Governing the mixed health workforce: learning from Asian experiences

Abstract

Examination of the composition of the health workforce in many low and middle-income countries (LMICs) reveals deep-seated heterogeneity that manifests in multiple ways: varying levels of official legitimacy and informality of practice; wide gradation in type of employment and behaviour (public to private) and diverse, sometimes overlapping, systems of knowledge and variably specialised cadres of providers. Coordinating this mixed workforce necessitates an approach to governance that is responsive to the opportunities and challenges presented by this diversity. This article discusses some of these opportunities and challenges for LMICs in general, and illustrates them through three case studies from different Asian country settings.

Diversity in the editorial boards of global health journals

“…Representation of women in medical journals has been studied extensively including for authorship, peer-reviewers and editorial positions in several medical specialities,5–14 with only a few studies analysing geographical diversity 15 16. Although many journals champion diversity narratives in several domains of global health,17–19 the issue of diversity in specialty global health journals has not been studied previously.…”

Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia

“…Private HCPs are used substantially more than public HCPs in many low-income and middle-income countries (LMIC). Their dominance is particularly pronounced in many Asian countries 3–7. This heterogeneous group encompasses traditional healers as well as allopathic ‘western medicine’ providers, of which some are highly qualified and officially licenced by the government (referred to as formal providers) while others do not have qualifications or licensing that is recognised by local authorities (referred to as informal providers) 3 8–10…”

A National Survey of Private-Sector Outpatient Care of Sick Infants and Young Children in Nepal

“…Our study documented deficiencies in quality for both medicine shop-based practitioners and private physicians but, as documented in nationally representative household surveys [10,11], medicine shop providers are clearly filling an important need. Currently, efforts by major global health actors addressing outpatient care of sick infants and children focus almost exclusively on peripheral-level government primary healthcare services and community health workers, under the rubric of IMNCI and iCCM, although there is a growing recognition of the need to engage private providers [22,23,34]. In settings like Nepal, most such care is actually provided by informal or semi-informal private practitioners.…”

“…In both Nepal and Bangladesh, medicine shop-based practitioners are responsible for a large proportion of outpatient care of sick infants and newborns, but in neither case is this role officially sanctioned (particularly when it involves dispensing antibiotics without prescription). So, there are different versions of "informality" for outpatient services [21,22]. In Bangladesh, we could consider both the practice (operating a de facto clinic out of a medicine shop) and the cadre ("village doctor") as informal, or not formally recognized.…”