Tackling unregulated health markets
In Africa and Asia, many people buy their own medicines and seek health care from providers who are informally trained. Patients may receive drugs that they don’t need or that don’t work - with antibiotics, in particular, being widely overprescribed.
These unregulated health markets have spread rapidly in low- and middle-income countries, in most cases faster than regulatory frameworks to ensure quality of care and equity in access. They are a major cause of concern for global public health that is going unrecognized by the World Health Organization, argue IDS Fellow Gerry Bloom and David Peters, a fellow researcher from the Future Health Systems Consortium at Johns Hopkins Bloomberg School of Public Health, in a Comment piece in this week's Nature.
Meeting the health needs of poor people
In many low- and middle-income countries, appropriate health services are in short supply. Country studies conducted by the Future Health Systems Consortium in Bangladesh, India and Nigeria, and compiled in a forthcoming book 'Transforming Health Markets in Asia and Africa: Improving quality and access for the poor', have highlighted the importance of these informal providers, variously referred to as 'village doctors', 'rural medical practitioners', and 'patent medicine vendors'. In Chakaria, a rural area of Bangladesh, researchers found that these informally trained village doctors are often the first port of call for the poor.
One cannot deny that informal providers and systems have made medicines, information and primary-care services available in all but the most remote areas. Getting care from these providers means, for example, not having to lose potential wages by travelling for hours (or maybe even days) to government-operated facilities – where there is no guarantee of being seen. They also represent a savings on transport costs. Additionally, 'village doctors' often offer flexible payment terms and favourable loans, which can mean the difference for poor people between receiving some treatment or none at all.
The problem with informal providers
These alternative, informally trained, providers are largely ignored by governments and international agencies. The World Health Organization (WHO) continues to highlight a shortage of primary health workers as the main barrier to accessing health care in low- and middle-income countries. This is largely due to the difficulty of regulating these informal providers.
Informal markets create problems with drug safety and efficiency, equity of treatment and the cost of care. Village doctors and midwives often prescribe unnecessary pills or injections, with patients bearing the expense and the costs to their health. Counterfeit drugs are rife and drug resistance is growing.
Innovations for equitable health systems
To meet the health and welfare needs of the poor, we need to understand and improve how these evolving markets operate. Recognizing that health markets represent complex adaptive systems, the authors argue that bringing order to unregulated markets will take more than singular interventions. Indeed, establishing poly-centric governance models for accountability in these health systems are critical.
A recently published book by Future Health Systems, Doctoring the Village Doctors: Giving Attention Where it is Due, gives a candid description of their attempts to improve these services. Their efforts to create a social franchise found limited success – while prescription of harmful drugs dropped slightly, there was actually an increase in the provision of unnecessary drugs. Finding the right incentives for change will also be essential for improving care.
Following the example of China, which reached out to village doctors in 2003 to address the SARS epidemic, governments, citizen groups and companies can build partnerships with local providers to support innovation and improve the delivery of safe, effective and affordable treatments for common conditions.