The role of informal providers

Informal care providers are essential in developing nations. They serve as an informal extension of the formal healthcare system and deliver substantial healthcare services, especially in areas where health services are scarce or inaccessible. Collaborating with these providers can improve healthcare accessibility and foster trust in the healthcare system.2 As an example, a study showed that traditional healers in Uganda had more success in testing people for HIV than healthcare providers in health facilities because they were closer to the local communities and offered trust and privacy.12 Informal care providers also support formal healthcare systems in treatment adherence, deliveries, and referrals in Ghana, Zambia and Pakistan.2

Through the Federal Ministry of Health, the Nigerian government recognises the informal private health sector, which comprises traditional and complementary medicine practitioners such as traditional healers, birth attendants, patent and proprietary medicine vendors (PPMVs), drug sellers, and bone setters.3 6 These informal care providers are widely accessible and serve as the primary source of healthcare in rural communities.2 They offer affordable services, flexible payment options, and convenient working hours. Their cultural sensitivity, especially regarding illness-related spiritual beliefs, influences the healthcare-seeking behaviours of most rural dwellers.2 For instance, about 60% of deliveries in rural areas of Nigeria are attended by traditional birth attendants (TBAs), who have strong ties and acceptance in their communities. Their greater accessibility, better relationships, affordability, and convenience make them highly preferred compared with skilled birth attendants. In Nigeria, where many births occur at home and are assisted by TBAs, a novel approach was implemented to improve maternal and neonatal care. The approach involved giving incentives to TBAs to encourage women to seek postnatal care from skilled health workers, which resulted in increased utilisation of professional care after childbirth. This strategy acknowledges the accessibility and cultural acceptance of TBAs while leveraging monetary incentives to encourage the adoption of formal healthcare practices.16 17

Furthermore, about 80% of people with mental health issues seek mental healthcare from informal providers such as priests, spiritualists, and traditional healers. These providers offer psychosocial therapies that can ease distress and enhance well-being for people with mild anxiety and depression. Interestingly, it was observed that patients who consulted non-orthodox providers tended to seek care earlier than those who sought care in a health facility.18 19 Rural patients may prefer non-orthodox practitioners for various reasons. These practitioners may use different methods of identifying and treating mental health issues that are more culturally appropriate or acceptable for rural patients. They may also be more available or affordable than orthodox practitioners. Moreover, they may have a different approach to reducing the stigma associated with mental health problems.

Traditional bone setters (TBSs) in Nigeria are essential, providing 70–90% of primary fracture care. This is due to the shortage of orthopaedic surgeons, the fear of hospital admissions, amputation and other surgical procedures, and the high costs associated with hospital treatments. Patients are drawn to TBSs as they offer attractive payment options, such as instalments or non-monetary compensation.20 21 Similarly, PPMVs have become vital sources of care in rural areas. They are the first point of contact for most childhood and adult illnesses, especially malaria. For instance, up to 55% of under-5 childhood illnesses and 35–55% of adult malaria treatment are provided by PPMVs. Their accessibility, extended opening hours and flexible payment options make them the first choice for a significant portion of the rural population seeking healthcare.22 23 A recent survey in rural Nigeria revealed that despite the introduction of health insurance and improvement of formal healthcare facilities, insured and uninsured individuals still relied heavily on informal care providers such as PPMVs.24

However, while informal healthcare providers may benefit the healthcare system, they could pose some challenges. Besides their lack of standardised training, regulating them is also challenging because they often operate in remote areas and sometimes have the support of local community leaders. These providers often fail to recognise the value of preventive and promotive healthcare and ignore established medical guidelines. They prioritise financial gains over patient-focused care, leading them to overprescribe medications, carry out unnecessary treatments, and delay patients from promptly seeking appropriate medical help. These actions often harm rural communities.2

Nevertheless, it is crucial to recognise that these informal healthcare providers address the challenges of physical distance and financial limitations to formal healthcare.25 They can act as a bridge between the local community and the formal healthcare system. For example, TBAs often accompany women to clinics for childbirth,16 26 and PPMVs assist with various health concerns such as HIV/AIDS, tuberculosis, malaria, and maternal and child health. They also conduct rapid diagnostic tests for malaria.22 23 Therefore, replacing them in these areas may be difficult and may not be the best solution.16 26 Again, ignoring them could lead to significantly worse health outcomes for rural inhabitants. Instead, their roles could be redefined to prioritise preventive and promotive healthcare. Several studies concur that proper health education, regular training and integrating informal providers into the PHC system while regulating their practices can improve their knowledge and attitudes. This approach would also reduce risky behaviours and enhance the referral of complex cases to formal healthcare facilities. Considering themselves as having made tangible contributions to the health sector and being able to do more, these informal healthcare providers are willing to enhance their skills through training by qualified experts to make a greater impact.20–22 27

Amid the ongoing efforts to strengthen Nigeria’s formal PHC system, it is essential to recognise the valuable contributions of informal providers while also working towards enhancing their collaboration with formal healthcare institutions. Balancing their unique strengths with the need for evidence-based care is essential in achieving comprehensive and equitable quality healthcare.

Linkages between the formal and informal health system

Research has shown that strengthening the links between public health systems and informal healthcare providers can boost rural healthcare access and improve health outcomes.28 Below is a conceptual framework (figure 1) that illustrates various platforms for establishing strong linkages between formal PHC systems and informal health providers in rural communities.

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Figure 1

Platforms to establish linkages between the formal primary healthcare system and informal health providers. Adapted from: Onwujekwe et al.28

However, achieving effective integration for a people-centred PHC system faces several complexities. Both groups demonstrate varying willingness, with some reservations and anxieties rooted in differing perceptions. Informal providers feel undervalued and distrusted by formal workers. Additionally, they are apprehensive about the negative implications of government oversight.29–31 Conversely, formal providers harbour scepticism about informal practices, especially over the lack of scientific evidence of their services, poor quality of care, and concerns about the challenges of running a mixed healthcare system.28 Competing institutional norms can also exacerbate conflicts arising from differing operational approaches and goals.32 Despite these challenges, fostering collaboration is possible through open communication channels, dialogue, and mutual respect. Establishing a negotiation forum is crucial for building respectful partnerships. The preferred areas for cooperation include training to enhance the skill set of informal providers; regulations to ensure high-quality services and prevent unqualified practitioners; provider incentives to motivate informal providers to provide enhanced practices and services; and improved access to formal healthcare through effective two-way communication and referrals.28–30 33 34 It is important to consider the larger political and economic context and other systems and factors influencing public health outcomes when seeking local partnerships. For managing the expanded PHC system at the macro level, it is imperative to have multidisciplinary cooperation and collaboration across different sectors.28 32

Framework for engagement of CHIPS personnel

The CHIPS Programme is designed to improve the quality and access to PHC services, especially for mothers and children, by training and deploying volunteer CHIPS personnel. The programme emphasises using CHIPS personnel as the primary community-based workers. Each political ward is assigned a team of 10 female CHIPS agents and 2 male community engagement focal persons (CEFPs), aligning with the programme’s goal of empowering women.15 Research has shown that women who serve as community health workers (CHWs) perform exceptionally well in their roles related to community health. This is because they have earned the respect and trust of their communities and are culturally accepted as caregivers and healthcare providers.35–38 Within the CHIPS framework, CHIPS agents provide counselling services, promote the utilisation of healthcare services, deliver basic preventive healthcare services such as health education and counselling, and manage cases of diarrhoea, fever, and cough, particularly in those under five years. Meanwhile, the CEFPs are responsible for stimulating community engagement and encouraging the participation of men in healthcare service delivery through community workshops, dialogues and town hall meetings. The programme’s success is highly dependent on the availability of a functional PHC facility in each political ward. These facilities serve as referral centres and are essential for planning, delivering supplies and stimulating service demand.15

The proposed CHIPS expanded interface framework (figure 2) is designed to harness the unique strengths of these community-based healthcare workers with a strong local presence and tailored training in counselling, preventive services, case management and patient referrals.15 It seeks to leverage CHIPS personnel’s expertise and community ties to drive positive health outcomes, foster collaboration between formal and informal healthcare providers, and ensure culturally sensitive healthcare delivery in Nigeria.

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Figure 2

CHIPS expanded interface framework. CHIPS, Community Health Influencers, Promoters, and Services.

The framework below illustrates the components and inter-relationships of an expanded PHC system (represented by the large light-blue rectangle) that leverages the CHIPS Programme to achieve UHC. The framework comprises several elements and components, including a larger central circle segmented into three parts and flanked by three smaller circles. The core of the segmented circle represents the CHIPS personnel who interact and coordinate the different components of the system, which are the colour-coded segments of the larger circle. The green segment signifies the community, while the blue segment represents PHC facilities. The brown segment depicts the informal health providers. The arcs that link the segments at the core represent the communication and coordination channels between the relevant system components and CHIPS agents. The smaller circles, which are also colour coded, represent the outcomes (labelled I–III) that can be achieved from the interactions between CHIPS agents and the various components of the system.

The primary goal of the ongoing CHIPS Programme in Nigeria is to create demand for and increase access to essential healthcare. A collaborative approach is employed where the CHIPS personnel, acting as a link between the community and the PHC system, engage with the community (I—community engagement) to promote health and mobilise them to use the available health facilities while also partnering with PHC facilities to improve referrals and follow-up services, thus addressing the issue of underutilisation and limited healthcare access.15 However, the framework proposes expanding the role of CHIPS personnel beyond community engagement to facilitating comprehensive and patient-centred care through collaboration between informal healthcare providers and the PHC system (II—collaborative integrated care). At this level, the CHIPS personnel can perform regulatory functions by monitoring the quality of services offered by informal healthcare providers in their communities. This would involve regular visits to these providers to ensure adherence to standards of practice, safety and effectiveness of care. They can also track the services provided by collecting and evaluating data such as the number of patients seen, treatments administered, and patient outcomes. The data can then be reported to the formal healthcare system to monitor the performance of informal providers. The CHIPS personnel can be equipped to provide training and capacity-building programmes to informal healthcare providers to improve their skills and adhere to best practices. This may involve workshops on basic healthcare, infection prevention and control, and record-keeping. They can help patients access appropriate care by facilitating referrals to a formal healthcare system, especially when complex cases are encountered. Additionally, CHIPS agents can organise collaborative programmes that bring together informal providers and formal health professionals. These forums can serve as platforms for sharing best practices, exchanging knowledge, and discussing ways to collectively improve healthcare delivery. Furthermore, they can make the community more aware of how important it is to have both formal and informal healthcare providers. This can help reduce obstacles to collaboration, build trust, and increase the utilisation of healthcare services. They can also work with local authorities and healthcare institutions to establish a supportive environment for such collaborations. Lastly, the framework further proposes a platform where the CHIPS personnel interface with the community and informal providers to ensure that the services provided align with the community’s cultural practices and religious beliefs without compromising the quality of care (III—community-based care).

Limitations of the CHIPS expanded interface framework

While this framework brings several advantages to healthcare delivery in remote areas, it is essential to recognise potential challenges that may be encountered. A significant drawback is the limited availability of resources, both financial and personnel-wise. Expanding the roles of CHWs may necessitate additional resources and personnel, which could be difficult to obtain. Informal healthcare providers may resist external oversight, perceiving it as threatening their independence and income. Encouraging their cooperation and adherence to medical guidelines may encounter resistance.

The effectiveness of the framework depends on the informal healthcare providers’ willingness to participate in training and partnership. Although studies show that these providers are generally open to collaboration,20–22 27 the extent of their willingness can vary. Cultural and economic factors can impact the adoption of the framework, as some communities may resist change due to cultural beliefs or economic concerns. Lastly, the smooth operation of the system may be obstructed by bureaucratic and administrative hurdles.

To address these issues, it is important to have a comprehensive implementation strategy, adequate resources, active participation from the community and policymakers willing to be flexible. Continual evaluation and feedback mechanisms could help improve the framework with time, ensuring its long-term sustainability and adaptability to evolving healthcare needs and community dynamics.