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??