Abt Associates Inc. in partnership with:Data Management Services Inc.

Dillon Allman and Partners. LLC

Family Health International

Forum One Communications

Global Microenterprise Initiatives

IntraHealth International

London School of Hygiene and Tropical Medicine

O’Hanlon Consulting

Population Services International

Tulane University School of Public Health and Tropical Medicine

Working with Traditional Providers in Improving Health Outcomes in India

Sanjeev Vyas

Abt Associates Inc.

GHC Conference, 27th May ’08

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Who are Traditional Providers?

� Not a very well defined group

� Comprises of a diverse set of providers including� Rural Traditional Healers

� Indigenous Systems of Medicine Providers (ISMPs)

� ISMPs � Less Than Fully Qualified (LTFQ ISMPs) providers

� Qualified practitioners of a combination of a traditional Indian system of medicine and modern allopathy (AYUSH ISMPs)

� Serve a large urban and rural populace without access to formal and affordable medical system

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The Caste System Among Private Healthcare Providers

Specialists - MS, MD

GP’s - MBBS

AYUSH - ISMPs

LTFQ ISMPs

Rural Traditional Healers

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Who are AYUSH ISMPs?

• AYUSH providers have degrees in Ayurveda, Unani, Siddh Tibb or Homeopathy from central, state or private colleges

• Including Surgery, Ob/Gyn, Anesthesiology, ENT, Ophthalmology, etc.

• Only AYUSH recognized by government and allowed legal practice

• Other ISMPs excluded and often prosecuted

• Over 800,000 registered AYUSH ISMPs in India

• Clients are charged for dispensed medicines and consultancy is included

• ISMPs ignored by pharmaceutical firms and most health programs

• Some pharma companies now realizing their importance

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AYUSH ISMPs

• IMCC, 1970 (Indian Medicine Central Council Act) allows supplementation of Indian medicine by ‘modern advances’

• Institutionally qualified ISMPs eligible to practice respective systems with modern scientific medicine including Surgery and GynecologyObstetrics, Anesthesiology, ENT, ophthalmology, etc. based on training and teaching

• CCIM (Central Council of Indian Medicine) – Statutory body under GoI, MoHFW to frame, implement and regulate curricula for Indian Systems of Medicine and standards of conduct of practitioners

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Why Work with ISMPs?

• High penetration across lower income communities and rural areas

• Enjoy high degree of credibility and acceptance

• Offer better accessibility and affordability

• Consulted mostly for everyday illnesses and certain chronic conditions

• Comparatively more customer oriented

• ISMPs regarded as qualified doctors by the lower income communities and across rural areas

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ISMPs: Filling in the Gap for Trained Medical Providers

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Our Experience with ISMPs

� Saathiya Youth-Friendly Network

� WHO ORS & Diarrhea Management Program

� Zinc Therapy Pilot Program

� Others

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Saathiya Youth-Friendly Network

• Model based on CELSAM Youth-Friendly Pharmacy network, Mexico

• Formative research conducted to explore feasibility of Retail Pharmacists as Youth-friendly providers

• For a pilot program in Lucknow, Uttar Pradesh

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Reality Check: Chemists: Privacy and Confidentiality?

A Typical Chemist Store –

Lucknow

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Access For Young Women too…?

Manned by Male Salesmen –

Lucknow

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What Potential Clients Thought about Pharmacists…

� Information sought will be limited to product level and referrals:

� “He can impart product knowledge but not counseling on reproductive health”

� Chemists level of involvement in offering this service is doubted:

� “Chemist is a businessman at the end… He won’ t be keen to solve queries

when customers have lined up”

� Apprehensions about their competence on reproductive health issues:

� “For simple information I have media and friends/cousins, for serious issues I

will always consult a doctor, where will chemists fit in?”

� Concerns about privacy and confidentiality:

� “We don’ t go to the chemists in our neighborhood to even buy condoms…how

can we go and ask?”� “ I will send my husband to get the information on the topics I want to know”

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ISMPs: Offer Privacy

AYUSH Allopathic Practice -Lucknow

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Most Dispense Products as Well

Homeopathic practice –

Lucknow

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They are Trusted and Easily Accessible…

ISMP Clinic -Lucknow

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…and Some of them are Women

Ayurvedic practice - Lucknow

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� FP not a regular service provided by ISMPs

� ISMPs can offer a friendly and private atmosphere � Clients want friendly but expert and reliable information

� Lady ISMPs preferred by young women

What Potential Clients Thought about ISMPs…

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� Score higher than Pharmacists in terms of

� privacy

� convenience

� reliable information

� Also score higher than Ob/Gyns and GPs on

� accessibility and

� affordability

What Potential Clients Thought about ISMPs…

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ISMPs: Keen to Participate…but had Concerns

� Issues of credibility

� Not regarded as registered/ legal medical practitioners by some and MBBS doctors have greater credibility

� ISMPs consulted mostly for every day problems like cough & cold, fever or for special chronic dieses like Arthritis and Diabetes

� Do not offer FP services

� Rarely infertility and potency issues are tackled

� At present a visit to an ISMPs gives the patient the satisfaction of visiting a doctor

� that too at a lower cost and without having to seek an appointment

Self-Image:

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ISMPs: Keen to Participate…but had Concerns

� “But chemists may become consultants at free of cost in family planning and contraceptive issues after this”

� Increasing the credibility of chemists may reduce the footfalls to ISMPs

� Sense of insecurity among ISMPs� MBBS doctors are irreplaceable… now I’ ll be seen at par with

the chemist

Commercial Aspects:

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Outreach activities

Clients

In-clinicPOS

WOM

Mass Media

Helpline

Chemists

ISMPs

Ob/Gyns & GPs

Product

s

Counse

ling

Products

Clinical Service

Saathiya YF Network Model

Clin

ical Serv

ice

Counse

ling S

upport

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Mystery Client Study

• ISMPs showing greater propensity to maintain privacy

• More patient in answering numerous client queries

• On an average spent more time with clients

• Displayed better quality of interpersonal skills

• Proactive in providing program reference materials to clients

• Better display of program signage and POS materials

Mystery Client Survey, GFK Mode, March-April ’08

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Elements of the Diarrhea Management Program

Celebrities

Mass Media

Govt.&

Regulatory

CommunityOutreach

Promotions&

Tie-ups

ORSManufacturers

Professional Associations

Saathi Bachpan Ke

Celebrity Endorsements

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Role of ISMPs in Diarrhea Management

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

Prescriptions

Any ORS 979,319 273,839 425,566 262,345 9,794

Others 4,884,865 2,215,604 1,591,333 986,916 42,578

All doctors GP (non-MBBS) Paedatricians GP (MBBS)Consulting

Physicians

Prescriptions for Symptoms/Diagnosis of Diarrhea (0-2 Age bracket)

Rx Audit – ORGAll India – 1 lakh+, Nov 2001

43%

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Interventions with ISMPs

• Training on diarrhea management practices

• Detailing to 30,000 ISMPs

• ORS prescription drives in diarrhea season

• ISMPs volunteered to counsel mothers in growth monitoring camps

• Merck conducted ISMP trainings and special prescription drives

• Most commercial ORS manufacturers initiated stocking with ISMPs

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ORS Sales Volume Growth

0

5000

10000

15000

20000

25000

30000

35000

2001 2002 2003 2004 2005 2006 2007

Vo

lum

e in

th

ou

san

d l

iter

s

Non-WHO WHO

Industry shift to single formulationCAGR 8%

ORS Sales Volume Growth: India

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ISMPs Role in Promoting Zinc Therapy

• Designed a variety of community pilot interventions in urban slums across three states with ISMPs as Zinc Champions

• Trained ISMPs on role of Zinc Therapy in diarrhea management

• Updates on Diarrhea Management and Zinc by PSP-One field personnel and mailers

• ISMPs participated in demand generation through prescription drives

• Actively counseled caregivers on Zinc therapy by participating in

diarrhea management camps

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Engaging with ISMPs: Key Findings

� Offer a high degree of engagement and support

� Eager to acquire new knowledge and updates

� Open to working with different sets of providers

� Keen to support social marketing programs

� Offered free consultancy on diarrhea management

� Reduced fee for Saathiya referral card holders

� Accepted as additional retail channel by pharmaceutical partners –

OTC products: ORS, Zinc, Condoms, ECs, CycleBeads

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Working with ISMPs: Key Learning's

� Very diverse set of providers, need to be screened carefully vis-a-

vis target clients and program objectives

� Need to ensure role clarity

� To be considered as credible channel require training, counseling

skills and repositioning

� Regular monitoring on quality parameters and compliance issues

� Regulatory issues can create barriers for some pharma companies

to work with ISMPs

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Thank you!