Infant and child mortality has declined dramatically across the globe in recent decades, in large part due to public health measures such as universal vaccination, better nutrition and improved health care services. However, deaths remain much higher in poor disadvantaged populations, in part, because of such issues as lower vaccination rates. A critical issue is the delay in infants obtaining skilled health services during illness. Children’s caregivers may not initially realise the seriousness of the child’s condition and as a result may not access appropriate health services. Key inhibiting factors are limited knowledge of critical symptoms and restricted access to professional advice. In addition the caregivers may lack quick and affordable access to appropriate services. Publically provided health care is often overcrowded and associated with poor service. Consequently caregivers generally rely on the private sector for assistance. While this may mean seeking treatment from trained health providers, for the poor who are unable to afford their services, it may mean seeking services from the informal sector.
In a recent paper, (Caldwell, B.K.; Rashid, S, and Murthy, S. (2014): ‘The informal health sector and health care-seeking behaviour of mothers in urban Dhaka slums’, Journal of Population Research, 31 (2), pp. 111-129), we explore some of these issues by examining the infant and child health care-seeking behaviour of women living in the urban slums of Dhaka, Bangladesh, and their use of health services, particularly in the informal health sector. We focus on the key role of pharmacists, who typically have little or no medical training, but perform a critical function in providing health services and advice for the urban poor.
The study draws on quantitative data from 847 interviews with ever-married women aged 15-49 years conducted in three slums in 2005. This was subsequently augmented by qualitative research from extended interviews conducted in two of the slums in 2006 with 42 mothers (‘caregivers’) and 18 health providers primarily from the informal sector.
The slum areas were not randomly selected but they were broadly representative of Dhaka’s slums. The selected areas were characterised by congested alleyways and flimsy housing. They had no proper roads or pavements, no government-provided services such as piped water, sewerage, electricity or gas (though unofficial connections, especially to electricity were common. Poor water provision and sanitation meant that drains overflowed with rubbish, sewerage and excrement, particularly during the wet season. However, they were located reasonably near major hospitals and other health facilities. Pharmacies were located either in or immediately adjacent to the slums.
The respondents’ answers emphasised the overwhelming importance of the informal sector in the provision of health care. In the quantitative survey the 513 respondents whose youngest child was aged less than 5 years were asked whether the child had been ill with a fever in the last two weeks. Of the 247 (48%) who had been, treatment had been sought for 199 (81%). Of these 199 cases, in 124 cases (62%) a pharmacist was cited as one of the sources of treatment – in 115 cases (58%) pharmacists were the only source sought. In comparison the combined formal sector (government sector, private medical doctors and clinics and NGO sector) were cited as a source of treatment in only 62 (31%) cases.
To gain a better understanding of the reasons for the predominance of the informal sector the respondents were asked about the advantages and disadvantages of the different types of health provider that they regularly dealt with. Overall they expressed most satisfaction with local providers including informal sector providers, such as pharmacies and traditional healers, but also private doctors, who were seen as more convenient, friendlier, and in the case of the informal sector, cheaper. Of the 541 respondents who answered the question regarding pharmacists 487 (90%) cited easy accessibility as an advantage. Few respondents saw any disadvantages for the informal sector.
The caregivers’ qualitative interviews reinforced the confidence that people expressed in informal health providers, and particularly pharmacists. Caregivers perceived most healthcare providers, formal and informal, to be respected figures in the community. Pharmacists were often referred to as ‘doctor’. Most caregivers preferred first seeking a provider in the informal sector, usually a pharmacy owner. Caregivers found local pharmacies more approachable than providers in clinics or hospitals. Because their incomes often depend substantially on poorer clients or customers, pharmacists are conscious of maintaining good relationships and providing medicines that are clearly understood. Pharmacists allowed caregivers to pay later or on credit helping to create continuing relationships. In contrast, hospitals and clinics, located sometimes nearby but usually outside of slums, typically have long waiting times and are perceived as treating poor patients badly, with treatment biased towards patients from higher socio-economic backgrounds.
The service of the pharmacists was particularly valued by women who in urban areas have increased responsibility for obtaining healthcare for their children. Historically men interacted with non-family members, while women stayed indoors. Men were also responsible for financial matters. Urban settings, where nuclear family structures are the norm and men work elsewhere, require women to interact with strangers, including health care providers. Women have to make key decisions regarding child health care costs with minimal input from family, and often limited financial resources. Mothers often must choose accessible, economically prudent and trusted health providers for their children. Pharmacists meet that need.
This reliance on pharmacists has dangers. Pharmacy owners rarely possess formal training to properly diagnose illnesses in children – particularly serious illnesses needing more extensive medical attention. They may delay effective care for many infants and children by not providing needed referral to trained providers in a timely manner. However, pharmacists also offer low-cost treatments to caregivers with few available alternative options. Oral rehydration solution, antibiotics and other treatments for common childhood illnesses provided by pharmacy owners have contributed significantly to the decline in under-five mortality in recent years.
The informal sector, including pharmacists, will remain a major part of Bangladesh’s health sector for many years as increasing demand for health services is unmatched by supply in the formal health sector. Ignoring its role has serious implications for ensuring the provision of effective services for those most in need.