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Implication for Future Health System

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

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Implication for Future Health System

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  1. Does incentive work for improvement of quality of care by Informal healthcare providers in rural Bangladesh? Implication for Future Health System Mohammad Iqbal

  2. 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

  3. 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

  4. 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

  5. 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

  7. Visible health achievements Serious lack of health human resource (HHR) Bangladesh: miss-matched reality •  in NMR, IMR,CMR and MMR ??

  8. Health Care Providers in Chakaria 2007 Formal sector Kabiraj Village Doctor Homeopath TBA Spiritual Healer

  9. 1st line of care, Chakaria 2007 Homoeopath Village Doctor/ Drug Vendor MBBS Home remedy SACMO=Sub-assistant community medical officer

  10. Health Service Facilities PRIVATE & INFORMAL PUBLIC SECTOR Sub-district Union Ward

  11. Appropriate (%) drug use for treating diarrhoea, viral fever, and pneumonia by the village doctors Harmful 7% Appropriate 18% Inappropriate 75%

  12. 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

  14. 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 franchise; aim

  15. ShasthyaSena intervention

  16. ShasthyaSenaCrest

  17. P>0.20 P<0.001 • Decreased in inappropriate or harmful drug advice among the SS ShasthyaSena impact

  18. Proportion of harmful drug prescription increased in less in SS ShasthyaSena impact (cont’d) Adherence to rational prescription comes at the cost of lost profit in terms of decreased drug sale P<0.05

  19. Popular • Easily available Village Doctors • Harmful prescription • Unnecessary and inappropriate medicines • Partial prescription Brand ShasthyaSena =Standard + Income Link VDs to formal doctors • Appropriate prescription • Referral Appropriate tool • Recognizes training • Financial loss restricts adherence • Referral linkage to the system and doctors Better disease management • Shared revinue • Acceptability Business model Profitable practice ?

  20. ShasthyaSena moves to mHealth;TRCL intervention

  21. 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 Lessons from the mHealth intervention

  22. ShasthyaSena’s own mHealth • Modules • Registration • Account top-up • Consultation and follow-up

  23. 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??

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