Public health systems in our countries are palpably inadequate with far less resources than the NHS. In Bangladesh, the average public sector general practitioner (GP) spends 48 seconds with a patient, in India slightly better, two minutes. In rural Bangladesh, there is just one physician for every 10,000 persons rising to 18 physicians per 10,000 in urban areas. Not surprisingly, people gravitate towards informal providers like pharmacies, supposed to merely dispense medicines against prescriptions but which end up diagnosing and treating people with symptoms but no prescriptions. In Bangladesh, for example, these community-based providers comprise 95% of all providers and are the first line of medical contact for 70% of the citizenry, playing a vital role in the health care ecosystem.

Given the widespread reach of these pharmacies turned “village doctors”, it would be a mistake not to use them more strategically. Worse, by criminalising their practices, we are driving them away from the formal health system. There is an underlying assumption that pharmacies are entirely responsible for over-prescribing antibiotics, dispensing low-quality or harmful drugs.

However, a closer examination reveals that the pharmacies are no more culpable than the rest of the health ecosystem. For instance, in both India and Bangladesh, they are rarely offered training to ascertain the dangers of overtreatment and antibiotic misuse. In Bangladesh, less than half have formally recognised qualifications to operate a pharmacy, let alone to prescribe medicines. Pressured by poor patients who demand quick cures at low cost, they dispense low-quality cheap drugs or powerful antibiotics at half-doses. Significantly, despite all of these factors, studies in India have shown public sector doctors prescribing unnecessary antibiotics more often than informal practitioners, who usually emulate the nearest doctors’ prescriptions.

Working with these informal health care providers at Jeeon Foundation for the past eight years suggests that, unlike the formal medical sector, they gain the trust and faith of their communities by providing more responsive and personalised care. It is time for a pragmatic look at the paradox of informal providers, treating them as a useful resource rather than an impediment. Some pointers are available in a high-profile report by the Observer Research Foundation launched this week at Raisina Dialogue in Delhi, entitled Health Equity and Inclusion in Action in which the Jeeon Foundation is featured.

There are several examples of education and upskilling initiatives that help informal providers improve case management, provide more effective primary care and increase utilisation of government health care facilities and programmes. In Tanzania, accreditation of drug dispensers reduced incorrect medicine prescriptions from 39 to 14%. In West Bengal, a J-PAL–World Bank randomised controlled trial (RCT) that trained registered medical pharmacists (RMPs) resulted in a sustained 8 per cent improvement in accurate case management, closing the quality gap with the formal public sector by half. Based on the RCT results, the West Bengal government has subsequently mandated all RMPs in the state to complete the training. This licence, renewable every two years, authorises them to prescribe over the counter drugs and some first line antibiotics but can be revoked if rules are violated. They are also required to drop the prefix ‘Dr’ from their names, a title previously employed by many rural practitioners. The effort is to make these self-taught “doctors” valuable primary health workers who can treat simple diseases but who are required to refer the rest to trained physicians.

In Bangladesh, 12,525 village doctors were trained through the Damien Foundation to refer suspected TB cases and provide Directly Observed Therapy Short (DOTS) treatment to ensure compliance. Around 18,792 patients received DOTS through the programme and the success rate was 90 per cent. Today, Bangladesh’s National Tuberculosis Strategy has village doctor-based screening, DOTS treatment and referral as an integral part of its TB control strategy. At Jeeon, we demonstrated the potential of pharmacies to identify and refer rare but visible conditions like cleft palate and cataracts, which often go undiagnosed and untreated. A small sample of pharmacies were able to identify and refer thousands of cases to free or discounted surgeries, and identified over 20,000 cases of near-vision disorders, dispensing reading glasses to correct vision for these clients. We also served over 10,000 patients with a telemedicine platform that connected rural pharmacies with physicians in the city, increasing access for the rural population to high quality treatment.

During the early days of the Covid-19 pandemic, local health authorities in a rural suburb of Dhaka trained 4,500 village doctors who received identity cards and were mandated to screen high-risk symptomatic patients. They were also able to provide primary treatment and counselling without using antibiotics, and to ensure home isolation and quarantine along with other Covid-19 protocols. The programme vastly reduced the number of fatalities.

Health authorities need to take a number of steps to implement a collaborative and productive relationship with primary care providers. Firstly, clear guidelines should be set for the management of all common conditions at a primary care level, including when and how to refer patients to physicians, and made available in print and on digital apps. A suitable paramedical course can be designed to teach informal providers and pharmacies key skills for handling primary care cases. A registration and certification authority should be created to register all primary health providers giving them a licence, renewable every two years with clear deadlines by when to get licensed with a list of medicines they can prescribe without a physician’s prescription. Those licensees must be linked to national health programmes and the regional health authorities asked to monitor, coach and make them accountable. Finally, strong medical laws must be enacted protecting patients from gross negligence or malpractice, not just from the newly licensed primary health practitioners but from all formal medical sector practitioners as well.

We at Jeeon Foundation firmly believe that these measures mainstreaming informal health practitioners will help in coping with common challenges facing South Asian health systems, and ensure universal access, greater quality, lesser harmful practices, and health equity for all.

This article is authored by Rubayat Khan, chairperson, Jeeon Foundation, Bangladesh.