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 2007 Population 4,21,000 Formal (4%) Qualified Physician (Regular)24 Qualified Physician (Guest)22 Sub-Assistant Community Medical Officer (Paramedics) 7 Family Welfare Visitor13 Midwife (ICDDR,B Trained)12 Family Welfare Assistant (Trained on midwifery by government) 13 Nurse8 Informal (96%) Village doctor (Allopathic)325 Village doctor (Homeopathy)174 Kabiraj (Traditional)289 Religious/spiritual healer694 Traditional birth attendant959 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 remedy23.5 MBBS10.5 Homeopath8.0 SACMO4.7 Others3.2 Total100 SACMO=Sub-assistant community medical officer Village Doctor/ Drug Vendor Home remedy MBBS Homoeopath

Health Service Facilities Upazila Health Complex 50 Bed Family Welfare Centre (Paramedics) Outreach Satellite 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 13

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 intervention Number Village Doctors offered training 157 Village Doctors joining the training programme 157 Village Doctors joining the Shasthya Sena Network 117

ShasthyaSena Crest

ShasthyaSena impact 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  Acceptability Business model

ShasthyaSena moves to mHealth; TRCL intervention

Lessons from the mHealth intervention From TRCL perspective  The return on investment was not fast enough From 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 once From 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  Registration  Account top- up  Consultation 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??