In FHS's first phase, we helped form a network of the village doctors (VDs) named ShasthyaSena (Health Soldiers) in Chakaria, a remote rural area in the southeast of Bangladesh in 2008. The ShasthyaSena intervention was devised as a regulatory strategy using a social franchise model with the aim of improving and influencing the performance of village doctors.
The inadequacies of the formal healthcare sector in Bangladesh has resulted in a widespread increase in informal providers as an alternative source of care providing basic and essential outpatient health services to millions of poor people in the rural areas. Close proximity to clients, availability to the community day and night, sympathetic behavior, well established relations within the community, and flexible payment methods have made the village doctors a popular source of care.
Findings from our initial studies confirmed that the VDs provide care of questionable quality with considerable over-prescription of drugs, including the prescription of drugs that are mostly inappropriate and potentially harmful. Regardless, the widespread existence of VDs and their significance as an integral contributor of healthcare within rural communities in Bangladesh necessitates an effective regulatory arrangement that improves and ensures a minimum standard in the quality of services provided.
The ShasthyaSena intervention employed a combination of three strategies. All of the 157 village doctors (VDs) practicing in the intervention areas were invited to participate in a free training in managing common illnesses such as pneumonia, diarrhea, hepatitis, malaria, tuberculosis, viral fever, and various complications related to labor and delivery. A small booklet with information on what to do and what not to do for eleven common illnesses was distributed as a source of future reference. As members of the SS network, qualified village doctors were awarded crests containing the SS logo. A memorandum of understanding outlining the responsibilities and objectives of SS was signed between each joining member and the network. To promote accountability of the village doctors within the community, a governing committee was established consisting of 33 members representing various groups of stakeholders, namely: the SS, local government, local elites, religious leaders, beneficiaries, civil society, school teachers, health experts and ICDDR,B representatives. The committee was responsible for promoting the ShasthyaSenas within the community, motivating and supporting the SS members, monitoring the activities of the SS and providing feedback on their performance.
A significant change in the prescription of appropriate drugs by village doctors was observed in the intervention area. There was an increase in appropriate treatment practices in the control group as well. An increase in the prescription of harmful drugs was observed in both the intervention and comparison groups. However, the increase was smaller for the intervention area. Interestingly, there has been a decline in inappropriate drug choices or prescribing patterns for both areas. Prescriptions containing appropriate choices of drugs in combination with unnecessary or inappropriate drugs were observed to have decreased in both areas. The proportion of prescriptions containing harmful and inappropriate choices of drugs, either in combination with appropriate drugs or not, for the selected illnesses decreased from 94.3% to 87.2% in the intervention group in comparison to 92.8% from 89.9% in the control group in the final phase of the intervention.
The significant finding that the prescription of appropriate choices of drugs for the three health conditions has increased in the group of village doctors who had received training on what to do and what not to do for the 11 common diseases is encouraging. The increase in appropriate practices was also observed in the comparison group of village doctors which might have been the consequences of spill over effects. However the increase in harmful practices in both the areas was not an anticipated consequence of the intervention. Since the livelihoods of village doctors depend on the profit from the medicine they are able to sell, refraining from prescribing or selling harmful drugs, which are known to have higher mark-up prices represent financial loss to the informal healthcare providers in the study. The reasons why harmful drugs are prescribed may be explained by the financial motives and the VDs as human beings making rational choices are expected to maximize their earning potential. However, if they had been convinced that adhering to treatment guidelines would increase their client base and increase the possibility of earning more than the prescriptions of harmful drugs, then the impact on harmful drugs might have been different.
The study has shown that training and branding has acceptability among village doctors although their behaviour has had no drastic changes due to the lack of financial incentives. The ShasthyaSena intervention has also resulted in a change in the attitude of the government toward informal healthcare providers.
Future directions include pursuing branding and social franchising mechanisms and marrying them to new technologies such as the “health box”. This will show and guide the informal healthcare providers how to treat and manage many common illnesses through the use of computer-based diagnostic algorithms. These components together will create a brand with serious content that is attractive to village doctors and even more attractive to customers through improvements in the quality of care. The intervention will further link village doctors with formal healthcare providers for more complicated illnesses. While over-the-counter drugs can be dispensed by the village doctors themselves, dispensing prescription drugs will be guided by linking them with qualified physicians. Dispensing of medicines will be part of the profit made by village doctors and will provide them with a financial incentive. All the above activities will be ensured and supervised by the project. If acceptability and efficacy of the intervention can be shown, a stronger case can be made that shows that using informal healthcare providers will be profitable in a country that has a huge shortfall in the health workforce.