. They're not great, but they work.

What about informal health providers? In many low and middle-income countries, informal providers (IPs) cover healthcare provision for significant segments of rural, poor and undeserved populations. Just like in my water provision example above, this is the result of a response to an unavailability of access to formal services. In India, a 2007 survey counted 24,807 qualified doctors (77% worked in urban areas) and 89,090 IPs (90% worked in rural areas). That, to me, indicates a strong presence in healthcare provision and an important standing as the primary source of healthcare provision and consultation in rural areas. In two rural India communities (one in northern and one in southern India) a survey of IPs found that the majority that were practicing had received some state-sponsored training and had apprenticed under a doctor. There appears to have been some professional assocations to supplement state-sponsored training and many IPs maintained relationships with doctors working in the formal sector. It appears that in this particular case the formal and informal providers have reached a working arrangement where they are complementary to one another. Of course there is an open debate on whether IPs should be allowed to practice bio-medicine. Some see IPs as necessary and worth investment in improving their quality of care, and some see them as a public health danger that need to have their practices terminated (3).

What do you guys think, what magnitude of difference in quality of care is allowable while striving to reach a global state of "health for all"? I'm sure I wouldn't be alone if I said that ideally IPs would be replaced by formal providers that were fully accessible to everyone, but we've seen in the course that there is a significant amount of international and state-specific policy work that needs to be done before that could ever become a reality. For now, I think further investment in IPs in low and middle-income nations is important as the rate of urbanization increases across the world. Increasing population densities in major urban areas reduces some of the geographic challenges to reaching everyone who needs healthcare, but the increasing population densities will continue to stretch existing urban infrastructures and resources. State-directed training and certification programs could go a long way towards improving the care received by people who seek out IPs and increase the healthcare provider to patient ratio in urban areas that will be increasing over the coming decades.








Citations:

1. Srinivasan, V. (2013). The impact of urbanization on water vulnerability: A coupled human-environment system approach for Chennai, India. Global Environmental Change, 23, 229-239.
2. Stoler, J., Fink, G., Weeks, J., Otoo, R., Ampofo, J., & Hill, A. (2011). When urban taps run dry: Sachet water consumption and health effects in low income neighborhoods of Accra, Ghana. Health and Place, 18, 250-262.
3. Guatham, Meenakshi, KM Shyamprasad, Rajesh Singh, Anshi Zachariah, Rajkumari Singh, and Gerald Bloom. "Informal Rural Healthcare Providers in North and South India." Health Planning and Policy 29 (2014): 20-29. Web.