Does incentive work for improvement of quality of care by Informal healthcare

providers in rural Bangladesh?

Implication for Future Health System

Mohammad Iqbal

Introduction

• This is an ongoing study in Chakaria since 2006

• Chakaria is a sub-district, situated in the south-eastern costal area of Bangladesh in Cox’sBazar district

Introduction (contd.)

• Bangladesh is one of the resource poor countries of south Asia

• Bangladesh has a population of about 160 million

• It’s area is 144,000 square kilometer • 72% of the population lives in the rural

areas

Introduction (contd.)

• The rural population are mostly poor

• Village Doctors (without formal medical education) and Drug Vendors are the dominant source of healthcare services for the rural population

Background• Bangladesh is one of the health workforce crisis

countries in the world with a shortage of over 60,000 doctors, 280,000 nurses and 483,000 technologists (BHW 2009)

• The informal healthcare providers dominate the health workforce occupying 96% of the share in Bangladesh

• However, the quality of services provided by them is questionable

• An intervention programme was carried out to reduce the harmful/inappropriate practices by the Village Doctors in Chakaria

6

Distribution of Physicians and Nurses

Bangladesh: miss-matched reality

Visible health achievements

??

Serious lack of health human

resource (HHR) in NMR,

IMR,CMR and MMR

Health Care Providers in Chakaria 2007Population 4,21,000

Formal (4%)Qualified Physician (Regular) 24

Qualified Physician (Guest) 22

Sub-Assistant Community Medical Officer (Paramedics)

7

Family Welfare Visitor 13

Midwife (ICDDR,B Trained) 12

Family Welfare Assistant (Trained on midwifery by government)

13

Nurse 8

Informal (96%)Village doctor (Allopathic) 325

Village doctor (Homeopathy) 174

Kabiraj (Traditional) 289

Religious/spiritual healer 694

Traditional birth attendant 959

TBA

Spiritual Healer

Village Doctor

Homeopath

Formal sector

Kabiraj

1st line of care, Chakaria 2007

Type of providers %

Village Doctor/Drug Vendor (Allopathic)

50.1

Home remedy 23.5

MBBS 10.5

Homeopath 8.0

SACMO 4.7

Others 3.2

Total 100

SACMO=Sub-assistant community medical officer

Village Doctor/ Drug Vendor

Home remedy

MBBS

Homoeopath

Health Service Facilities

Upazila Health Complex50

BedFamily Welfare

Centre(Paramedics)

OutreachSatellite Clinic, EPI Centre, CC

PUBLIC SECTOR

Zamzam

Hospital

Missionary

Hospital

Formal

Doctors

Informal (Village Doctor,

Drugstore/Traditional)

Informal (Village Doctor,

Drugstore/Traditional)

PRIVATE & INFORMAL

Sub-district

Union

Ward

Appropriate (%) drug use for treating diarrhoea, viral fever, and pneumonia by the village doctors

Inappropriate 75%

Appropriate 18%

Harmful 7%

The Intervention• Implement a training intervention for improving

treatment practices of Village Doctors in 11 commonly occurring illnesses in Chakaria: pneumonia, severe pneumonia, diarrhoea, hepatitis, malaria, tuberculosis, viral fever, obstructed labour, blood loss before labour, and blood loss after labour

• Establish a membership-based-network involving trained and eligible Village Doctors branded as “ShasthyaSena” (Health Force)

• Form a monitoring committee, known as local health watch to monitor practice pattern of joining members to ensure adherence to certain clinical and public health standards

1313

Cover page of the booklet

ShasthyaSena franchise; aim Establish VDs as ShasthyaSena who would

benefit from a reputation for skill and ethical behavior; own income, career, prospects, status and influence

Mobilize local government to develop an interest in the healthcare system in their locality

Accreditation by branding as ShasthyaSena

ShasthyaSena interventionNumber

Village Doctors offered training 157

Village Doctors joining the training programme

157

Village Doctors joining the Shasthya Sena Network 117

ShasthyaSena Crest

ShasthyaSena impact

93.9 92.487.1 91.7

0

20

40

60

80

100

Shasthya Sena Non-Shasthya Sena

% o

f pre

scrip

tion

BaselineEndline

P<0.001

P>0.20

Decreased in inappropriate or harmful drug advice among the SS

ShasthyaSena impact (cont’d)

P<0.05

Adherence to rational prescription comes at the cost of lost profit in terms of decreased drug sale

Proportion of harmful drug prescription increased in less in SS

Brand ShasthyaSena =Standard + Income

Recognizes training Financial loss

restricts adherence Referral linkage to

the system and doctors

Popular Easily available

Harmful prescription Unnecessary and

inappropriate medicines Partial prescription

Village Doctors

Link VDs to formal doctors

Better disease management

Appropriate tool Appropriate prescription Referral

Profitable practice ?

Shared revinue AcceptabilityBusiness model

ShasthyaSena moves to mHealth;

TRCL intervention

Lessons from the mHealth interventionFrom TRCL perspective

The return on investment was not fast enoughFrom the SS perspective Technology: Problem with connectivity to the call center Communication : Miscommunication and misconception

regarding TRCL Financial Benefit: Lack of financial benefit as some patients

can’t pay the fee at onceFrom the community perspective Concerns around accuracy of diagnosis: no face to face

interaction No follow-up system Poor were not subsidized in the program Community engagement was lacking

ShasthyaSena’s own mHealth

Modules Registratio

n Account

top-up Consultati

on and follow-up

Conclusion • We have tried different non-financial and financial incentives,

but did not give us expected results• There are other incentives in the market, those have more

financial benefits• Which approach will work better; Carrot? stick? Or Carrot

and stick??