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Social Science & Medicine 71 (2010) 1593e1600

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Social Science & Medicine

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Knowledge, legitimacy and economic practice in informal markets for medicine:A critical review of research

Jamie Cross a, Hayley Nan MacGregor b,*aGoldsmiths, University of London, New Cross, London, SE14 6NW, UKb Institute of Development Studies, University of Sussex, Falmer, Brighton, East Sussex BN1 9RE, UK

a r t i c l e i n f o

Article history:Available online 18 September 2010

Keywords:Informal providersMarketsMedicine vendorsAccessQualityExpertiseSouth AsiaAfricaReview

* Corresponding author. Tel.: þ44 01273 915676; faE-mail address: h.macgregor@ids.ac.uk (H.N. MacG

0277-9536/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.socscimed.2010.07.040

a b s t r a c t

Current debates and market based interventions in international public health seek to bring aboutexplicit improvements in the quality of care offered by informal providers. In this paper we examine howinformal providers are framed as problematic and question assumptions about what constitutesappropriate knowledge and expectations of how economic actors in the medical marketplace willbehave. We argue that existing portraits of informal providers tend to establish clear cut distinctionsbetween different kinds of practitioner; ‘dis-embed’ biomedical transactions from the broader rela-tionships within which they take place; freeze or anatomise what are dynamic economic relationshipsbetween stakeholders, and obscure or ignore the position of informal providers in a global pharma-ceutical supply chain.

� 2010 Elsevier Ltd. All rights reserved.

The problem of informal providers

The question of what to do about the problems posed bydangerous practices among informal providers of health care inAfrica and Asia is an immediate and pressing concern among pol-icymakers, academic researchers as well as civil society stake-holders (Berman, 1998; Mills, Brugha, Hanson, & McPake, 2002;Travis & Cassels, 2006), with the health objectives established bythe Millennium Development Goals adding urgency to theirengagement. In many low andmiddle-income countries, upward ofthree-fourths of care is provided in the non-state sector (WHO &USAID, 2007). A contemporary body of health policy literatureaddresses the specific dangers to public health presented by thediagnostic and dispensing practices of informal providers, andproposes a range of interventions that would exploit their potentialwhile regulating their practice.

To date most research has focused on issues around malaria(Goodman, Brieger et al., 2007; Williams & Jones, 2004), tubercu-losis (Floyd et al., 2006; Gharat, Bell, Ambe, & Bell, 2007; Salimet al., 2006) and HIV/AIDs (Brugha, 2003; Mills et al., 2002); aswell as to a lesser extent sexual, reproductive and mental health.

x: þ44 01273 621202.regor).

All rights reserved.

Unchecked dispensing practices are shown to have a number ofpotentially harmful effects. These include: unintended side effectsfrom super or sub-therapeutic dosages or from drugs used incombination; increased microbial resistance, for example, to inef-fective malaria prophylactics (WHO, 2001); and the transmission ofblood-borne diseases like Hepatitis by unsterile administrationpractices (El Katsha, Labeeb, Watts, & Younis, 2006). Studies of therole played by Nigeria’s patent medical vendors in the treatment ofmalaria (Brieger, Osamor, Salami, Oladepo, & Otusanya, 2004;Okeke, Uzochukwu, & Okafor, 2006), for example, have focusedattention on the sale of cheaper, ineffective, out of date and poorquality anti-malarials by patent medical vendors and their limitedknowledge of more efficacious artemisinin-based combinationdrugs. The failure of informal providers to provide appropriatediagnoses can also result in haphazard referral systems and delayeddecisions in seeking care. In India and Bangladesh, for example, theinability of informal providers to recognise the gravity of symptomsis seen to contribute to the persistence of high pregnancy relatedmorbidity, child and maternal mortality (George, 2007; Killewo,Anwar, Bashir, Yunus, & Chakraborty, 2006).

Historically international public health policy has advocated theinclusion of some informal providers, such as traditional birthattendants, into formal health systems. A range of current inter-ventions seek to bring about explicit improvements in the quality ofcare offered by informal providers by harnessing their unmetpotential in new markets for health care. Current interventions are

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broadly focused around four areas: 1) Knowledge: improving theappropriateness of the drugs or information informal providersdispense; 2) Performance and safety: increasing access to theirgoods and services, bettering the safety and affordability of theirpractices; and 3) Accountability: building social mechanisms thatcan regulate their activities (Travis & Cassels, 2006). Knowledgebased interventions, that aim to educate or train both providers andclient communities in order to balance asymmetries in information,have emerged as one popular model. Market based interventionswhich seek to improve the practices of informal providers byintroducing good practice and performance targets, are another.Social franchising and ‘drugs for performance’ schemes, forexample, essentially reward sellers if they comply with minimumstandards of diagnostic procedure, disease classification, treatmentregimens, referral, recording and reporting procedures.

Questioning the existing terms of debate

But who are the informal providers of medicinal services andproducts in Africa and Asia and what do they do? In a growing andheterogeneous literature on the subject informal providers are saidto vary considerably in terms of their formal qualifications andinstitutionalised training; their commercial orientation or depen-dence onmedicine as a livelihood option; the complexity or scale oftheir organisation; and their position in a broader supply chain ofhealth commodities (Conteh & Hanson, 2003).

One approach to uncertainty over a precise definition ofinformal providers would be to narrow down their characteristics,to better delineate or fix them as a discrete category. In this paper,however, we resist such an inclination. Instead we take our cuefrom medical anthropologist Sarah Pinto (2004) and approachinformal providers as people who ‘operate on the margins oflegitimacy’ (p. 337). This approach allows us to include all thosewho sell medical goods and services and dispense information onhealth, without the endorsement or permission of biomedical anddevelopment institutions or state authorities. It is a broaderperspective that includes non-allopathic practitioners, pharmacyattendants and street venders, as well as all those peer educatorsand lay health workers whose very existence is an artefact offormer health policy interventions.

In this paper we argue that the current problematisation ofinformal providers and the design of interventions to check theirpractices rests on two sets of assumptions about who informalproviders are and what they do. The first set of assumptions hingeson a particular understanding of expertise. Ideas about whatconstitutes appropriate knowledge proceed from a biomedicalframe which calls into question ways of knowing or practisingmedicine that fall outside it. This is most apparent in the repeatedexclusion of non-allopathic health care providers or alternative,non-biomedical systems and by the emphasis on universal stan-dards of practice. From this perspective, informal providers onlyshow up on the health policy radar when they raise concerns overclaims to biomedical expertise or over their use of biomedicalproducts. The second set of assumptions hinges on expectations ofhow economic actors in the medical marketplace will behave, andare based on a particular rendering of the human subject asa rational, calculating, profit maximising individual. This is mostevident in anxieties around the immorality and self-interest of ‘self-made medical authorities’ or ‘entrepreneurial practitioners’.

Pinto’s phrase allows us to unpack these assumptions byfocusing on the relational and temporal character of who informalproviders are and what they do, rather than on constructinga typology based on static, technical differences. In appropriatingPinto’s phrase, we hope to draw attention to the constant move-ment of informal providers between positions of legitimacy and

illegitimacy, and the redrawing of boundaries between what islegitimate and illegitimate as a result of shifts in public healthpolicy. We argue that this is the key distinguishing mark thatdifferentiates today’s informal providers. Pinto’s definitionsucceeds in capturing the fluidity and transience of people oper-ating in medical marketplaces that many studies attempt todescribe, helping us to make sense of a broader body of evidence.

Methodology and structure of the paper

This paper is not intended to be a systematic literature review.Rather it is meant as a discussion paper based upon secondarysources that seeks to flag a series of issues around knowledge andexpertise, markets and economic transactions. Our aim here is notto promote a new set of interventions but to encourage a criticalreflection on the underlying assumptions, the classificatoryschemas, and the kinds of evidence being used to design regulatoryinterventions in the medical marketplace.

To do sowe look again at empirical studies of informal providersfrom development academia, public health research, healtheconomics and medical anthropology. The studies we look at arebased on data collected through questionnaires and some combi-nation of structured interviews, observations, simulated clientmethods (which use actors, role plays and vignettes), outletmapping, exit interviews and household surveys. We concentratedon our two regional areas of expertise, South Asia and Africa, andfocused on research published between 2003 and 2008, althoughwe made exceptions to include important earlier work. In partic-ular, we sought to include a body of qualitative anthropologicalresearch that has remained outside of current policy debates aboutinformal providers.

Our discussion begins (in part two) by addressing the global,national and local politics of biomedical knowledge. We argue thatcurrent debates about informal providers tend towards the impo-sition of a classificatory order on the frontlines of the medicalmarketplace. While policymakers are primarily concerned with thequestion of how to effectively and safely practise biomedicine,‘critical medical anthropology’ offers a perspective situated outsidethis frame.

Our discussion proceeds (in part three) by exploring the trans-actions that take place between informal providers and theircustomers in the medical marketplace. We argue that portraits ofinformal providers which draw on only one kind of evidence tendto establish clear cut distinctions between different kinds of prac-titioner; ‘dis-embed’ biomedical transactions from the socialstructures withinwhich they take place; invest themotivations andinterests of actors with an over-riding economic rationality; freezeor anatomise what are dynamic economic relationships betweenstakeholders, and obscure or ignore the position of informalproviders in a global pharmaceutical supply chain. It is this latterpoint that we emphasise in our conclusion.

Knowledge economies, expertise and legitimacy

New theoretical approaches within health research have begunto address health care systems as knowledge economies ratherthan ‘simple assemblages of technical services, goods andpersonnel’ (Bloom & Standing, 2008; Bloom, Standing, & Lloyd,2008; Leonard, 2002). This approach reorients health policy inter-ventions aimed at improving the private sector provision ofmedicine and places the emphasis on redressing asymmetries ininformation. Informational inputs into this knowledge economy(that aim to improve the knowledge of practitioners about appro-priate medications and drug dosages, and the knowledge ofconsumers around quality and performance) are presented as

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correctives that will assist in the development of proper func-tioning markets for curative services and preventative publichealth.

For the purposes of this paper we step outside an interventionisthealth policy frame to ask what insights can be gained fromunpicking the production of knowledge in current debates aboutinformal providers. Working within the framework of criticalmedical anthropology we approach biomedical knowledge as‘discourse’, in that it defines and produces the objects of ourknowledge (Hall, 1997: p. 44). Critical medical anthropologyemerged from a tradition of Marxist political economy to ask howbiomedicine is embedded in the capitalist world system (Baer,Singer, & Johnsen, 1986). In the Foucauldian tradition, medicalanthropologists have asked how biomedical knowledge comes tohave authority and how this knowledge shapes the world that itdescribes (e.g. Young, 1995). In this tradition biomedicine appearsas a ‘system amongst systems’; a modern discipline that has cometo exert a hegemonic influence over bodily knowledge and practice(Lock & Scheper-Hughes, 1996).

The use of an exclusively biomedical framework to assess thequality of care offered by informal providers and their level ofexpertise has specific discursive outcomes that shape humansubjects and social relations. This raises the question of whatconstitutes appropriate or legitimate knowledge, and what are thecircumstances under which people acquire legitimacy. In thefollowing subsections of the paper we explore firstly the politics ofdelineating boundaries between expert and non-expert andsecondly the blurring of boundaries between formal and informal,biomedicine and non-allopathic practices.

Boundary making

Efforts to define legitimate and illegitimate health careproviders can often appear to have a hidden transcript. On thesurface concerns over the level of training and the type of qualifi-cations held by informal providers are about providing guaranteesof competence that they can use biomedical knowledge safely. Butbelow the surface, these concerns also have unintended outcomesthat work to assert, protect and defend the legitimacy of thebiomedical ‘expert’.

Future health systems, it is said, are ‘unlikely to be characterisedby the kinds of clear boundaries between experts and non-expertsthat have characterised 20th century systems in advanced marketeconomies’ (Bloom& Standing, 2008: p. 8). Yet current debates overinformal providers e the type, quantity and quality of theirbiomedical knowledge, their qualifications to know or practisebiomedicine, and the exclusion of those who practise in othertraditions (and in fact often integrate elements of biomedicine) eseem precisely to be about constructing and maintaining bound-aries between lay-practitioner and legitimate expert. If oneconsequence of the ‘marketisation’ of and spread of health relatedknowledge is a shift in the boundaries of professional expertise(Standing & Chowdhury, 2008: p. 4), it should come as no surprisethat national debates over future health systems also reveal localanxieties among those who have an interest in protecting anddefending their claims to expertise.

The construction of boundary lines between proper or pureknowledge is socially and historically situated, and is not limited toallopathic systems (Sujatha, 2007). In particular contexts and atparticular junctures the line between expert and inexpert knowl-edge, appropriate or inappropriate practice, shifts. The contempo-rary diversity between different kinds of informal providers ata national level and their geographic distribution is, in part, a legacyof different political regimes and histories of state intervention, aswell as a reflection of shifts in international health policy over time.

Community health workers, for example, represent a classicexample of this phenomenon (e.g. Standing & Chowdhury, 2008).They might occupy a position in a formal health system during oneregime, only to find themselves out of a job as policies shift withonly their former associations to formal state institutions givingthem continued legitimacy as informal providers of health services.Thus in one era they are a solution, in another they becomea problem. Similarly, while international organisations like theWHO might advocate the use of informal providers in the imple-mentation of a particular vertical programme, for example in theextension of the DOTS programme against TB, it may conflict withnational level policies and priorities that exclude practitioners whodo not carry state recognised qualifications or licences.

In South Asia national debates and concerns over the absence ofregulation with respect to informal providers can all too easilyreproduce associations between specific ways of knowing andparticular categories of people. The distinction between what isconsidered legitimate or illegitimate medical knowledge andpractice is then mapped onto a local social landscape. Descriptionsof informal providers as ‘irrational’ or ‘thug-like’ by registeredpractitioners, for example, offer a reminder that statements aboutknowledge andmorality are often deeply entwined with prejudicesand pre-conceptions based on hierarchies of caste, class, gender orethnicity. As Stacy Leigh-Pigg’s work in Nepal has shown, the fieldof rural health care can prove to be a potent site for the productionand reproduction of politically salient social categories (Leigh-Pigg,1990, 1996).

Reading between the lines of studies on informal providers fromSouth Asia one can discern the social politics of boundary makingthat we are concerned with in this paper. Typologies of the medicalmarketplace that slip into a distinction between ‘doctors and non-doctors’ (Ahmed & Hossain, 2007), for example, reveal preciselythis kind of boundary making. This recent study of informalproviders in north Bangladesh maps biomedical knowledge andpractice onto a social cartography. The authors define knowledge as‘a delineated set of biomedical concepts and procedures accom-panied by formal certified guarantees of competence’. Their studyidentifies informal providers not simply by their lack of educationor training but by their specific lack of certified knowledge fromrecognised institutions. The portrait of irrational village practi-tioners and their fatalistic rural patients also marks a social hier-archy between agents of development and the people they target,so that lay knowledge or practice comes to be defined by andagainst the rational, educated, elite cosmopolitan. As Sarah Pintohas put it, informal practitioners are ‘those against whom theeducated and rational self is defined’ (Pinto, 2004: p. 356).

Fuzzy boundaries and hybrid practices

There is considerable interest in the contemporary healthliterature on the ‘blurred boundaries’ between public and private,formal and informal health systems (Bloom & Standing, 2008;Bloom et al., 2008). To date this phrase has been used largely inrelation to public health professionals who supplement or subsi-dise their low pay by selling goods and services in the medicalmarketplace (Bloom & Standing, 2008). We would advocatebroadening this debate in two ways: firstly, to consider howinformal medical entrepreneurs use their associations with ‘legit-imating institutions’ in order to build reputations, gain status, andpursue their livelihoods; secondly, to think about the ways thatnon-allopathic providers may draw upon the biomedical. Just asformal providers constantly assert and defend the legitimacy oftheir knowledge and practice in reference to those who operateillegitimately, informal providers constantly draw upon the signs,symbols, and language of formal actors and institutions to

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legitimise themselves. Thinking about these boundaries as porousallows us to acknowledge movement in both directions.

In Africa and Asia people engage with medical practitioners whoare not doctors but who ‘invent roles for themselves as medicalexperts and representatives of development’ (Pinto, 2004: 337). Theseinformal providers may include village ‘big men’ with pre-existentpower bases, such asprominent landowners andpoliticians, aswell aswomen with prior roles as care-givers. In the gaps left by legitimatepublic health systems, a wide range of such self-made or entrepre-neurial practitioners draw upon the authority of medical and devel-opment institutions tooffer services inamedical frame.Theirclaims toexpertise and authority invoke outside institutions (NGOs, politicalparties) and ideologies, as well as mobilise associations by kinship ormarriage, deploy biomedical technologies or commodities, andcommunicate in ways that present themselves as beacons of educa-tion or ‘rationality’. In India and Southern Africa alike, practitioners of‘traditional’ medicine e healers and Ayurvedic doctors e draw onbiomedical symbols, treatments, instruments, and diagnostic tech-nologies, as a source of legitimating authority (Lambert, 1996; Nisula,2006: p. 209; Reynolds Whyte, Van Der Geest, & Hardon, 2003: p. 9).For unqualified and self-appointed ruralmedical practitioners inUttarPradesh, for example, the use of hypothermic needles provides entryinto a legitimating structure; the injection is a performance thatborrows from the work of doctors and the stuff of hospitals (Jeffery,Das, Dasgupta, & Jeffery, 2007; Jeffery, Ecks, & Brhlikova, 2007; Pinto,2004: p. 353). We find a similar identification with legitimatinginstitutions taking place in efforts to construe African traditionalhealing as ‘African Science’ (Ashforth, 2005).

Development interventions in the arena of public health havefrequently incorporated informal providers into formal, institu-tionalised structures. Rural development projects and village healthcampaigns frequently recruit self-appointed local medical practi-tioners as participants. Participation in NGO/state training pro-grammes can sanction or legitimise informal providers. Trainingprogrammes can offer formerly illegitimate practitioners newlivelihood opportunities as assistant nurses, village or communityhealth workers. Alternatively, they can also offer new sources ofinstitutionalised identity and language with which informalproviders can assert themselves as experts in the medicalmarketplace. Biomedical research programmes can offer a similarsource of institutional legitimacy. People who are employed tooversee and administer clinical trials can draw on this connectionwhen the trial is complete in order to invest themselves with aninstitutional authority.

Current debates on informal providers within the existingliterature tend not to include in the discussion a consideration oftraditions of treatment, healing and care that exist outsidea biomedical frame. Yet in Africa and Asia allopathic and non-allopathic medicine exist side by side in the marketplace. Workingdefinitions of ‘informal provider’ that fail to fully address theinfluence and integration of biomedicine into other therapies, missthe everyday plurality of therapeutic practice with respect toconcepts, discourse, diagnostic technology, instruments and phar-maceuticals. In South Asia, for example, while not all non-allopathicpractitioners may be concerned to draw upon biomedicine(Sujatha, 2007), there is more blurring of boundaries betweenAyurvedic, Homeopathic and Allopathic traditions (Bode, 2006;Frank & Ecks, 2004; Nisula, 2006) than is commonly granted, tothe degree that medical systems, structures and symbolics can besaid to ‘intermingle’ (Khare, 1996). Rigid definitions of biomedicalpractice miss the hybrid character of everyday medical practice inmany parts of the world where providers adapt or syncretisepractices and, in doing so, blur the boundaries between biomedi-cine and non-allopathic traditions (Datye et al., 2006; Frank & Ecks,2004; Kielmann, 2002; Kielmann et al., 2005).

In the second half of this paper we turn to look at howassumptions about knowledge and expertise are bound up withassumptions about the nature of providerepatient transactions andpractices in the medical marketplace.

Markets, medicine and the morality of exchange

Much of the current interest in improving the efficiency andeffectiveness of informal health care providers hinges on theinstitutionalisation of new forms of market regulation (Bloom &Standing, 2001; 2008; Peters & Muraleedharan, 2008). Recognis-ing that states are unable to shoulder the regulatory burden andthat there are ‘major divergences between the necessary conditionsfor the appropriate use of pharmaceutical products and theeveryday situations of their use’ in actually existing markets forhealth care (Jeffery, Ecks et al., 2007: p. 45), new regulatoryapproaches envisage a shift away from the enforcement of rulesthrough the State’s exercise of administrative and bureaucraticcontrols towards alternative market based, consumer oriented, andcollaborative approaches (Peters & Muraleedharan, 2008).

Our intention in this section of the paper is to consider howthese attempts to rethink the regulation of health care alsoconstruct the market, the behaviour of market actors, and trans-actions between informal providers and their patient-clients. Thisis a question that concerns the moralities and ethics of care,questions of demand and competition and, finally, the role of theglobal pharmaceutical supply chain; and we address each of thesein turn.

The terms of recent debate around the regulation of markets forhealth services, we would suggest, rest on paradoxical under-standings that offer little scope for understanding the sociologicalcomplexity of transactions between informal providers and theirpatient-clients. On one hand, for example, the informal economy ispresented as essentially ‘unregulated’ and informal providers areportrayed as ‘unaccountable’ economic actors prone to self-inter-ested behaviour. On the other hand informal providers are alsofrequently recognised as locally situated social actors who areentwined in binding relationships, networks of kinship, patronageand reciprocity (e.g. Kamat & Nichter,1998) that could be harnessedby systems of social regulation. High profile initiatives e like‘financing tools’ that create incentives to improve quality and ‘socialfranchises’ that identify good practitioners e are designed to ‘buildup trust between providers and patients, reduce informationasymmetries, and reflect the rising role of consumers and brands inthe market’ (Peters & Muraleedharan, 2008: p. 2141).

Similarly, informal providers are frequently shown to be locatedin fiercely competitive marketplaces where everyday dispensingpractices are shaped by consumer demand. Yet the economies ofknowledge and practice in which informal providers of biomedicaldrugs operate are frequently discussed without reference to therole of a global pharmaceutical industry in the construction ofdemand. Indeed, informal providers are often isolated anddetached from the pharmaceutical supply chains in which they areconstituent actors.

Transactional analyses

Existing health policy perspectives largely present interactionsbetween informal providers and their patient-clients as consulta-tive, diagnostic or advice giving moments. To this end, policyoriented studies frequently conclude that medical sellers, vendorsand pharmacists have an important role inmeeting the informationdemands of their clients regarding general health knowledge, druguse and family planning (Gül, Omurtag, Clark, Ayfer, & Özel, 2007).But to what extent do public health concerns with the quantity of

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biomedical knowledge or the quality of biomedical practice matchthe everyday expectations and preferences that people bring totheir transactions with providers?

The circumstances under which customers actually prompt aninformal medicine seller for information or advice often remaindeeply unclear. And, in many empirical studies, information isactually a minor feature of observed interactions between patentmedical vendors or pharmacy attendants and their customers.Research from Sub Saharan Africa, South and South East Asia, forexample, reports that customers rarely engage vendors in anythingapproaching a ‘therapeutic consultation’ and medical sellers rarelyask customers questions about their illness (Chalker, Chuc,Falkenberg, Do, & Tomson, 2000; Goodman, Brieger et al., 2007).In many cases, the moment of interaction between an informalprovider and their customers would seem to be better understoodas an economic or commercial transaction rather than imaginedthrough the normative lens of public health policy as a clinicaltransaction. For example, ethnographic studies of informalproviders that pay close attention to the micro-social politics oftheir transactions with customers reveal that vendors commonlyact primarily as salesmen who simply respond to direct requestsfrom their clients rather than as repositories of diagnostic wisdomor advice (Brieger et al., 2004; Goodman, Brieger et al., 2007; Kamat& Nichter, 1998).

Interventions aimed at improving the knowledge and practice ofretailers and salespeople often appear to ignore the practicalquestion of whether, when, how, or in which contexts customersactually ask the seller of medical drugs and treatments for advice.Little surprise, perhaps, that vendor-training programmes some-times appear to have little or no impact on the everyday content oftransactions. Examples from Uganda (Goodman, Brieger et al.,2007) show that while interventions may leave vendors betterinformed about dosages and drugs, everyday business pressuresand economic concerns about losing customers arewhat determinewhether or not this information is actually used.

Many studies seem to suggest that informal health providers bebetter understood as economic agents who are involved inprimarily commercial rather than primarily biomedical trans-actions. This is not to argue that these transactions be understoodas primarily calculating or self-interested. Economic anthropolo-gists do not deny that economic decisions may be logicallyreasoned or utility maximising. They do, however, question theuniversality of this model of microeconomic behaviour (even inadvanced capitalist societies) and argue instead that the processesby which people arrive at decisions and evaluate their optionsremain embedded in wider moral economies.

Ethics of care

Transactions between informal providers and their clients in themedical marketplace may not conform to the ethics of consultativepractice within a biomedical paradigm but this is not to say thattransactions exist outside or beyond ‘the ethical’. Bottom-upapproaches to biomedical ethics recognise that informal or marketbased providers remain embedded within a moral economy of carethat influences ‘the content and the nature’ of their decisions, aswell as their communication with clients (Datye et al., 2006:p. 435). This is to recognise that alternative value systems andethics of care can also configure norms of practice, shaping howproviders perceive their role and responsibilities to patients/clients,as well as what is expected or demanded of them.

Studies of individual providers operating small scale, localisedmedical or health care businesses inhighly competitivemarketplacesrepeatedly show them building and maintaining relationships withtheir clientele by offering goods and services that meet local

expectations of care or value for money. In rural African contexts, forexample, this might meanmaking drugs available on credit if peoplecannot pay for medication up front (see, for example, Bierlich, 1999;Marsh et al., 1999). In urban South Asian settings like the slums ofKarachiandMumbaiewherepoorpatientswhocannotafford towaitand see if they have been ‘cured’ look for a temporary reprieve thatcan get them through the day e this might mean that diagnosticprocedures and dispensing practices with no immediately percep-tible physiological outcome are likely to be taken as signs of ineffec-tiveness or corruption (Kamat & Nichter, 1998: p. 902).

It cannot be assumed that practitioners are always andstraightforwardly profit maximising. The social forces acting oninformal providers in what are highly competitive medicalmarketplaces can create very real regulatory dynamics, eventhough this dynamic might not correspond to normative assertionsof what a well or properly functioning market for health careshould look like. A study of dispensing practices in Mumbai’s slumpharmacies, for example, showed that vendors frequently refusedto sell prescription drugs to clients who were new or unknown tothem because of concerns that they presented a ‘suicide risk’(Kamat & Nichter, 1998). When presented with a list of medicinesby cash-strapped clients suffering from chronic illnesses, theyinvariably guided them towards low cost, curative drugs over moreexpensive palliative medicines (ibid). In cases where low-incomepatients were observed presenting prescriptions for multiplemedicines, pharmacy attendants frequently made decisions on thebasis of their appropriateness and utility rather than their profit-ability. In East Africa, meanwhile, where state hospital pharmaciesseldom have stocks of necessary drugs, drug shop owners aretacitly allowed to infringe regulations designed to restrict the saleof prescription medications and government doctors commonlywrite informal ‘scripts’ for patients to take to the shops (Goodman,Kachur, Abdulla, Bloland, & Mills, 2007). Increased policing of stateregulations in this context would constitute a fundamental denialof access to basic medication. Regulatory enforcers have acceptedthat tightening controls on the sale and circulation of drugs wouldconflict with basic public health objectives, not to mention theirown understandings of the morality of the situation.

Demand and competition

The exchange of medical commodities or services for money isa livelihood strategy for people with vastly different kinds of social,cultural and economic capital. Conceptual distinctions betweeninformal providers and formal practitioners suggest some kind offundamental difference in their business practice. Yet theprescribing practices of formally regulated doctors and thedispensing practices of unregulated medical vendors exhibitimportant commonalities. The forces of demand and competitionconfront both informal providers and formal practitioners alike inways that blur any clear cut separation between them. Empiricalstudies of both groups show that educated, certified and licensedgeneral practitioners confront the same pressures of competitionand customer expectations as the small-scale patent medicinevendor operating in an informal marketplace. Practitioners andvendors both struggle to retain the patronage of their clients in theface of stiff competition and must do so by meeting the demandsand expectations of customers for a particular kind of product,service and/or treatment.

Studies of private general practitioners in South Asia, forexample, repeatedly demonstrate how massive competitionbetween providers drives diagnostic and prescriptive practices.Government doctors who moonlight as private practitioners inKarachi’s slums, for example, recognise that they are over-medi-cating patients but blame the incessant demands among patients

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for ‘more medicine’ and the cut throat competition between prac-titioners (Thaver, Harpham, McPake, & Garner, 1998; Kamat, 2001).Similarly, the proliferation of practitioners and vendors in India’smedical marketplace has created intense competition for patientsand customers.

Informal providers repeatedly inform researchers that thedemands of their customers determine their sales practice butthese claims are consistently discredited by researchers asa convenient cover for self-interest and profiteering. On the basis oftheir review of literature from Sub Saharan Africa, Goodman,Brieger et al. (2007), for example, counsel against accepting state-ments by medicine sellers that ‘consumer pressure’ drives theirsales practices. They warn that vendors often choose to ‘blameconsumers for their own profit maximising behaviour’. An alter-native reading of these claims, however, sees them not as deliber-ately disingenuous but as straightforwardly un-reflexive accountsof market demand. If doctors can sometimes fail to recognise theincreased reporting of sickness, ill-health and disease as theproduct of their own prescription practices (e.g. Ecks, 2008a; Vander Geest, Reynolds Whyte, & Hardon, 1996) why should we notalso see how informal medical vendors fail to recognise consumerdemand as an artefact of their own dispensing practices.

Pharmaceutical supply chains

Current attempts to correct inefficiencies and failures inmarketsfor health care centre on knowledge asymmetries in the trans-actions between informal providers and their patienteclients. Yetdespite widespread acknowledgement that the pharmaceuticalindustry is ‘the main knowledge generator in the field’ (Jeffery, Daset al., 2007; Jeffery, Ecks et al., 2007; Ecks, 2008b) it continues to beremoved or absented from this equation. By maintaining a rigidfocus on the knowledge and practice of retailers or salespeople,current debates about the role of informal providers in futurehealth systems deflect attention away from other actors in thepharmaceutical supply chain.

The effectiveness of pharmaceutical industry marketing is evi-denced by the increased familiarity of patients/clients in poorcontexts with the names of branded pharmaceutical commoditiesand commonly prescribed allopathic medicines. Even in theabsence of information about the effects of pharmaceuticalcommodities, allopathic drugs continue to be invested with socialand symbolic meanings which lead to them being highly valued(Reynolds Whyte, 1992; Reynolds Whyte et al., 2003). Yet qualita-tive health policy studies of the services provided by drug vendorsfrequently continue to ignore the role of pharmaceutical compa-nies, wholesalers and marketers in shaping everyday dispensingpractices or customer demand (see, for example, Chuc et al., 2002;Syhakhang, Stenson, Whalstrom, & Tomson, 2001). The ‘logic ofpractice which unfolds as different stakeholders in the medicalmarketplace interact and respond to each others’ immediate andlonger term needs and motivations’ (Kamat & Nichter, 1998: p. 793)is everywhere plugged in to these global networks of informationand drugs (Petryna, Lakoff, & Kleinman, 2006). Yet very fewcontemporary public health interventions targeting the problemsposed by informal providers of medicine take into account thespecific effects of capitalist marketing and strategies of supply asdrug producers direct their products into the marketplace.

Relatively little is known, for example, about the ‘pharmaceu-tical gift cycle’ (Oldani, 2004: p. 337) that involves exchangesbetween representatives and doctors and links between sales-people and wholesalers, marketers and pharmaceutical companies.Yet in a medical marketplace increasingly defined by thecommercial interests of pharmaceutical companies, the dispensingpractices of informal providers, the ‘institutional arrangements

within which patent medical vendors obtain their supplies’, theway that credit schemes and targets manifest themselves in retailpractice, and the role of middlemen demand to be examined ingreater detail (Petryna et al., 2006: p. 21; Kamat & Nichter, 1998).

Discussion about knowledge and practice among informalproviders that does not move beyond the providereclient interfacecreates a limited and rigid frame around their transaction. Currentconcerns with the regulation of markets for health care lift informalproviders out of their wider commercial relationships to suppliers,wholesalers, and pharmaceutical companies. In doing so they leavethe wider networks that connect actors, agents and institutions inbiomedical supply chains outside the frame.

In the biomedical tradition, it is the potentially toxic, noxiousand harmful effects of pharmaceutical drugs that represents a keyconcern for public health (Reynolds Whyte et al., 2003). Expertanxieties with regards to informal providers of allopathic medicineare rooted in this pharmacological knowledge that understands thepotential for harm in poorly dispensed or prescribed drugs (Jeffery,Das et al., 2007; Jeffery, Ecks et al., 2007). But if biomedical expertsrecognise that pharmaceutical products are inherently unsafe, whydo small-time dispensers (who are more likely to respect thepotency of drugs) rather than pharmaceutical giants carry theburden of responsibility for safety? It is to the role of the phar-maceutical industry and its absence from the debates surroundinginformal providers that we turn to in our conclusion.

Conclusion

We have used this paper to examine the production of knowl-edge about informal providers and their economic practices.

The first half of this paper interrogated questions of expertise,arguing that classificatory schemasmust also been seen to manifestrelations of power. All knowledge and practice e whether that ofinformal providers or health policy researchers e can be describedas situated, within particular social institutions, moral universesand networks of power. We have attempted to show this by lookingat different scales of context and by treating ‘expert’ and ‘non-expert’ as equivalents. Discussions about private health provision ininternational and national fora are not divorced from the locatedpolitics of boundary making that works to maintain authoritativebases of biomedical expertise. One of the implications of thisdiscussion is that narrow or rigid definitions of competency thatremain exclusively within a biomedical frame can limit potentiallypositive contributions to future health interventions by a broaderrange of practitioners.

Assumptions about expertise are intimately bound up withassumptions about the nature of providerepatient transactions andpractices in the medical marketplace. The second half of the paperaddressed these questions and drew on existing research to painta more complex sociological portrait of informal providers asmarket actors. Normative assumptions about providereclientrelations can misconstrue the content, the interests and the ethicsof existing transactions and result in ineffective or limitedoutcomes.

In particular, we would argue, research around informalproviders and the design of interventions has underemphasised oroverlooked the role of the pharmaceutical supply chain. Informalhealth care providers acting on the frontlines of medical market-places in Africa and Asia present international public health withimmediate and pressing concerns. But existing debates aroundinformal providers are, almost without exception, focused on low-level providers of health care products in ways that neglect theirrelationships to the higher levels of the pharmaceutical supplychain. Understanding what creates the demand or need for medi-cine requires attention to a bigger picture beyond the small-time

J. Cross, H.N. MacGregor / Social Science & Medicine 71 (2010) 1593e1600 1599

economic actor. Patients are situated in medical marketplaceswhere ideas about health, well-being and disease are beingconstantly ‘re-ordered as biomedicine becomes an increasinglysignificant reference point and a primary therapeutic resource’(Kielmann, 2002: p. 153). Patient perspectives and expectationsshape the everyday practices of health providers and, as ‘practi-tioners cater to patient perceptions of their perceived morbidity’(ibid: 148), they find themselves offering as many services or asmany drugs as possible.

In conclusion, then, we call for a shift in attention away from thelow-level informal providers of health care products to higherlevels of the biomedical supply chain. This shift would focus on theproduction of allopathic commodities and knowledge about drugsrather than on the consumption of drugs and distribution ofknowledge, presenting an opportunity for critical engagement withthe institutions and interests that shape markets for health care.Indeed we would argue that public health interventions cannot beplanned without considering or engaging with the globalbiomedical supply chain. As it stands, however, many currentinterventions aimed at improving the practices of informalproviders place a substantial burden of responsibility for thedelivery of health commodities and care on actors who occupymarginal or peripheral positions of economic, political and socialpower; people who in relative terms remain quite poorly placed tolook after themselves.

Acknowledgements

Acknowledgements to Gerry Bloom, Hilary Standing and DavidPeters from the Future Health Systems Consortium for their feed-back. We are grateful also to Alice Street for her insightfulcomments on the draft version. The opinions presented are those ofthe authors.

References

Ahmed, S., & Hossain, M. (2007). Knowledge and practice of unqualified and semiqualified allopathic providers in rural Bangladesh: implications for the HRHproblem. Health Policy, 84, 332e343.

Ashforth, A. (2005). Muthi, medicine and witchcraft: regulating,‘African Science’ inpost-apartheid South Africa? Social Dynamics, 31, 211e242.

Baer, H. A., Singer, M., & Johnsen, J. H. (1986). Towards a critical medical anthro-pology. Social Science & Medicine, 23.2, 95e98.

Berman, P. A. (1998). Rethinking health care systems: private health care provisionin India. World Development, 26.8, 1463e1479.

Bierlich, B. (1999). Sacrifice, plants, and western pharmaceuticals: money andhealth care in northern Ghana. Medical Anthropology Quarterly, 13, 316e337.

Bloom, G., & Standing, H. (2001). Pluralism and marketisation in the health sector:Meeting needs in contexts of social change in low and middle-income countries.Brighton: Institute for Development Studies.

Bloom, G., & Standing, H. (2008). Future health systems: why future? Why now?Social Science & Medicine, 66.10, 2067e2075, [Special Issue].

Bloom, G., Standing, H., & Lloyd, R. (2008). Markets, information asymmetry andhealth care: towards new social contracts. Social Science & Medicine, 66.10,2076e2087, [Special Issue].

Bode, M. (2006). Taking traditional knowledge to the market: the commoditisationof Indian medicine. Anthropology & Medicine, 13, 225e236.

Brieger, W. R., Osamor, P. E., Salami, K. S., Oladepo, O., & Otusanya, S. A. (2004).Observations of patent medicine vendor and customer interactions in urbanand rural areas of Oyo State, Nigeria. Health Policy and Planning, 19, 177e182.

Brugha, R. (2003). Antiretroviral treatment in developing countries: the peril ofneglecting private providers. British Medical Journal, 326, 1382e1384.

Chalker, J., Chuc, N. T. K., Falkenberg, T., Do, N. T., & Tomson, G. (2000). STDmanagement by private pharmacies in Hanoi: practice and knowledge of drugsellers. Sexually Transmitted Infections, 76, 299e302.

Chuc, N. T. K., Larsson, M., Do, N. T., Diwan, V. K., Tomson, G. B., & Falkenberg, T.(2002). Improving private pharmacy practice: a multi-intervention experimentin Hanoi, Vietnam. Journal of Clinical Epidemiology, 55, 1148e1155.

Conteh, L., & Hanson, K. (2003). Methods for studying private sector supply ofpublic health products in developing countries: a conceptual framework andreview. Social Science & Medicine, 57, 1147e1161.

Datye, V., Kielmann, K., Sheikh, K., Deshmukh, D., Deshpande, S., Porter, J., et al.(2006). Private practitioners’ communications with patients around HIV testingin Pune, India. Health Policy and Planning, 21, 343e352.

Ecks, S. (2008a). Three propositions for an evidence based medical anthropology.Journal of the Royal Anthropological Institute S77eS92.

Ecks, S. (2008b). Global pharmaceutical markets and corporate citizenship: the caseof Novartis’ anti-cancer drug Glivec. BioSocieties, 3, 165e181.

El Katsha, S., Labeeb, S., Watts, S., & Younis, A. (2006). Informal health providers andthe transmission of hepatitis C virus: pilot study in two Egyptian villages.Eastern Mediterranean Health Journal, 12.6, 758e767.

Floyd, K., Arora, V. K., Murthy, K. J. R., Lonnroth, K., Singla, N., Akbar, Y., et al. (2006).Cost and effectiveness of the PPM-DOTS for tuberculosis control: evidence fromIndia. Bulletin of the World Health Organisation, 84.

Frank, R., & Ecks, S. (2004). Towards an ethnography of Indian homeopathy.Anthropology & Medicine, 11.

George, A. (2007). Persistence of high maternal mortality in Koppal district, Kar-nataka, India: observed service delivery constraints. Reproductive HealthMatters, 15.30, 91e102.

Gharat, M. S., Bell, C. A., Ambe, G. T., & Bell, J. S. (2007). Engaging communitypharmacists as partners in tuberculosis control: a case study from Mumbai,India. Research in Social and Administrative Pharmacy, 3, 464e470.

Goodman, C., Brieger, W., Unwin, A., Mills, A., Meek, S., & Greer, G. (2007). Medicinesellers and malaria treatment in sub-Saharan Africa: what do they do and howcan their practice be improved? American Journal of Tropical Medicine andHygiene, 77, 203e218.

Goodman, C., Kachur, P. S., Abdulla, S., Bloland, P., & Mills, A. (2007). Drug shopregulation and malaria treatment in Tanzania e why do shops break the rulesand does it matter? Health Policy and Planning, 22, 393e403.

Gül, H., Omurtag, G., Clark, P. M., Ayfer, T., & Özel, S. (2007). Nonprescriptionmedication purchases and the role of pharmacists as healthcare workers in self-medication in Istanbul. Medical Science Monitor, 13, 9e14.

Hall, S. (Ed.). (1997). Representation: Cultural representations and signifying practices.London: Sage.

Jeffery, P., Das, A., Dasgupta, J., & Jeffery, R. (2007). Unmonitored intrapartumoxytocin use in home deliveries: evidence from Uttar Pradesh, India. Repro-ductive Health Matters, 15.30, 172e178.

Jeffery, R., Ecks, S., & Brhlikova, P. (2007). Prescribing regulation: rethinking theTRIPS and GMP regimes. Biblio, 30.3, 45e52.

Kamat, V. (2001). Private practitioners and the role in the resurgence of malaria inMumbai (Bombay) and Navi Mumbai (New Bombay), India: serving the affectedor a new epidemic? Social Science & Medicine, 52, 885e909.

Kamat, V. R., & Nichter, M. (1998). Pharmacies, self-medication and pharmaceuticalmarketing in Bombay, India. Social Science & Medicine, 47, 779e794.

Khare, R. S. (1996). Dava, Daktar, and Dua: anthropology of practiced medicine inIndia. Social Science & Medicine, 43, 837e848.

Kielmann, K. (2002). Theorizing health in the context of transition: the dynamics ofperceived morbidity among women in peri-urban Maharashtra, India. MedicalAnthropology, 21, 157e205.

Kielmann, K., Deshmukh, D., Deshpande, S., Datye, V., Porter, J., & Rangan, S. (2005).Managing uncertainty around HIV/AIDS in an urban setting: private medicalproviders and their patients in Pune, India. Social Science & Medicine, 61,1540e1550.

Killewo, J., Anwar, I., Bashir, I., Yunus, M., & Chakraborty, J. (2006). Perceived delay inhealthcare-seeking for episodes of serious illness and its implications for safemotherhood interventions in rural Bangladesh. Journal of Health, Population &Nutrition, 24.4, 403e412.

Lambert, H. (1996). Popular therapeutics and medical preferences in rural northIndia. The Lancet, 348, 1706e1709.

Leigh-Pigg, S. (1990). Inventing social categories through place: social representa-tions and development in Nepal. Comparative Studies in Society & History, 34,491e513.

Leigh-Pigg, S. (1996). The credible and the credulous: the question of “villagers’beliefs” in Nepal. Cultural Anthropology, 11.2, 160e201.

Leonard, K. L. (2002). When both states and markets fail: asymmetric informationand the role of NGOs in African health care. International Review of Law &Economics, 22, 61e80.

Lock, M., & Scheper-Hughes, N. (1996). A critical interpretive approach in medicalanthropology: rituals and routines of discipline and dissent. In C. F. Sargent, &T. M. Johnson (Eds.), Handbook of medical anthropology: Contemporary theoryand method (pp. 47e72). Westport, Connecticut: Greenwood Press.

Marsh, V. M., Mutemi, W. M., Muturi, J., Haaland, A., Watkins, W. M., Otieno, G., et al.(1999). Changing home treatment of childhood fevers by training shop keepersin rural Kenya. Tropical Medicine & International Health, 4, 383e389.

Mills, A., Brugha, R., Hanson, K., & McPake, B. (2002). What can be done about theprivate health sector in low-income countries? Bulletin of the World HealthOrganization, 80, 325e330.

Nisula, T. (2006). In the presence of biomedicine: ayurveda, medical integrationand health seeking in Mysore, south India. Anthropology & Medicine, 13,207e224.

Okeke, T. A., Uzochukwu, B. S. C., & Okafor, H. U. (2006). An in-depth study of patentmedicine sellers’ perspectives on malaria in a rural Nigerian community.Malaria Journal, 5.

Oldani, M. J. (2004). Thick prescriptions: towards an interpretation of pharma-ceutical sales practices. Medical Anthropology Quarterly, 18, 325e356.

Peters, D. H., & Muraleedharan, V. R. (2008). Regulating India’s health services: towhat end? What future? Social Science & Medicine, 66, 2133e2144.

Petryna, A., Lakoff, A., & Kleinman, A. (2006). Global pharmaceuticals. Ethics, markets,practices. London: Duke University Press.

J. Cross, H.N. MacGregor / Social Science & Medicine 71 (2010) 1593e16001600

Pinto, S. (2004). Development without institutions: Ersatz medicine and the politicsof everyday life in rural north India. Cutural Anthropology, 19, 337e364.

Reynolds Whyte, S. (1992). Pharmaceuticals as folk medicine: transformations inthe social relations of health care in Uganda. Culture, Medicine & Psychiatry, 16,163e186.

Reynolds Whyte, S., Van Der Geest, S., & Hardon, A. (2003). The social lives ofmedicines. Cambridge: Cambridge University Press.

Salim, M. A. H., Uplekar, M., Declercq, E., Aung, M., Daru, P., & Lönnroth, K. (2006).Turning liabilities into resources: the informal village doctors and TB control inBangladesh. Bulletin of World Health Organization, 84, 479e484.

Standing, H., & Chowdhury, A. M. R. (2008). Producing effective knowledge agentsin a pluralistic environment: what future for community health workers? SocialScience & Medicine, 66.10, 2096e2107.

Sujatha, V. (2007). Pluralism in Indian medicine: medical lore as a genre of medicalknowledge. Contributions to Indian Sociology, 41(2), 169e202.

Syhakhang, L., Stenson, B., Whalstrom, R., & Tomson, G. (2001). The quality of publicand private pharmacy practices: a cross sectional study in the SavannakhetProvince, Lao PDR. European Journal of Clinical Pharmacology, 57, 221e227.

Thaver, I. H., Harpham, T., McPake, B., & Garner, P. (1998). Private practitioners in theslums of Karachi: what quality of care do they offer? Social Science & Medicine,46, 1441e1449.

Travis, P., & Cassels, A. (2006). Safe in their hands: engaging private providers in thequest for public health goals. Bulletin of the World Health Organization, 84,427e428.

Van der Geest, S., Reynolds Whyte, S., & Hardon, A. (1996). The anthropology of phar-maceuticals: a biographical approach. Annual Review of Anthropology, 25, 153e178.

WHO. (2001). WHO global strategy for containment of antimicrobial resistance.Geneva: World Health Organization.

WHO, & USAID. (2007). Public policy and franchising reproductive health: currentevidence and future directions, Guidance from a technical consultation meeting,Geneva.

Williams, H. A., & Jones, C. O. H. (2004). A critical review of behavioral issues relatedto malaria control in sub-Saharan Africa: what contributions have socialscientists made? Social Science & Medicine, 59, 501e523.

Young, A. (1995). The harmony of illusions: Inventing post-traumatic stress disorder.Princeton: Princeton University Press.