Interventions on informal healthcare providers to improve the delivery of healthcare services in low-and middle-income countries: a systematic review

Objective: Informal healthcare providers (IHCPs) play a big role in health systems in low-and middle-income countries (LMICs) and are often the first point of contact for healthcare in rural and underserved areas where formal healthcare infrastructure is insufficient or absent. This study was performed to systematically review the literature on interventions targeting IHCPs in improving the delivery of healthcare services in LMICs.

Methods: PubMed, Embase, and Cochrane CENTRAL databases were searched for studies that assessed any type of intervention among IHCPs to improve the delivery of healthcare services in any LMIC. Outcomes included changes in knowledge, attitude, and reported practice of appropriate case diagnosis and management; improved referral services; effective contraceptive use; and medication appropriateness (PROSPERO ID: CRD42024521739).

Results: A total of 7,255 studies were screened and 38 were included. Most of the studies were conducted in Africa and Asia. The IHCPs who were trained included medicine sellers, community health workers/traditional healers, and traditional birth attendants. The main intervention used was educational programs in the form of training. The other interventions were health services, policy and guidelines, and community-based interventions. Most of the interventions were multi-faceted. The disease/service areas targeted were mainly maternal and child health, sexually transmitted diseases, common infectious diseases, medicine use/dispensing practices, and contraception. The outcomes that showed improvements were knowledge, attitude, and reported practice; diagnosis and case management; improved referral services; contraceptive uses; and medication appropriateness. Around one-fourth of the studies reported negative results. The certainty of evidence generated (GRADE criteria) was very low.

Conclusion: Some multifaceted interventions coupled with training showed improvements in the delivery of healthcare services by IHCPs. However, the improvements were inconsistent. Hence, it is unclear to identify any context-specific optimum intervention to improve the delivery of healthcare services by IHCPs.

1 Introduction

Informal healthcare providers (IHCPs) play a big role in providing healthcare services in low-and middle-income countries (LMICs), especially in places like India, Bangladesh, and various parts of Africa due to their accessibility, affordability, and familiarity within the community (1–3). IHCPs practice allopathic and non-allopathic medicine with minimal or no formal training and constitute a significant portion of the private healthcare sector (1–3). IHCPs are broadly categorized based on the nature of their practice. This encompasses retail medicine sellers, traditional healers, faith healers, traditional birth attendants, untrained allopathic providers, and traditional medicine practitioners (1, 2). Additionally, IHCPs include individuals trained in one field but practicing in another, such as nurses offering medical consultations as doctors within their communities (1).

IHCPs are often the first point of contact for healthcare in rural and underserved areas where formal healthcare infrastructure is insufficient or absent. The gap in healthcare systems in LMICs is primarily due to inadequate infrastructure, a shortage of formally trained healthcare professionals, and logistical challenges in reaching remote areas. Limited resources and funding constraints often mean that formal healthcare facilities are sparse, poorly equipped, or concentrated in urban centers, leaving rural and impoverished communities underserved. IHCPs, despite their lack of formal training, attempt to fill this gap by offering various health services, often tailored to the specific needs and cultural contexts of their communities (1, 2). People seek out the services of IHCPs for a range of interventions, including preventive, curative, and restorative care.

Despite their significant role, IHCPs are often overlooked in the healthcare system, which particularly affects the poor who rely on them. Unlike formal private actors, IHCPs lack recognition within a country’s regulatory and legal framework, despite being sought after by the clients they serve. Payment is usually received directly from patients, without documentation, rather than from institutions (2). They may also belong to professional associations that lack certification or regulatory authority (2, 4). Many IHCPs may be hesitant to formalize their practice, especially if government penalties exist for those who advertise themselves illegally as legitimately trained professionals (2, 4).

Despite the renewed emphasis on primary healthcare, surprisingly few studies have explored the potential of the informal sector to extend healthcare to communities (5). Interventions recognizing IHCPs’ contribution to healthcare provision could help legitimize their profession and identify opportunities to expand essential healthcare in LMICs in alignment with public health goals of quality and affordability. Training IHCPs could potentially enhance healthcare in these communities, but implementing such an approach necessitates identifying these providers, their practice locations, and the specific training they require. Currently, there is a lack of summarized data about the types of interventions and their effectiveness in improving the quality of healthcare delivery provided by IHCPs. Conducting a systematic review of interventions targeting IHCPs is essential to consolidate existing knowledge and evaluate the effectiveness of these interventions in enhancing healthcare delivery in LMICs. Given the significant role IHCPs play in providing accessible healthcare services, especially in rural and underserved areas, a comprehensive review was aimed at identifying successful interventions.

2 Methods

2.1 Search strategy and information sources

The researchers conducted a literature search in the PubMed, Embase, and Cochrane CENTRAL electronic databases for original interventional studies published in English from LMICs between 1990 and June 2024. The search was last conducted on 30 June 2024. Systematic reviews, qualitative studies, editorials, commentaries, conference proceedings, and case series/reports were not included. Various search terms were utilized, as outlined in Supplementary Table S1. These search terms were adapted for different bibliographic databases, incorporating database-specific filters. Two independent authors identified relevant studies based on their titles and abstracts using the search strategy. They then obtained the abstracts and, if necessary, the full texts of the studies to evaluate their suitability for inclusion. The discrepancies were resolved by discussion with the arbiter.

2.2 Eligibility criteria and study selection

Since the informality of care varies depending on the context, rigid criteria cannot universally define IHCPs. Therefore, a set of operational criteria was established to define IHCPs operating in LMICs: individuals lacking formal training in an institution recognized and affiliated by the regulatory authority/council of a particular country; those without registration, regulation, or oversight by any institution or governing body for their practice; and those working in a private setting whose scope of work is not recognized by the regulatory authority/council of that particular country (2). Community health workers trained and recognized by non-governmental organizations and governments, such as the Accredited Social Health Activist women workforce in India, who act as the first point of contact for any health-related issue, were excluded. Original interventional studies assessing any type of intervention (educational, behavioral, social, etc.) among IHCPs to enhance the delivery of healthcare services in any setting in any LMIC were included. The comparator was no intervention or any specific active intervention. Outcomes included changes in knowledge, attitude, and reported practice of appropriate case diagnosis and management; improved referral services; effective contraceptive use; and medication appropriateness. Specifically, studies were not included if they did not meet our predefined selection criteria, such as studies that were not quasi-experimental or randomized controlled trials (inappropriate study design) or studies that did not focus on IHCPs in LMICs based on our operational criteria (inappropriate population) (Figure 1).

Figure 1

Figure 1. Study flowchart.

2.3 Data items and analysis

A standardized, pre-formatted form was used to extract data from the eligible studies. The extracted information encompassed various aspects, including the study setting, study population (type of IHCPs), participant demographics and characteristics, details of interventions and comparators, and outcomes. The data was managed using Microsoft Excel. Descriptive statistics were used to summarize the results. Additionally, The World Health Organization (WHO) Health Intervention Classification Framework categories were used to classify the interventions as follows (62):

(1) Education and training: activities aimed at improving knowledge and skills.

(2) Health services: direct healthcare services provided to individuals.

(3) Policy and guidelines: implementation of policies or guidelines to improve health outcomes.

(4) Community-based interventions: activities that engage community members in health promotion and disease prevention.

2.4 Risk of bias assessment

For the risk of bias analysis, the ROBINS-I tool (6) was used for quasi-experimental studies and the Cochrane risk of bias tool 2 (59) was used for randomized controlled trials by an independent author. The ROBINS-I tool includes the assessment of the following biases: confounding, selection of participants in the study, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, selection of the reported result, and overall. The Cochrane risk of bias tool 2 includes the assessment of the following biases: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, selection of the reported result, and overall. Attrition rates, including dropouts, loss to follow-up, and withdrawals, were also examined. Issues of missing data and imputation methods were critically evaluated.

2.5 Certainty assessment

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess the certainty of the generated evidence (7, 57).

2.6 Study protocol

This systematic review complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42024521739).

3 Results

3.1 Study selection, characteristics, and results of quality assessment

A total of 7,255 studies were screened and finally, 38 were included (Figure 1). The studies were published between 1992 and 2021. The results of the risk of bias analysis are itemized in (Supplementary Tables S2, S3). Eight quasi-experimental studies had high risk of bias, while the randomized controlled trials had a moderate or low risk of bias. The summary of the study characteristics is enumerated in Table 1. The quasi-experimental study design was used in most of the cases (68%). Most of the studies were conducted in Africa (50%) and Asia (40%). The sample size ranged from 17 to 1,133.

Table 1

Table 1. Summary of the study characteristics (n = 38).

3.2 Synthesis of study results

The main intervention used was educational programs in the form of training. These interventions included regular interactive educational training programs, both short-term (up to 3 months) and long-term (9 months to 2 years), aimed at improving knowledge in specified areas. Additionally, outreach education programs and interactive seminars were employed to enhance knowledge and management practices. The IHCPs who were trained included medicine sellers (34%), community health workers/traditional healers (34%), and traditional birth attendants (29%). The common disease/service areas that were targeted were maternal and child health (39%), sexually transmitted diseases/infections (STDs/STIs) (24%), and malaria (16%) (Table 2). We identified various types of interventions categorized based on their intended impact on provider behavior. Many interventions were implemented in combination with related strategies. Approximately 68% of all studies employed multiple intervention strategies, with nearly all studies measuring more than one outcome. The common strategy was management improvement, including training, provision of supplies, job aids, and financial incentives (market-based approach). However, the interventions were inconsistent and heterogeneous across studies. The comparator was no intervention in all studies except two (8, 9), where specific active interventions were used as a comparator.

Table 2

Table 2. Summary of the findings (n = 38).

Twenty-eight studies reported changes in knowledge, attitude, and reported practice of appropriate case diagnosis and management after intervention for common conditions (respiratory infection, diarrhea, malaria, etc.), STDs/STIs, and perinatal care. Seven studies evaluated improvement in referral services post-intervention for perinatal care, STDs/STIs, and tuberculosis. Seven studies evaluated increased knowledge of contraceptive use and increased sales of condoms. Eight studies evaluated post-training improved medication appropriateness focusing on antibiotics for common diseases (respiratory infection, diarrhea, malaria, etc.). Among the studies, 26% reported positive outcomes with training alone, while 47% reported positive outcomes with training combined with other interventions. Most studies assessed provider performance as a basic measure of intervention effectiveness. Traditional healers showed the greatest improvement in provider knowledge. Post-training, improvements were observed in knowledge, attitude, and reported practice of appropriate case diagnosis and management; improved referral services; effective contraceptive use; and medication appropriateness. However, the improvements were inconsistent across studies. A high proportion (89%) of randomized controlled trials reported positive outcomes, while 26% of all studies reported one or more negative outcomes. The certainty of evidence generated (GRADE criteria) was; however, very low for all outcomes (Supplementary Tables S4–S8).

The interventions from the study primarily fall under the WHO Health Intervention Classification Framework categories of education and training, health services, policy and guidelines, and community-based interventions (Table 3; Supplementary Table S9) (World Health Organization, 2023). Education and training were the most common and reported in most of the studies, leading to improved knowledge and skills among healthcare providers, traditional healers, and community workers, often resulting in better health practices, increased treatment adherence, and reduced mortality rates. The service areas covered by education and training were common infectious diseases, STDs, malnutrition, and antenatal care. Health services interventions, such as the establishment of birthing homes in villages for perinatal care (10) or the establishment of a novel community-based delivery system for effective infectious disease management (11). Multi-component policy and guidelines intervention led to improved knowledge and reported practice of the treatment of acute respiratory infections and STDs and the sale of antibiotics (12). Lastly, community-based interventions demonstrated success in the deployment of anti-malarial medicine sellers and village health motivators for increased identification of malaria and improved correct chloroquine use (13).

Table 3

Table 3. Summary of the interventions and outcomes based on the World Health Organization (WHO) Health Intervention Classification Framework categories.

4 Discussion

This systematic review aimed to summarize the evidence on various interventions in improving the delivery of healthcare services by IHCPs in LMICs. A total of 38 studies published between 1992 and 2021 were included. The majority of these were conducted in Africa and Asia, targeting IHCPs, including medicine sellers, community health workers, and traditional birth attendants. Interventions primarily focused on maternal and child health, STDs/STIs, and malaria employing educational programs in the form of training. Training included both short-term and long-term interactive educational sessions, along with outreach education programs and interactive seminars. Post-intervention improvements were observed in areas such as knowledge, diagnosis, referral services, contraceptive use, and medication appropriateness, although some studies reported negative outcomes. A context-specific optimum intervention strategy to improve healthcare delivery by IHCPs in LMICs was not identified overall.

Our results show that the interventions to improve the IHCPs’ delivery of healthcare services were heterogeneous and while the majority reported positive outcome(s), the improvements were inconsistent. Education and training were the most common interventions, leading to improved knowledge and skills of IHCPs, often resulting in improvement in health practices. However, when considering the training of IHCPs, greater attention is required to integrate it within a broader context of factors likely to promote better practices and reinforce the training. The effectiveness of training likely requires continuous efforts rather than one-time initiatives, and its retention should be evaluated at multiple points in time (14). As IHCPs operate within the private sector, their livelihood often depends on customer satisfaction and repeat business. As a result, interventions like external quality assessments, mandatory training programs, and the distribution of printed materials, which IHCPs believe do not affect their financial outcomes, have not been well customized (15, 16). Institutional innovations, like franchising, or locally tailored regulatory approaches, such as performance reviews, could create the necessary pressure for IHCPs to adhere to norms and deliver improved care (17). Training played a supplementary, yet potentially crucial, role alongside marketing efforts that could shape public expectations and demand. In our review, we also found that financial incentives as a market-based approach that involves using economic motivations to influence behaviors were useful (52). Similarly, interventions that altered incentives and enhanced accountability for providers were more effective in changing provider behaviors.

We found that a significant factor consistently influencing the delivery of healthcare services by IHCPs was the combination of interventions that mutually reinforced each other. For example, studies combined training with organizational changes to establish referral systems, integrating strategies such as accreditation and the provision of educational materials and resources. This approach proved effective across various subject areas and settings, ranging from establishing emergency trauma systems to assisting medicine sellers in managing sexually transmitted diseases to collaborating with traditional medical practitioners on family planning services (5, 18, 19). The range of studies on interventions with IHCPs is limited, indicating insufficient data to advocate for any specific intervention. Moreover, very few studies report on the costs of interventions, despite the necessity of this data to justify public funding. The overall impression is that the long-term effects of interventions with IHCPs are uncertain, and many of the strategies would be challenging to replicate. Very few studies provided detailed information about the interventions, such as training curricula, contents of birthing kits, or frequency of supervision. However, we found evidence supporting the effectiveness of IHCPs in certain medical conditions, such as lay health volunteers in tuberculosis, fever, and malaria management, and trained birth attendants in neonatal healthcare.

The studies included in our review do not definitively identify the most impactful interventions; however, it is evident that initiatives aimed at enhancing basic health service coverage through IHCPs or improving the quality of care they provide should be accompanied by rigorous evaluation research, publication of findings, and dissemination of lessons learned to maximize benefits (20, 21). The certainty of evidence generated was very low for all outcomes. Some interventions did not yield favorable results, and while study design issues might have played a role, other non-educational factors (e.g., deployment of anti-malarial medicine sellers and village health motivators or negotiation sessions) could indirectly hinder the promotion of appropriate dispensing in private pharmacies and medicine shops.

The strength of our study is the inclusion of a fairly large number of interventional studies across various LMICs and the comprehensive summary of the findings. The included studies were published between 1992 and 2021. The decision to search for a 35-year period was made to ensure a comprehensive review of the literature, capturing the historical evolution and long-term trends of interventions targeting IHCPs. While social changes in recent years are significant, the inclusion of earlier studies allows for a broader understanding of how interventions adapted over time. This wide margin provides a more complete picture of the evidence, identifying consistent patterns and emerging strategies that can inform current and future practices, despite the potential bias from earlier data. However, there are some limitations to this study. Only studies published in the English language were included. Changes in the practice of IHCPs over time contextualizing the societal perspective were not captured. Country-or context-specific interventions were not analyzed separately. The included studies had heterogeneities in the study populations, interventions, and outcomes and this debarred us from performing a meta-analysis. All required information was not available from all studies. Further limitations include the absence of providing a direction towards generalizability, sustainability, feasibility, and scalability of the interventions used across various studies and the certainty of evidence generated was very low for all outcomes.

There is a clear demand for high-quality intervention research targeting IHCPs. Given the high level of positive provider behaviors and knowledge among traditional birth attendants, further research into sustainable interventions and population-level outcomes with these providers would be particularly valuable. To achieve the greatest benefit, interventions should target providers most frequently used by the target demographic or for the target disease, rather than implementing blanket strategies across a geographic region (17, 21). Efforts should be directed toward identifying effective approaches for collaborating with traditional healers and unqualified doctors, who are relied upon by many. Given the constraints in resources to train and retain allopathic practitioners, both public and private health financiers must acknowledge the extensive market access and population interaction available to IHCPs. They have the potential to be valuable allies in extending the right to health for all individuals (22).

The practice of IHCPs raises ethical concerns about the quality of healthcare, accountability, and patient rights (23). The findings of this systematic review highlight the importance of addressing these considerations in policy and practice to safeguard patient outcomes and uphold ethical principles in the delivery of healthcare services. IHCPs must have adequate training and competency to deliver safe and effective care, respecting patients’ autonomy and right to informed decision-making, and addressing potential conflicts of interest, such as profit motives that may influence treatment decisions. Moreover, there is a need to balance the benefits of engaging IHCPs, such as improved access to care and cultural relevance, with potential risks, such as misdiagnosis, inappropriate treatment, and delays in seeking care from qualified healthcare professionals. The local context and situation also need to be addressed; for example, IHCPs were found to be useful in certain healthcare delivery during the Coronavirus Disease 2019 pandemic in LMICs (24, 25). By promoting transparency; accountability; and collaboration between IHCPs, formal healthcare providers, and regulatory bodies, various stakeholders can work together to ensure that patient care is delivered ethically and responsibly in a quality manner, ultimately improving health outcomes for underserved populations. It is essential to address the balance between the profit motives of IHCPs and the health goals of the public system.

The findings of this research may provide practical implications for various stakeholders in the healthcare system in LMICs. It is practical to recognize the role of IHCPs as primary care providers and the trust and acceptance they receive from the community (1–3). Regulatory bodies can establish guidelines for IHCPs to ensure compliance with quality care standards for fostering a people-centered health system (26). Often initiatives are taken from different stakeholders to train and integrate IHCPs as a part of the formal healthcare system (27). The Indian Medical Association does not endorse this (28) as this is illegal as per section 15.2(b) of the Indian Medical Council Act, 1965 (29). Healthcare providers and professional associations can collaborate with IHCPs to enhance care delivery, while community organizations and non-government organizations can implement targeted interventions to improve IHCP capacity. Overall, our findings can inform policy, practice, and community engagement efforts, aiming to improve the delivery of healthcare services by IHCPs and address health disparities for underserved populations.

5 Conclusion

In many LMICs, IHCPs often serve as the initial point of care for common illnesses like diarrhea, fever, and cough in children, as well as for family planning and reproductive healthcare in adults. Several multifaceted interventions coupled with training showed improvements in the delivery of healthcare services by IHCPs. However, the improvements were inconsistent across studies and the certainty of evidence generated was very low for all outcomes. Based on the review, it is difficult to identify any context-specific optimum intervention strategy to improve the delivery of healthcare services by IHCPs in LMICs. Implementing additional strategies, such as increased regulatory oversight, or the establishment of referral systems to qualified providers, alongside training, could enhance the delivery of healthcare services by IHCPs.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

SD: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. SK: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization. JE: Writing – review & editing, Supervision, Resources, Conceptualization. VD: Writing – review & editing, Supervision, Project administration, Conceptualization. CS: Writing – review & editing, Writing – original draft, Supervision, Resources, Project administration, Methodology, Conceptualization. KS: Writing – review & editing, Writing – original draft, Supervision, Resources, Project administration, Methodology, Investigation, Conceptualization.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

The authors acknowledge Ingrid Andersson and Emma-Lotta Säätelä from the University Library, Karolinska Institutet, Stockholm, Sweden for their kind support with the literature search.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2024.1456868/full#supplementary-material

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