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 sector Formal (4%) Qualified Physician (Regular) 24 Qualified Physician (Guest) 22 Sub-Assistant Community Medical Officer (Paramedics) Family Welfare Visitor 13 Midwife (ICDDR,B Trained) 12 Family Welfare Assistant (Trained on midwifery by government) 13 Nurse Kabiraj 7 8 Informal (96%) Village doctor (Allopathic) 325 Village doctor (Homeopathy) 174 Kabiraj (Traditional) 289 Religious/spiritual healer 694 Traditional birth attendant 959 Village Doctor TBA Homeopath Spiritual Healer 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 Homoeopath MBBS Home remedy Village Doctor/ Drug Vendor Health Service Facilities PRIVATE & INFORMAL PUBLIC SECTOR Upazila Health Complex 50 Bed Family Welfare Centre (Paramedics) Outreach Satellite Clinic, EPI Centre, CC Sub-district Zamzam Hospital Missionary Hospital Formal Doctors Union Informal (Village Doctor, Drugstore/Traditional) Ward Informal (Village Doctor, Drugstore/Traditional) Appropriate (%) drug use for treating diarrhoea, viral fever, and pneumonia by the village doctors Harmful 7% Appropriate 18% Inappropriate 75% 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 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 Village Doctors joining the training programme Village Doctors joining the Shasthya Sena Network 157 157 117 ShasthyaSena Crest ShasthyaSena impact Decreased in inappropriate or harmful drug advice among the SS 100 % of prescription 93.9 87.1 92.4 91.7 80 60 P>0.20 40 P<0.001 20 0 Shasthya Sena Non-Shasthya Sena Baseline Endline ShasthyaSena impact (cont’d) Proportion of harmful drug prescription increased in less in SS Adherence to rational prescription comes at the cost of lost profit in terms of decreased drug sale P<0.05 Brand ShasthyaSena = Standard + Income Popular Easily available Harmful prescription Unnecessary and inappropriate medicines Partial prescription Recognizes training Financial loss restricts adherence Referral linkage to the system and doctors Village Doctors Link VDs to formal doctors Appropriate tool Appropriate prescription Referral Better disease management Business model Shared revinue Acceptability Profitable practice ? 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 topup 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??