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LINKAGES OF RURAL MEDICAL PRACTITIONERS WITH HEALTH SYSTEM ACTORS: A Social Network Analysis from Indian Sundarbans

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Abstract and Figures

2 | P a g e PREFACE The human resource for health in India is complex network of trained, untrained, formal and informal workforce. The two third of human resource and health service delivery is accounted from private sector. The shocking truth is Informal providers estimated to account for over 50 percent of health Informal provides commonly called as Rural Medical Practitioners plays a huge contribution in delivering the primary health services to the marginalized and poor which is never acknowledged but always neglected and criticized. There is lacking evidence on their relationship with formal sectors. This report illuminates the social network of RMPs in Indian Sundarbans, the social context, relations and the emerging informal healthcare market. It throws a light on RMPs pathways of survival over the years. As they are socially embedded within the community, they exhibit social ties with various health system actors which make them resilient to face the shocks from the formal system being in geographically vulnerable region.
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INSTITUTE OF HEALTH MANAGEMENT RESEARCH (IIHMR) UNIVERSITY
REPORT
ON
LINKAGES OF RURAL MEDICAL PRACTITIONERS
WITH HEALTH SYSTEM ACTORS
A Social Network Analysis from Indian Sundarbans
MAY 2016
RITTIKA BRAHMACHARI
SABYASACHI MANDAL
IIHMRU INHOUSE RESEARCH GRANT 2015-2016
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PREFACE
The human resource for health in India is complex network of trained, untrained, formal and
informal workforce. The two third of human resource and health service delivery is accounted
from private sector. The shocking truth is Informal providers estimated to account for over 50
percent of health Informal provides commonly called as Rural Medical Practitioners plays a huge
contribution in delivering the primary health services to the marginalized and poor which is never
acknowledged but always neglected and criticized. There is lacking evidence on their relationship
with formal sectors.
This report illuminates the social network of RMPs in Indian Sundarbans, the social context,
relations and the emerging informal healthcare market. It throws a light on RMPs pathways of
survival over the years. As they are socially embedded within the community, they exhibit social
ties with various health system actors which make them resilient to face the shocks from the
formal system being in geographically vulnerable region.
The research project on understanding the linkages of Rural Medical Practitioners with other
health system actors was awarded by the Institute of Health Management Research University In-
house research grant award 2015-2016. The study was conducted in Patharpratima block of Indian
Sundarbans.
I hope these insight and suggested opportunities will encourage, policy makers, healthcare
professionals, academicians, researchers, non-government organizations and donors to pay
additional attention and pursue suggested implementation from this report.
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ACKNOWLEDGEMENT
I must acknowledge my heartfelt gratitude to all those who contributed directly and indirectly to this
journey.
First and Foremost, I appreciate IIHMR University for announcing In-house research grant for providing
me this opportunity for planning and executing independent research and financially supporting me
throughout. This report is the outcome of IIHMR In-house research grant 2015-2016.
My prime gratitude goes to Prof. Barun Kanjilal (Professor, IIHMR) for his continuous support and
supervision throughout. I am very thankful to Dr. Manasee Mishra (Head, research and training, IIHMR)
for extending scientific support throughout my research work. I must acknowledge my sincere thanks to
Mr. Sabysachi Mandal (Research Assistant, IIHMR) for being patient and excellent colleague during the 3
to 4 months of field work.
I appreciate the support and inspiration received throughout from Future Health System Team. I would
like to thank Ms Upasona Ghosh, senior research officer IIHMR for giving me insight on social network
analysis and supporting me throughout. I am also immensely grateful to Mr. Shibaji Bose (PIRU Officer,
IIHMR) for his valuable inputs. I would like to thank Ms Debjani Barman, (Assistant faculty, IIHMR) for
always motivating me in each and every step.
Last but not the least I am indebted to all respondents- the Rural Medical Practitioners from Indian
Sundarbans for giving us their valuable time from busy schedule and enrich us with the information
required for the research.
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Table of Contents
PREFACE ......................................................................................................................................................... 1
ACKNOWLEDGEMENT ..................................................................................................................................... 1
LIST OF FIGURES……………………………………………………………………………………………………………………………………………….
1. INTRODUCTION ........................................................................................................................................... 6
2. STUDY OBJECTIVE ........................................................................................................................................ 8
3. DATA AND METHODS .................................................................................................................................. 9
3.1 STUDY SETTING ..................................................................................................................................... 9
3.2 SAMPLE ................................................................................................................................................. 9
3.3 DATA COLLECTION METHOD ............................................................................................................... 10
3.3.A REFLEXIVE DAIRY .......................................................................................................................... 10
3.3.B ETHNOGRAPHIC OBSERVATIONS .................................................................................................. 10
3.3.C PARTICIPATORY NETWORK MAPPING ........................................................................................... 10
3.4 DATA COLLECTION PERIOD: ................................................................................................................. 12
3.5 DATA MANAGEMENT .......................................................................................................................... 12
3.5.A. DATA FORMATS ........................................................................................................................... 12
3.5.B. DATA STORAGE............................................................................................................................ 12
3.5 DATA ANALYSIS ................................................................................................................................... 13
3.6 DATA SATURATION .............................................................................................................................. 13
3.7 ETHICAL CLEARANCE ........................................................................................................................... 14
4. RESULTS .................................................................................................................................................... 14
4.1 Profile of the RMPs .............................................................................................................................. 14
4.2 THE SOCIAL NETWORK OF RMPs WITH DIVERSE HEALTH SYSTEM ACTORS ........................................... 15
4.2. A. THE SOCIAL TIES ......................................................................................................................... 16
4.2.B CHANGES IN NETWORK OVER TIME .............................................................................................. 25
5. CONCLUSION ......................................................................................................................................... 26
6. DISCUSSION........................................................................................................................................... 26
7. PROSPECTIVE PAPERS AND BRIEFS FROM THE STUDY ............................................................................ 27
8. ANNEXURE ............................................................................................................................................ 27
9. REFERENCES .......................................................................................................................................... 28
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List of Tables
Table 1. The social network matrices of figure 6 ............................................................................................ 19
Table 2.The social network matrices of figure 7 ............................................................................................. 19
Table 3. The social network matrices of figure 10 .......................................................................................... 22
Table 4. The social network matrices of figure 11 .......................................................................................... 22
Table 5. The social network matrices of figure 14 .......................................................................................... 25
Table 6. The social network matrices of figure 15 .......................................................................................... 25
List of Figures
Figure 1 Sampling Matrix................................................................................................................................. 9
Figure 2 Participatory network mapping process ........................................................................................... 11
Figure 3 The GIS Map of RMPs in Pathrapratima block of Indian Sundarbans ................................................ 15
Figure 4. The frequency of contact between RMPs and Government Healthcare providers in deltaic locations
..................................................................................................................................................................... 18
Figure 5. The frequency of contact between RMPs and Government Healthcare providers in non- deltaic
locations ....................................................................................................................................................... 18
Figure 6. The social network of RMPs with Government Healthcare providers in deltaic locations ................ 18
Figure 7 The social network of RMPs with Government Healthcare providers in non- deltaic locations ......... 18
Figure 8. The frequency of contact between RMPs and Private Healthcare actors in deltaic locations ........... 21
Figure 9. The frequency of contact between RMPs and Private Healthcare actors in non- deltaic locations ... 21
Figure 10. The social network of RMPs with Private Healthcare actors in deltaic locations ............................ 22
Figure 11.The social network of RMPs with Private Healthcare actors in Non-deltaic locations ...................... 22
Figure 12.The frequency of contact between RMPs and Community actors in deltaic locations ..................... 24
Figure 13.The frequency of contact between RMPs and Community actors in non- deltaic locations ............. 24
Figure 14.The social network of RMPs with Community actors in deltaic locations ........................................ 25
Figure 15.The social network of RMPs with Community actors in Non-deltaic locations ................................ 25
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1. INTRODUCTION
The present document reflects on the research process and findings from the study ‘Linkages of Rural
Medical Practitioners (RMP) with other health system actors’. The research study was carried out for
fulfillment of IIHMR In-house Research Grant awarded in the year 2015-2016.
Informal Healthcare market
In India and most of the Low and middle income countries faces the scarcity of qualified health workforce to
deliver primary healthcare services to rural populations residing in hard to reach areas. Hence, the health
care delivery in India is majorly sought from the private sector with potential contribution of informal health
providers (IHP) (Bloom et al, 2011). Evidence suggest there is a need to develop in-depth understanding of
local health market dynamics, RMPs relationships with formal sector and their systematic mapping
(Sudhinaraset, Ingram, Lofthouse, & Montagu, 2013).
Who are Rural Medical Practitioners?
They are heterogeneous groups of providers with difference in type of training, service provision and
regulatory framework. These IHPs are called by various names like Village doctors, quacks, Rural Medical
Practitioners (RMPs). RMPs comprises large, complex and significant component of health system in
developing nation. They also referred as village doctors or quacks or Rural Medical Practitioners (RMPs). They
are the primary point of reference by the communities for healthcare and advice for the community Over the
years they have drawn sustenance from various sources and developed niche areas in healthcare market
(George & Iyer, 2013). They are evolving within well developed institutional arrangement (Gautham et al.,
2014a). The RMPs covers broad range of health areas including maternal and child health and reproductive
health (Sudhinaraset, Ingram,Lofthouse, & Montagu, 2013). Studies shows RMPs sustain unregulated market
pressure and depends on government and private providers for treatment and referral (George,2013). This
research has been carried out to explore the social ties of RMPs with other health system actors by using
social network analysis. It will illuminate the pathways of evolution and survival by dependence on qualified
providers, its genesis and social context.
Why Social network analysis?
Social network analysis serves as a powerful brush to sketch a systematic picture of social structure (Gill,
2006).The concept of Social network analysis has been evolved from the basic image of social structure
where we see the social relation among the actors which involve the exchange of valued things which can be
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material, practical, informational or symbolic. The network analysis looks this interactions and exchange in a
network (S. Borgatti, 2011). This leads to linking of exchange theory to network analysis (Cook & Whitmeyer,
1992). As per Social Network Analysis (SNA) is concern in the areas like public health, in the last decade
researchers started to see SNA as a significant approach to understand spread of the communicable diseases
and linkages between different service providers in public health domain. Moreno (1934) looked into the
quick epidemic spread among the pupil in New York. He was the first to see the graphical representation of
the network. However, the system thinking approach, where system networks are an important element to
see the linkages, relationships, interactions, and behaviour among the actors that constitutes the entire
system (Don de and Adam, 2009)1. According to Blanchet and James (2013)2 ‘Social network analysis has not
been yet applied to Health systems research, which remains a nascent field of investigation’. Griffiths et al
(2012) explains self organizing and adaptive networks are central to future health care delivery. He argues
that social networking has potential to change the patterns of health inequalities and access to health care.
The analysis of health system actors provides information’s on the properties of systems and key influential
actors - How the elimination and entry of new actors affect the whole structure. Health system shows
significant change in the structure when it experienced key shocks, hence managing health systems requires
understanding of who the actors are? What is the relationship existing between them (Blanchet and James,
2013). Each RMPs participate in the social system with many other actors where Each actor act as a reference
point for other in decision making process (Knoke and Kuklinski,1982). Social anthropologist studies network
relations are effective in understanding diffusion of innovations among the physicians (Coleman and Kaltz,
1996). Rarely any study reflected on qualitative mapping of social structure to understand the genesis,
dynamics and evolution of RMPs network over time. Hence, understanding the dynamics of their dominance
in rural healthcare market and their support network is very pertinent. Hence, The study adopted Social
Network Analysis (SNA) approach to explore the genesis of social ties of RMPs with diverse health system
actors and identifies the gaps within the network and the drivers contributing their sustenance over the
years.
The Indian Sundarbans
The global shortage of health workforce to meet the health needs remains in the same pace which gets even
worst in geographically inaccessible regions. Sundarbans is the world largest contiguous single-tract
mangrove forest shared between two neighboring countries Bangladesh and India. The Sundarbans provides
buffer for the lives and livelihoods of 4.5 million people (SBCP, 2001). Around 1.4 million people are
1 Don de, S. & Adam, T. (Eds) (2009) system thinking for health system strengthening, Alliance for health policy and system research, WHO
2 Blanchet and James, (2013) How to do a social network analysis in health system research, Health policy and planning, pp: 438-446
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dependent on sundarbans for their livelihood activities where 0.25 million are directly dependent on it for
their household income. The health system of climatically fragile and geographically inaccessible Indian
Sundarbans is highly dominated by huge army of RMPs. In terms of the overall picture of the health service
provision in the Sundarbans, there exist a parallel structures where public, private and voluntary providers
operate in their respective convenient zones without effective linkage or regulation and leaving a large
section of population under -served. IIHMR’s previous research (Kanjilal et.al 2009 & 2012)3 on health and
health system in Indian Sundarbans revealed existing health system as far from being in a socially optimal or
desirable state. People often do not have many ‘desirable’ choices regarding health care. Publicly funded
health care facilities are either non-existent or non-functional in most of the vulnerable part. More so the
functional facilities are often physically inaccessible for a large section of population due to difficult-to
navigate terrain. Voluntary agencies (NGOs) only reach a small fraction of the population despite their best
efforts. Consequently, the gaps are filled in by a huge army of informal providers known as Rural Medical
Practitioners4 (RMPs) who practice modern medicine without any formal training or authorization (Kumar
et al., 2007; Kanjilal et al., 2008) – who act as the only resort in normal times as well as during climatic crisis. .
In India the terminology for defining Rural Medical Practitioners (RMP) is very diverse and different for
different context hence in this study by RMP we mean the private unqualified providers who provide curative
care without having any of the degrees for medicine recognized by Govt. of India (Gautham et al., 2014,
Kanjilal et al., 2008). It is important to note that the dependence on RMPs is discernibly higher for child
health care. About 85 percent of the ailing children sought treatment from RMPs making them an
important health system actor in Sundarbans (Kanjilal et.al 2012).
2. Study Objective:
To understand the structure and dynamics of RMPs network by assessing the contextual factors,
further its implications on health care delivery in Sundarbans.
To what extent rural medical practitioner network gets influenced by the healthcare market?
I. To identify the gap within the network by assessing the weak ties
II. To explore the ways of strengthening the weak ties.
3 Kanjilal, B. et al (2010) Health care in the Sundarbans (India): Challenges and plan for better Future, Future Health Systems, Institute of Health
management Research, Jaipur
Kanjilal, B. et al (2012) , How healthy are the children of Indian Sundarbans, Future Health Systems, Institute of Health management Research, Jaipur
4 Rural Medical Practitioners are often identified as ‘informal’, ‘unqualified’, less than ‘fully qualified ‘or simply ‘quacks’- A book ‘Transforming
Health Markets in Asia and Africa, improving quality and access for the poor’, edited by Bloom et al.
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3. DATA AND METHODS
3.1 STUDY SETTING: The study considered one Blocks of Indian Sundarbans that is Patharpratima
keeping in mind the presence of two geographic locations within it – deltaic (totally river locked) and non-
deltaic (connected with main land at least at one part). The block has also been selected considering
‘vulnerable blocks’ in terms of available service delivery space and physical inaccessibility (Kanjilal et al,
2010). The typical typography, geographical hurdles and multi ethnic composition of this population
makes it appropriate to explore the social ties of Rural Medical Practitioners with other health system
actors and the barriers and challenges to it.
3.2 SAMPLE: Total 34 participants selected purposively by maximum variation principle on seven
criterion- demographic characteristics (age, sex, and education) and service delivery (type of practice and
average monthly patients) from two geographic locations (deltaic and non-deltaic) of Indian Sundarbans.
Based on these seven criteria we made 23 categories (See annexure 1), from each category we selected
one or two RMPs depending on proximity to health centre by far and nearby.
Figure 1 Sampling Matrix
Multistage Purposive sampling based on Maximum Variation Principle
Block- Patharpratima, South 24 Parganas, West Bengal
Based on seven criterion
-
demographic characteristics (age, sex, and education) and service delivery (type of practice
and average monthly patients)
Demographic Characteristics
Age
Sex
Male/ female
Education
Less than Secondary/ Above secondary
Service Delivery
Type of practice
Allopathic/ Homeopathic
Average Monthly patient
Less than 760 / 760 & Above
P
resence of Government Health Centre
B
lock
P
rimary
H
ealth
C
entre (BPHC)
P
rimary
H
ealth
C
entre (PHC)
Deltaic
G.Plot (G.P)
Deltaic
-
Patharpratima(G.P)
Non-Deltaic – Digambarpur (G.P)
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3.3 DATA COLLECTION METHOD:
The study has taken Qualitative Ego-network method(Bott 1957, Mitchell 1969, Fisher 1982, Wellman
1990) where data were collected using personal-network research design which constitutes a focal node
called ‘Ego’ i.e. RMP and ‘Alters’ i.e. the list of people the Ego is directly connected to. A qualitative design
has been taken to serve the purpose of complete understanding of different dimensions of RMPs network.
Qualitative part help us to explore the real lived experience of social network (Emmel & Clark, 2009), what
passes through the network (Crow, 2004) and spatial embedding of network ties (Clark, 2007). It also
collected data on nature of ties an ego exhibit with a specific alters, alters attributes like sex, age and the
type of support received. To carry out the above the study undertaken the following steps:
3.3.A REFLEXIVE DAIRY: It is important to remember that participants as well as researchers bias
exists in all social research both intentionally and unintentionally (Fields and Kafai, 2009). To
minimize the same, we did reflexive diary prior to the data collection, which involved writing down
ones knowledge or perception regarding the research questions developed for the study. Then
keeping in mind those should not hinder during data collection period.
3.3.B ETHNOGRAPHIC OBSERVATIONS: A period of two months for general ethnographic
observations was the first step towards the study. The objective of this method is to understand the
social and physical context of the study area and its implication on the social network of RMPs. This
period was also helpful for rapport establishment with the villagers, RMPs, local NGOs, CBOs, and
other important members of the village.
3.3.C PARTICIPATORY NETWORK MAPPING: The study mapped out the social network of RMPs
keeping in mind three different inquiries (Edwards, 2010): the flow and exchange of resources, the
flow of information and ideas and the type of social support.
The process start with taking the demographic characteristics about the Ego (RMPs) like name, age,
sex, education and type of service of each network member was enumerated. This was followed by
the mapping exercise. We took the life history approach towards generating names of all the person
whom the Ego is connected to, life history gives an good opportunity to capture entire range of alters
which may not come while using traditional name generator exercise. The network mapping with
each of the sampled Ego was started by taking them into historical timeline where each of them were
asked about their life history, when they decided to come into this profession, who were all
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supported and motivated, how they proceeded (See figure 2). Slowly the names of actors started
coming out and we asked them to free list all those people whom they perceives that they routinely
provide with the interpersonal social support. To understand the strength of ties we have measured
the frequency of contact of RMPs with each alters on scale of 1 to 5: 1-Very frequent, 2- Frequent, 3-
Sometimes, 4-Rare, 5- Very rare (See figure-2) In the second stage, after mapping the network more
in-depth understanding on the most crucial points has been done by taking in-depth interview. This
process helped to get in-depth insight and rich narrative of the entire network and its genesis. These
data has been collected keeping in mind to gain a more textured understanding of the different
dimensions of the networks, underlying the provision of support, and the utilization of support
networks and continuity of this support in the immediate and routine context.
Figure 2 Participatory network mapping process
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3.4 DATA COLLECTION PERIOD:
The source of data is primary collected over the period of 6 months (not continuously). Keeping in
mind the geographical inaccessibility issues during monsoon the data collection was started post
monsoon. Data collection was done in three phases- First phase is Ethnographic Observations
constitutes the ethnographic field work and piloting which was carried out the month of October-
November, Second phase is Social Network Analysis constitutes the main data collection covering all
samples in the month of December- January and the third phase is Data saturation carried out in the
month of March-April 2016.
3.5 DATA MANAGEMENT:
The study produced following types of data in accordance with IRB Human subject protocol. Data are
Qualitative in nature generated from Participatory Network Mapping, Life histories and in-depth
interviews (IDI) and Ethnographic field work. The different forms of data are:
Field notes and participant observation
Text Transcription of IDIs and audio recordings
Digital photographs of the social network analysis process
3.5.A. DATA FORMATS: The above forms of data has been kept in following formats: Text of field
notes, interviews and participant observation were in their original language and has been saved in rich
text format (.rtf) in order to allow maximum accessibility on multiple software programs. Audio
recordings of all the interviews was transcribed into textual form (.rtf) and also kept in .mp4 format to
allow accessibility. Digital photographs were converted and retained into TIFF version 6 uncompressed
(.tiff) formats. All the data formats will be anonymized in accordance with IRB human subject protocol.
3.5.B. DATA STORAGE: All the data and analysis files were stored safely in digital form in various
locations which allows maximum accessibility as well as longevity of storage. The medium of storage
are external hard drives, Digital Versatile Discs (DVDs). For long term and safe preservation all the data
has been stored in Cloud-Microsoft One-drive. Any updates in the data files and analysis files if done,
will be systematically updated in all the storage locations. The Metadata has been maintained in
specific format (.xlsx) which will include the date, time, role and responsibility, file type, and file
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location mentioned in a detailed way for each and every steps starting from data collection, entry,
cleaning, coding and analysis.
3.5 DATA ANALYSIS:
The qualitative essence: The different types of data like interviews were tape recorded and textual
data like observation notes and diary entries were directly imported and managed in qualitative data
analysis software NVivo (QSR International Pty Ltd, version 10). An extensive interpretative thematic
approach to the analysis was considered. The recordings were coded broadly based on the thematic
coding tree. The textual data were also coded line by line following the selective code categorization.
Links and relationships between the categories were explored based on analytical concepts from
Social Network Theory. An iterative process was used to derive the codes which were then compared
with the existing literature. The coding process has been done by two individual researchers to
compare the inter-coding validity. To measure it observations on emerging difference in codes and
themes were compared and discussed as a part of the analysis. The codebook development
procedure was the combination of static (predefined or partially defined based upon the hypothesis
or secondary literatures) and evolving codes (emergent knowledge from the data itself).
Network Visualization: The network measures and visualizations have been analysed by using
software for social network analysis named Gephi-open access (McSweeney, 2009). The measures
like network size, graph density, network diameter, modularity has been calculated
3.6 DATA SATURATION
In qualitative research addressing data saturation is one of the challenges. Data triangulation is the
method to address data saturation (Denzin, 2009, (Fusch & Ness, 2015) In this study, we followed
methodological triangulation by collecting data through various medium like Participatory mapping,
Indepth interview, and ethnographic field work. Also the data saturation has been explored by four steps:
1) across the aspects 2) across tools 3) within groups 4) across groups. Keeping these aspects in mind a
saturation grid has been developed after one round of data coding and data saturation was assessed. To
understand few unexplored areas, after one round of coding in NVivo we compared the data and went for
second round of data collection. NVivo provides an excellent opportunity to understand data saturation.
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3.7 ETHICAL CLEARANCE:
The study has been ethically reviewed and approved by IIHMR ethical review board dated 20/06/2015.
The study tools and methods designed for these purposes have kept in mind the socio-cultural sensitivities
and rights of the respondents. All respondents of the interviews have been informed of the objectives and
procedures involved in the study. A written consent has been obtained from all the respondents regarding
participation in the study. All respondents have read and provided with the copy of the consent form
which includes the following information – a) details of the study- objective, methods, key areas of
information sought; b) Voluntary participation: Declaration of the right to refuse participation or accepting
participation; c) Confidentiality. Complete anonymity of the data will be maintained. No identifiers of the
persons involved will be divulged outside the research team. The data will be used purely for academic
and research purposes. d) Declaration of Risks and Benefits- No specific risk is posed by the study. No
specific incentives will be provided for participation; e) Contact Information – Complete details of the
interviewer, address, and email and office phone number.
4. RESULTS
The main findings of the study relates to the social network of RMPs showing their relationship with
various health system actors. It constitutes the web of connected strong and weak social ties between
RMPs and various health system actors. The sections has been divided according to the objectives of the
research into three parts- 1) Profile of RMPs 2) The social network of RMPs with diverse health system
actors 3) Changes in network over time
4.1 Profile of the RMPs
Among the 34 RMPs who were participated in network mapping and interview (N=34), the average age
was 48 years (range = 27 to 68). The sex was skewed towards one side that is Male, out of 34; there were
only one Female and 33 Male respondents. 21 out of 34 discussions have been taken place in RMPs clinic
and 12 have been taken place in RMPs home. The average year of experience is 29 years. They have
different kinds of specialization (they are famous for) like child, gynaec, ganglion disease, dental,
Ayurvedic, Orthopedic, surgical, gastro, dermatology etc. The place of practice are of three types- own
clinic, home and door to door visit. Most of them have two or more options. Also they perform OPD in
some medicine shops or diagnostic centers. Most of them took land or chamber on lease. Very few have
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owned clinic (3 out of 34). They got interest and guidance from their father or uncle to get into this
profession. Some CBOs also supported few of them to open up the clinic by providing land.
The presence of RMPs in Rural Sundarbans is very high, in FHS-IIHMR previous study we found 375 RMPs
in a Patharpratima block in year 2012 (see figure 3), now it has increased to around 1200 verbally reported
from RMP association. They are very densely situated even around the government health facilities. The
FHS study found their concentration is quite high in deltaic location due to geographical inaccessibility.
Figure 3 The GIS Map of RMPs in Pathrapratima block of Indian Sundarbans
Source: GIS data FHS-IIHMR 2013
4.2 THE SOCIAL NETWORK OF RMPs WITH DIVERSE HEALTH SYSTEM ACTORS
The structure constitutes the interaction between various actors via social ties which establish web of
patterned relationship which involves flows of information’s exchange. The actors are able to identify each
other’s within the system by their intrinsic properties through spatial and temporal relationships between
them. The following section explains the types of social ties present between RMPs and various health
system actors, the type of support they receive from each other, network measures, presence of strong
and weak ties, changes in network over time and its impact on health system functioning.
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4.2. A. THE SOCIAL TIES:
The study found three types of significant ties in RMPs network viz, with Government Healthcare actors,
Private healthcare actors and Community actors. These linkages have been developed over the years due
to the evolving demand and unavailability of quality health facilities. In all the three categories we can
understand how the information and resources flows through social ties. RMPs in deltaic location exhibit
higher and denser number of social ties with Private healthcare actors (517) and community actors (392) in
comparison with government healthcare actors (165).
4.2.A.1 THE TIES WITH GOVERNMENT HEALTHCARE ACTORS:
The study found mixed linkages of RMPs with government healthcare actors. The deltaic networks is
dense and closely associated whereas the non-deltaic network is sparse and weakly tied. The reason
reported is the RMPs in non-deltaic locations are more accessible to nearby towns and cities; they are
more dependent on private healthcare actors rather than government; whereas due to geographical
inaccessibility the deltaic RMPs have to maintain formal relations with ground level government health
actors. The following actors in this category are- Doctors posted in government facility/institutions
(MBBS/MD/MS); frontline health workers like ASHA, ANM and AWW; compounders; government
medical colleges, government training institutions and government hospitals like Sub-divisional
Hospitals and Rural Hospitals.
The type of relational ties (Adapted from Wasserman and Faust 1994) found are-
Formal relations.
Kinship
Advice and Referral
Formal relations:
o RMP maintain formal relations with BPHC and PHC for referring pregnant mothers, vaccination. The
formal relation of RMPs with the ASHA and ANM is there in terms of connecting pregnant mothers with
ASHA after the preliminary test done. An RMP says: “If I see positive result I immediately call up ASHA and
inform about the patient or ask the patient to consult ASHA; because nowadays we have been instructed
not to perform any delivery. Hence I never indulge in such cases”.
Kinship:
o RMPs exhibit few biological social ties with the government doctors who provides advice on the line of
treatment and also ask for support when organize any vaccination camps in the village. An RMP says: “My
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father, and grandfather both of them were doctor, I learnt everything from them. They did a lot for the
village people. At that time there were no hospitals nearby, they were the only one to provide healthcare
services. They motivated me for this profession”.
Advice and Referral
o RMPs made good relationship with government hospitals doctors like PG Hospital, Kolkata; and Calcutta
medical college. They connect with them over phone if they got stuck in any critical problem while
treating patient in village. As per the directions received from the doctors based on the symptoms
explained they function accordingly. An RMP explain one of the situations: “One day patient family calls
me up and asked to come urgently, She was not my patient, I told them no because I don’t want to take
the responsibility if anything goes wrong. Still they requested and I went there and saw their daughter in
law has gone through home delivery via untrained traditional birth attendant. The situation was very
critical, I checked and saw the legs coming out, I observed it is breech delivery, I suggested them to take
her outside to some nursing home or hospital. But here the accessibility is a major obstacle. If we want to
go outside in an emergency case we cannot go immediately. So I took the risk because I had an experience
with one or two breech delivery. I called my senior Gynaec, that time he was in Operation theatre in AMRI
Hospital salt lake, still he said “tell me fast”. I explained, he said- pull out, I took the baby out then, saw
there was another baby inside, even the patient family didn’t know about the second baby as they didn’t
done any USG. He said, listen to me carefully and do it. I did accordingly and saved her”. Another RMP
says: “we always been in touch with some senior Gynecologist before handling critical delivery cases”.
The RMPs in deltaic location exhibit relatively denser linkages in comparison with the non-deltaic which is
sparse and loosely connected. Overall, the strength of majority of ties is very weak. In deltaic, 42 percent
of ties are in scale of five (very frequent) with the Government doctors in City hospitals, few doctors in
kinship relation, government hospitals. Only Five percent of the ties are weak found in the scale of one
(very rare) with Sub divisional hospital and government doctors in BPHC and PHC which is comparatively
lesser (28 percent) in non-deltaic locations. On the other hand, in Non-deltaic, the strength of ties is
somewhat equally distributed and the Very frequent ties are with PHC Doctors, and sub divisional
hospital. The very rarely contacted actors are 6 percent in deltaic whereas it in 17 percent in non-deltaic
where the prominent actors are ASHA, ANM, AWW (See figure 4 & 5). The number of linkages in deltaic
(165) is very high in comparison with non-deltaic (47) (see table 1 & 2).
18 | P a g e
Figure
4
.
The frequency of contact between RMPs
and Government Healthcare providers in deltaic
locations
Figure
5
.
The frequency of contact between RMPs
and Government Healthcare providers in non-
deltaic locations
Figure 6. The social network of RMPs with
Government Healthcare providers in deltaic
locations
Figure 7 The social network of RMPs with
Government Healthcare providers in non- deltaic
locations
42%
35%
15%
2% 6%
Strength of ties between RMPs in deltaic
locations with Government Healthcare
actors
Very frequent Frequent
Sometimes
Rare
Very rare
28%
20%
13%
22%
17%
Strength of ties between RMPs in Non-
deltaic locations with Government
Healthcare actors
Very frequent Frequent
Sometimes Rare
Very rare
19 | P a g e
Table
1
. The social network matrices of
figure 6
Deltaic Location
No of nodes
96
No of edges
165
Modularity
0.512
Average degree
1.53
Average weighted
degree
12.30
Network density
0.016
Network diameter
1
Connected
components
Weakly connected
-
1
Strongly connected-96
Average path
length
1
Table
2
.The social network matrices of figure
7
Non-Deltaic Location
No of nodes
43
No of edges
47
Modularity
0.561
Average degree
1.093
Average weighted
degree
6.744
Graph density
0.026
Network diameter
1
Connected
components
Weakly connected
-
6
Strongly connected-43
Average path
length
1
Source: Primary data analyzed in Gephi software
4.2.A.2 THE LINKAGES WITH PRIVATE HEALTHCARE ACTORS:
The study found diverse connections of RMPs with private healthcare actors. The linkages are dense and
closely associated (see figure 10 & 11). The following actor’s are- Private qualified doctors, Private
nursing homes, Diagnostic centers, medical representatives from various pharmaceutical companies,
medicine wholesalers and distributors, journalist, private training institutions, chemist, private
ambulance services, unions and associations.
The type of relational ties (Adapted from wasserman and Faust 1994) found are-
Taking advice on the line of treatment and referral.
Transfer of material resources
Capacity building
Movement between places
Behavioral interactions.
Taking advice and referral:
o There exist a symbiotic relationship between the RMPs and private healthcare actors.
Majority of RMPs reported they get continuous advice and mentoring on the line of
treatment and referral over phone or by visiting private qualified providers via private
20 | P a g e
healthcare market ties. Almost all RMPs are dependent on Private qualified doctors who visit
nearby towns like Kakdwip and Patharpratima and Diamond Harbour for OPD services (See
Figure 10 & 11). Over the years they have developed close ties with them by taking patients
for treatment based on severity of the disease and unavailability of instruments and other
facilities. Due to behavioral interactions and incentives from the medicine wholesalers where
the doctors conduct the OPD since then they are embedded in a dense linkages.
o Private Nursing Home (PNH) also acts as a bridge in developing the network between the
RMPs and the specialized doctors (See Figure 10&11). Type of supports provided, are
knowledge, suggestions and advice on critical situations. The nursing homes also provide
incentives (10percent of the total cost) to the RMPs for taking or referring patients for any
kind of operation. Few PNH are accredited with government insurance scheme like Rastriya
Swasthya Bima Yojana(RSBY) and safe motherhood intervention like Janani Suraksha Yojana
(JSY). It helps the patient family to access the services and also RMP get incentives and advice
from the doctors in Nursing home.
Transfer of material resource and capacity building:
o The medicine wholesalers act as a medium in developing the connections between the RMPs
and the Pharmaceutical Multinational Companies (MNC)(See Figure 10&11). The
pharmaceutical MNCs arrange conference and workshops in nearby towns and update them
on new diseases, new drugs and its use. Medical representatives also visit each RMPs to
update on latest drugs and also supplies medicines.
o RMPs are very well connected with the diagnostic centre’s play a crucial role(See Figure
10&11). They provide agents who visit the RMPs and collect the samples which help them in
preliminary diagnosis the patient’s conditions being located in such a remote region.
Private Training institutions:
o RMP exhibit linkages with several institutions like alternative medical college, BHIMS college,
Indian dental association, and Humai association, which provide the training on following
areas- RMP training, paramedics training, poly clinic, RNTPC training, essential drug
practitioner, BIAM, Family worker training, community medicine and science.
Movement between places:
o Due to shortage and unavailability on time of Public Ambulance many Private Ambulance has
started from last five years. RMPs maintain a good relationship with them and call at the time
of emergency. They address the issue of geographical inaccessibility to a larger extent.
21 | P a g e
The strength of ties with private healthcare providers is very equally distributed in both deltaic and non-
deltaic locations; in deltaic 31 percent is very frequently contacted actors which is 33 percent in non-deltaic
(see figure 8&9). The actors constitute private specialist doctors, Nursing homes, Diagnostic Centers,
medicine wholesalers’, private ambulance and medical representatives (see figure 10&11). Rest others also
exhibit similar strength except the very rare case where it is 7 percent in deltaic and 22 percent in non-deltaic
(see figure 8&9). The actors are private hospitals, Medical representatives and medicine shops (see figure
10&11).
Figure
8
. The frequency of contact between RMPs and
Private Healthcare actors in deltaic locations
Figure
9
. The frequency of contact between RMPs
and Private Healthcare actors in non- deltaic
locations
The RMPs network with private healthcare actors is dense in deltaic and scattered in non-deltaic locations
(See Figure 10 & 11). As the deltaic location is largely inaccessible hence, RMPs always remain in touch with
private qualified doctors for advice. The number of linkages in deltaic (516) is very high in comparison with
non-deltaic (146) (see table 3 & 4).
31%
34%
16%
12%
7%
Strength of ties between RMPs in deltaic
locations with Private Healthcare actors
Very frequent Frequent Sometimes Rare Very rare
33%
18%
13%
14%
22%
Strength of ties between RMPs in Non-
deltaic locations with Private
Healthcareactors
Very frequent Frequent Sometimes Rare Very rare
22 | P a g e
Figure
10
. The social network of RMPs with Private
Healthcare actors in deltaic locations
Figure
11
.The social network of RMPs with Private
Healthcare actors in Non-deltaic locations
Table
3
. The social network matrices of figure 10
Deltaic Location
No of nodes
367
No of edges
516
Modularity
0.658
Average degree
1.406
Average weighted
degree
10.305
Graph density
0.0
4
Network diameter
1
Average path length
1
Table
4
. The social network matrices of figure 11
Non
-
Deltaic Location
No of
nodes
123
No of edges
146
Modularity
0.632
Average degree
1.187
Average weighted
degree
7.504
Graph density
0.01
Network diameter
1
Average path length
1
Source: Primary data analyzed in Gephi software
4.2.A.3 THE LINKAGES WITH COMMUNITY ACTORS:
RMPs are embedded in the community. They practice in the same village where they have born. Hence
their community social ties are very important to capture. Over the years they received blind faith from
the Community because of their all time availability during night, in case of emergency, and in case of any
climatic hazard. They remain with the community and serve them to a greater extent utilizing their above
two categories of social ties i.e with Government Healthcare actors and Private healthcare actors. The
23 | P a g e
following types of community actors found with whom RMPs exhibit social ties- the family, the relatives,
school teachers, Community Based Organisation(CBO), Non Governmental Organisation (NGO), Panchayati
Raj Institutions (PRI), RMP association, boat-van puller association, Member of Legislative Assembly
(MLA), and political leaders. Over the years they built blind faith from the community by giving
unconditional support and health care services during the emergency cases where thinking of providing
the public services is a myth.
The type of relational ties (Adapted from Wasserman and Faust 1994) found are-
Biological relationship or Kinship
Behavioral interaction
Movement between places
Formal relations
Association or affiliation
Biological relationship or Kinship
o RMPs are part of community. They exhibit strong linkages within their biological relations. They
received mental, motivational and financial support from the kinship ties. This type of ties is prominent
in only this category of community actors not in others two categories. The following actors came under
the kinship ties are Father, mother, brother, sister, sister-in-law, husband, wife, relatives, son,
grandfather, and brother-in-law.
Behavioral interaction
o Through behavioral interactions RMPs developed social ties with School teachers, CBOs, NGOs, and
political leaders. They stand besides the RMPs in any cases of emergency and disaster. School teachers
call RMPs to the school in case a student gets ill.
Movement between places
o The two important linkages under this relation tie are with Boat services and van puller association.
In case of any emergency RMPs call them directly to take the patient to nearby hospitals or outside the
village. During night, the boat service took huge amount to cross the river, RMPs have a good
connection with them and due to developed relation they negotiate with them based on patient family’s
financial situation. The boat and van services also help in transportation of medicines and pathological
samples like blood to and from the vendor. An RMPs says ‘I delivered 28 babies in last 3 years on boat
while crossing the river or when the boat gets non-functional, out of fuel otherwise they would have died
on the way due to heavy bleeding’.
24 | P a g e
Formal relations
o They exhibit formal relations with local administrations like Block development officer (BDO) and PRI.
Association or affiliation
o Some RMPs belongs to elite families in the village or with political family background. They have
proper association with local administration like PRI and BDO. The groups of RMPs formed association or
unions. These association initially started training by outsourcing qualified doctors from cities. Almost all
the RMPs who were above 40 years have taken training from those doctors and applied the knowledge
in practice over the years. They maintained the connection with those doctors to take advice over
phone. They acknowledge the training was very useful for them and the advice over phone is helping
them built their own capacity.
As they are community embedded, their strength of ties shows very strong in both the categories deltaic
and non deltaic (46 percent and 51 percent respectively) in comparison to other two type of linkages i.e
with government health actors and private healthcare actors (see figure 12&13)
Figure
12
.The frequency of contact between RMPs
and Community actors in deltaic locations
Figure
13
.The frequency of
contact between
RMPs and Community actors in non- deltaic
locations
46%
25%
16%
7% 6%
Strength of ties between RMPs in deltaic
locations with community actors
Very frequent
Frequent
Sometimes
Rare
Very rare
51%
15%
19%
7% 8%
Strength of ties between RMPs in
Non-deltaic locations with
community actors
Very frequent Frequent Sometimes Rare Very rare
25 | P a g e
The overall network diameter is higher for deltaic location which is lesser in non-deltaic. The number of
linkages in deltaic is 390 which is very high in comparison with non-deltaic -94 (See table 14 & 15)
Figure 14.The social network of RMPs with
Community actors in deltaic locations
Figure 15.The social network of RMPs with
Community actors in Non-deltaic locations
Table
5
. The social network matrices of figure 14
Deltaic Location
No of nodes
332
No of edges
390
Modularity
0.773
Average degree
1.175
Average weighted degree
9.392
Graph density
0.004
Network diameter
4
Average path length
1.975
Table
6
. The social network matrices of figure 15
Non-Deltaic Location
No of nodes
84
No of edges
94
Modularity
0.691
Average degree
1.119
Average weighted degree
8.667
Graph density
0.013
Network diameter
3
Average
path length
1.38
4.2.B CHANGES IN NETWORK OVER TIME
According to social network theory (S.P.Borgatti,Mehra,Brass,&Labianca,2009) every social network changes
over the years involving entry of new actors and exit of already existing actors. It is very difficult to measure
the change in social network. Hence the study adopted life history as a tool to capture the changes. Over the
years, RMPs network has also changed following the entry of actors like frontline health workers like ASHA,
26 | P a g e
ANM, AWW, Private nursing homes, private ambulance services, private specialized doctors. The exit actors
observed are Traditional Birth attendant (TBA) and traditional healers
5. CONCLUSION
The study illuminates the social context, and structure of RMPs network by understanding the context
embedded healthcare market dynamics. This network comprises of strong and weak social ties which acts as
a safety net for RMPs to cope with daily existence stressors. They have strong linkages with the community
because of trust, round the clock availability and affordability. Additionally, they had dense ties with private
healthcare providers and healthcare market for continuous advice and mentoring on the line of treatment
and referral. Presence of ‘structural hole’ due to negligible grouping, small and sparse network with the
government providers’ mainly frontline health workers was major barrier for effective functioning of any
health system. The study found possible measures to strengthen the weak ties exist within RMPs network.
6. DISCUSSION
The social construct of RMPs highlights the complex relationship existing between various actors within the
health system. They are very resilient actors within the health system. Over the years, community
embedded RMPs respond to the health system crisis by utilizing their strong social ties with various health
system actors. The characteristics of these linkages as a whole may be used to interpret the social behavior
of the informal healthcare market. RMPs have the potential to complement the formal health system
providers, both in normal times and during health system crisis. Their network acted as backbone which
leads them to fight with the Health system crisis and cope with the frequent climatic shocks facing the
islanders in remote Sundarbans. RMPs strong linkages with communities and healthcare market ensure their
potential role in achieving universal health coverage by working as community health worker. Strengthening
of weak ties can act as a catalyst to enhance equitable healthcare service delivery to meet the health need
of these vulnerable communities. The RMPs are firmly embedded in the health system due to their social
ties which calls urgent policy level exploration of how to regularize and integrate this parallel health market
who are solely catering the health needs of vulnerable communities. Given their strong linkages with the
communities and healthcare market ensure their potential role in achieving universal health coverage by
working as community health workers. Their integration into the health system enable focus on cost
effective, resource mobilization and sustainable solutions to address health inequities especially for the
geographically vulnerable communities in India as well in other countries. This report will help readers to
27 | P a g e
understand the context embedded healthcare market dynamics and inform the decision makers during pilot
and up scaling of their RMP mainstreaming initiative to achieve Universal Health Coverage.
7. PROSPECTIVE PAPERS, BRIEFS AND BLOG FROM THE STUDY
Journal publication:
The significance of social ties of informal health providers : social network analysis from
Indian Sundarbans
Qualitative sampling in social network analysis
Understanding Data saturation in social network analysis
Qualitative method in data collection for Ego-network analysis: Life history approach
Brief:
Use of Social network analysis in understanding Informal health market
Strength of weak ties in Informal Healthcare market
Blog: (Published)
Titled- Incorporating rural Medical Practitioners to shore up universal health coverage
http://www.futurehealthsystems.org/blog/2016/1/12/incorporating-rural-medical-
practitioners-to-shore-up-universal-health-coverage
8. ANNEXURE
Annexure 1: The sampling categories
Categories No. of RMPS
selected
based on
(proximity to
health centre
1-far/2-close)
C1: Less than 45
yrs/male/less than
760/ secondary&
above/ allopathic
2
C2- Less than 45
years/ Less than 760/
Above secondary/
Homeopathic
2
C3-Less than 45 years/
760 & Above/ Above
secondary/
Homeopathic
2
C4- Less than 45
years/ 760 & Above/
Above secondary/
Allopathic
2
C5- 45 & Above/ Less
than 760/ Above
secondary/ Allopathic
2
C6- 45 & Above/ Less
than 760/ Above 2
Categories No. of RMPS
selected based
on (proximity to
health centre 1-
far/2-close)
C8- Less than 45 years/
male/less than 760/ above
secondary/ Allopathic
2
C9-Less than 45 years/ male/
less than 760/ above
secondary/ homeopathic
2
C10- Less than 45 years/ male/
less than 760/ above
secondary/ gynaec
1
C11- Less than 45 years/
male/760 & above/ above
secondary/ skin
1
C12- Less than 45 years/
male/760 & above/ above
secondary/ allopathic
2
C13-Less than 45 years/
Female/ Less than 760/ Less
than Secondary/ Homeopathic
2
C14- 45 & above years/ male/
less than 760/ above
secondary/ Allopathic
2
C15- 45 & above years/ male/ 1
Categories No. of
RMPS
selected
based on
(proximity
to health
centre 1-
far/2-
close)
C18- Less than 45 years/
male/less than 760/
above secondary/
Allopathic
2
C19- Less than 45 years/
male/less than 760 /
above secondary/
homeopathic
1
C-20 Less than 45 years/
male/760 above/ above
secondary/ homeopathic
1
C21 - 45 & above years/
male/less than 760 /
above secondary/
allopathic/ secondary/
Allopathic
2
C22- 45 & above years/
male/less than 760 / 2
28 | P a g e
secondary/
Homeopathic
C7- 45 & Above/ 760
& Above/ Above
secondary/ Allopathic
2
less than 760/ above
secondary/ Homeopathic
C 16- 45 & above years/ male/
above 760/ above secondary/
Allopathic
2
C17- 45 & above years/ male/
above 760/ above secondary/
homeopathic
1
above secondary/
Homeopathic
C23- 45 & above years/
male/760 above/ above
secondary/ allopathic
1
Annexure 2 : Abbreviations used for Alters
ANM
Assistant Nurse Midwife
Pvt Car
Private car
ASHA
Accredited Social
Health Activist
Pvt Clg
Private college
AWW
Aanganwadi Worker
Pvt Doc
Private doctor
BIL
Brother
-
in
-
law
Pvt Doc cardio
Private doctor
-
cardiologist
BMOH
Block Medical Officer of Health
Pvt Doc child
Private doctor
-
pediatrician
BPHC
Block Primary
Health centre
Pvt Doc ENT
Private doctor
-
ENT
BPHC Doc
Block Primary Health centre doctor
Pvt Doc Gynaec
Private doctor
-
Gynecologist
CBO
Community Based Organisation
Pvt Doc Neuro
Private doctor
-
Neurologist
CMOH
Chief Medical Officer of Health
Pvt
Doc ortho
Private doctor
-
Orthopedic
Diag Cntr
Diagnostic centre
Pvt Hosp
Private car
DIL
Daughter
-
in
-
law
RMP
Rural Medical Practitioner
EX BMOH
Ex
-
Block Medical Officer of Health
SDH
Sub
-
Divisional Hospital
Gov Doc
Government doctor
SIL
Sister
-
in
-
law
Gov Doc homeo
Government doctor homeopathic
TBA
Traditional Birth Attendant
Govt Hosp
Government Hospital
Trng Inst
Training Institution
Govt Training Inst
Government training institute
Vet Doc
Veterinary Doctor
Med Distb
Medicine
distributor
MP
Member of parliament
Med Shp
Medicine shop
MR
Medical representative
Med whl
Medicine wholesaler
NGO
Non
-
Governmental Organisation
MLA
PHC
Primary Health Centre
PHC Doc
Primary Health Centre Doctor
PRI
Panchayati
Raj Institutions
members
PNH
Private Nursing Home
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Informal health care providers (IPs) comprise a significant component of health systems in developing nations. Yet little is known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap we conducted a comprehensive literature review on the informal health care sector in developing countries. We searched for studies published since 2000 through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. The review found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems. Research and policies of engagement are needed.
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Emmel, N., & Clark, A. (2009). The Methods Used in Connected Lives : Real Life Methods, the Manchester / Leeds Node of the National Centre for Research Methods, (September).
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George, A., & Iyer, A. (2013). Social Science & Medicine Unfree markets : Socially embedded informal health providers in. Social Science & Medicine, 96, 297-304. doi:10.1016/j.socscimed.2013.01.022
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