Bill & Melinda Gates Foundation

Informal Health Providers Treating TB Are Here to Stay, So How Do We Work with Them?

March 28, 2013

Drug seller. Rural medical provider. Traditional healer. Village doctor. Traditional birth attendant. Quack. These are a few of the 50 terms  that refer to the informal providers who provide 9% to 90% of all healthcare interactions in low- and middle-income countries (depending on the country, the disease in question and the methods of measurement), according to a comprehensive literature review supported by the Center for Health Market Innovations (CHMI) and published recently by May Sudhinaraset and co-authors in PLoS ONE.

Informal providers also play a huge role in the treatment of TB, and we would do well to heed these facts:

  • Only an estimated 40% of TB cases worldwide are reported. Experts suggest that private health providers – including informal providers – handle many of the other 60%.
  • In India, the government believes there are more than 2.6 million people infected with TB but only about 1.5 million are under the government’s care. A study there found that 86% of TB patients first consulted private providers upon the appearance of symptoms.
  • In Vietnam, Philippines and Pakistan, half of patients chose a private provider for treatment of TB. These providers include physicians, nurses, pharmacists and informal providers.

Sudhinaraset’s review found that people prefer private providers for the convenience, affordability, privacy and social and cultural benefits. But it also found low knowledge and minimal adherence to national clinical guidelines among informal providers.

A 2012 study showed how patients found government TB treatment in India;  it's a meandering route that involves many informal providers and drug sellers. Patients will continue to seek out informal providers for TB treatment.  So how can we work with them to enhance TB treatment and not compromise it?

In CHMI’s data set of more than 1,100 social enterprises, public-private partnerships, non-profits and for-profits in 106 countries, we profile 58 programs with at least a partial focus on TB. In India, a country at the epicenter of the TB crisis with nearly a quarter of the world’s annual cases  (about 2 million per year), research published last year showed that informal providers and retail pharmacists were the first point of contact and source of clinical advise for two-thirds of patients at government TB centers. Now, innovators are developing new ways to treat TB in partnership with informal providers in some of India’s poorest communities.  

Let’s look at two programs that appear to have strong TB treatment results:

World Health Partners
Across Bihar, the third largest state in India and one of the poorest, World Health Partners is establishing a social franchise network  of over 14,000 rural health providers, dubbed SkyCare providers, that trains, monitors and supervises the management of TB, visceral leishmaniasis, pneumonia and diarrhea. The goal is to increase coverage of appropriate interventions for the four diseases by 15-20% and serve up to 70 million people.  

In my visits to World Health Partners, I have been particularly impressed by how its managers understand the structure and incentives of the existing Indian health system, including heavy reliance on informal providers.  They have created programs that work to harness this existing system toward improved health, while also employing new technologies, such as telemedicine, to ensure proper oversight.

The organization has reported impressive results. Patients travel half the distance to see a World Health Partner provider when compared to other private providers (doctors are often not present at government facilities). TB treatment with World Health Partners costs patients—80% of whom are in the poorest two quintiles of Indian society—one-third of the standard price charged by the private sector.

World Health Partners was one of six organizations to win the 2013 Skoll Awards for Social Entrepreneurship. This video shows the program in action.

Operation ASHA
In Delhi, quack medical practitioners often dispense misdiagnosis and sub-standard treatment. Unfortunately, many TB patients never make it to government clinics with inconvenient hours and poor service. Operation ASHA (“hope” in English) establishes TB treatment centers in existing community locales, such as homes, shops, temples, and health clinics, and trains residents (often former patients) to become TB health workers. Their job is to identify and educate patients and, most importantly, ensure adherence to the drug regimen.

ASHA combines high tech with old-fashioned shoe leather to ensure compliance, which is imperative in preventing the much harder-to-treat multi-resistant TB. ASHA employs eCompliance, a biometric technology that uses fingerprint scanners to track patients, who scan their finger every time they take medication. Missed doses trigger an SMS notification to managers, who then send out health workers to track down and deliver medicine to the patient where they live. ASHA has reduced the percentage of patients who don’t complete a full course of TB treatment to just 1.5%, much lower than the norm.

Operation ASHA works closely with the Government of India, which provides them with free medicine and diagnostic services. After a center has been established for two years, India’s National Tuberculosis Program awards a grant, providing financial sustainability of the centers.

When I visited Operation ASHA, I saw that many of their outlets were ordinary grocery shops where people in the neighborhood shop for basic items. The fact that it was also a TB treatment center was not at all obvious, eliminating the stigma for TB patients seeking treatment there, an important consideration in getting people to stick to their drug regimens.

I was also impressed by the technology that allows relatively low-skilled counselors and other staff to track patients biometrically to ensure they receive their full treatment, as well as the incentive system – counselors receive a sizable payment after the patient is found to be cured, which motivates them to continue tracking patients.

ASHA now has 209 treatment centers in 19 cities across India, like this one in Tughlakabad (near Delhi) and enrolled 7,930 TB patients in 2012 alone. The success of ASHA has led to its expansion to Cambodia where the model employs counselors on motorbikes, and it will soon expand to Vietnam as well.

These efforts demonstrate the potential to gradually integrate informal providers into the formal health system through training, oversight, technology, and incentives, so that their ubiquity can be become powerful force for good health.

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