The informal sector providers in Bangladesh: How equipped they are to provide rational health care?

In Bangladesh, there is lack of knowledge about the large body of informal sector practitioners who are the major providers of health care to the poor, especially in the rural areas. This is essential for designing a need-based, pro-poor health system. This paper addresses this knowledge gap by presenting descriptive data on their professional background including knowledge and practices of common illnesses and conditions from a nation-wide, population-based healthcare provider survey undertaken in 2007. The traditional healers (43%), traditional birth attendants (TBAs, 22%), and unqualified allopathic providers (village doctors and drug sellers, 16%) emerged as major providers currently active in the healthcare scenario of Bangladesh.  The TBAs/traditional healers had <5 years of schooling on average compared to 10 years for the others. The TBAs/traditional healers were professionally more experienced (average 18 years) than the unqualified allopaths (average 12 years) and community health workers (CHWs) (average 8 years). Apprenticeship and inheritance (traditional healers, TBAs, drug sellers), and short training (village doctors) of few weeks to few months duration from semi-formal, unregulated private institutions were the major routes of their entry into the profession. As such, their professional knowledge base was not up to the level necessary for providing basic curative services with minimum acceptable quality of care. The CHWs trained by the NGOs (46%) were relatively better in the rational use of drugs such as using antibiotics more frequently in childhood pneumonia than for fever and diarrhea, unlike indiscriminate use of antibiotics by the unqualified allopathic providers. It is essential that the public sector, instead of ignoring, recognize their importance for healthcare of the poor. Accordingly, their capacity should be developed through training, supportive supervision and regulatory measures so as to accommodate them in the mainstream health system, until supply side constraints of qualified and motivated healthcare providers can be alleviated.