Informal Providers-Ground Realities in South Asian Association for Regional Cooperation Nations: Toward Better Cancer Primary Care: A Narrative Review

Abstract

Purpose: South Asian Association for Regional Cooperation (SAARC) nations are a group of eight countries with low to medium Human Development Index values. They lack trained human resources in primary health care to achieve the WHO-stated goal of Universal Health Coverage. An unregulated service sector of informal health care providers (IPs) has been serving these underserved communities. The aim is to summarize the role of IPs in primary cancer care, compare quality with formal providers, quantify distribution in urban and rural settings, and present the socioeconomic milieu that sustains their existence.

Methods: A narrative review of the published literature in English from January 2000 to December 2021 was performed using MeSH Terms Informal Health Care Provider/Informal Provider and Primary Health Care across databases such as Medline (PubMed), Google Scholar, and Cochrane database of systematic reviews, as well as World Bank, Center for Global Development, American Economic Review, Journal Storage, and Web of Science. In addition, citation lists from the primary articles, gray literature in English, and policy blogs were included. We present a descriptive overview of our findings as applicable to SAARC.

Results: IPs across the rural landscape often comprise more than 75% of primary caregivers. They provide accessible and affordable, but often substandard quality of care. However, their network would be suitable for prompt cancer referrals. Care delivery and accountability correlate with prevalent standards of formal health care.

Conclusion: Acknowledgment and upskilling of IPs could be a cost-effective bridge toward universal health coverage and early cancer diagnosis in SAARC nations, whereas state capacity for training formal health care providers is ramped up simultaneously. This must be achieved without compromising investment in the critical resource of qualified doctors and allied health professionals who form the core of the rural public primary health care system.

FIG 1

The know-do gap in medical care. The horizontal axis plots what a provider knows, as measured by medical vignettes, using percentage compliance with a medically necessary case-specific checklist of history questions and examinations (by rotating the curve). The vertical axis plots what the provider actually did with a similar patient, observed in practice. Every history question and examination can be compared in a pairwise comparison. If providers did everything they told us they would do, we should observe them on the 45° line. At very low levels of knowledge, practice is constrained by knowledge; at higher levels of knowledge, there is a significant gap between knowledge and practice; the know-do gap is larger in the public sector (in which there is no correlation between practice and knowledge), but even in the private sector, there is a significant gap at higher levels of knowledge. Used with permission of Annual Reviews, Inc, from Annual Review of Economics, Quality of Primary Care in Low‐Income Countries: Facts and Economics, Das et al, 6:525‐553, 2014; permission conveyed through Copyright Clearance Center, Inc.