What are the roles, actions and positions of non-formal biomedical prescribers and providers in developing countries? A systematic literature review

Table of Contents

Statement of Authorship and Submission

Acknowledgment

List of tables and figures

Abstract

Chapter One- Introduction 7-12
Background
Review objectives and questions
Rationale for systematic review on the topic
Structure of the Thesis

Chapter Two- Methods
Defining key term “non-formal biomedical providers and prescribes” and a conceptual framework
Search strategy
Operational definitions of prescriber and provider
Database selection
Inclusion/exclusion criteria
Review procedures
Quality assessment of the papers
Data extraction, abstraction and analysis
Search results

Chapter Three- Results
Study attributes
Major issues observed in review
Typologies and definitions: scoping the practice of Non-formal biomedical prescribes or providers (NFBPs)
Qualifications of the providers and their activities

Chapter Four- Studying health workers in a pluralistic system: methodological challenges of systematic reviews
Quality assessment and synthesis of data: methodological challenges in systematic review
Confusing and unexplained terms used in the literature
What does prescription mean in developing countries?
“Self-medication” or consumer interactions in the pharmacy?
Vendors, distributors, sellers: problematic use of marketing terms in health
Non-formal Biomedical Prescriber/providers: ‘Definition dilemma’ з

Chapter Five- Cultural competence and theoretical approaches in positioning non-formal biomedical prescribers and providers
Cultural competency in health research:
A glance at cultural concepts as analytical frames
Habitus, Capital and Communitas: Cultural economy and NFBPs
Positioning the community in regard to NFBPs: everyday resistance
The global pharmaceutical market and NFBPs: neoliberalism in the non­formal clinic

Chapter Six- Conclusions
References
Appendices: Data appraisal forms and list of search keywords

Master of Culture, Health and Medicine (Advanced) College of Arts and Social Science and College of Medicine, Biology and Environment The Australian National University

This thesis is submitted in partial fulfilment of the requirements for the degree of Master of Culture, Health and Medicine in the College of Arts and Social Science for semester 2 on the date of 26th October, 2015.

Acknowledgments

I would like to express my gratitude to International centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b) and Department of Foreign Affairs and Trade (DFAT), Australia for giving me the opportunity to study with full scholarship; without Australia Awards funding it would have been difficult to reach at this stage doing this research project.

The person who sheds light to this research project and made it possible to carry on with my concept is my esteemed supervisor, Associate Professor Christine Phillips, who appreciated my thoughts and encouraged me to do this project; throughout the planning and writing. I am grateful to her for scholarly guidance and instructive critical discussions and her compassionate support in editing the thesis.

I would like to acknowledge support from the teaching and administrative staffs of the Master of Culture, Health and Medicine program at the ANU that made myjourney pleasant as a student. I am enthused by their compassion for sharing knowledge, experience that helped me achieving maturity in both personal and academic level.

I want to acknowledge the contribution of my wife Tajnin Marin Lopa who took most of my study stresses. Her endless support made this journey possible, from the start to end of my project.

All my fellow students and friends whom I met during the study period were valuable as learning partners and even as mentor who inspired me in engaging with wider spectators, my sincere thanks to those friends. Two of my friends deserve special thanks, Ade Prastyani and Stuart Marks for sharing their knowledge and providing some important references for my research.

List of tables

Table 1: Summary ofMeSH terms used in this systematic review

Table 2: study types, objectives and relevant results

Table 3: Identifying NFBPs’ role; qualifications, activities and biomedical affiliation:

List of Figures

Figure 1: Search structure and key terms development

Figure 2: Flowchart of the search result from databases

Figure 3: Examples of inappropriate and appropriate

Abstract

Background and objective: In developing countries, many health care practitioners work as prescriber in a biomedicine niche using their working experience or training within biomedical settings while remaining neither licensed nor authorised to prescribe medicine. This thesis aims to presents a systematic review of the peer-reviewed and grey literature to identify and synthesize the existing knowledge on role, activities and position of non-formal biomedical prescribes and providers (NFBPs) in developing countries. In this thesis I argue that this cadre is different from two established groups: formal biomedical practitioners and informal health care providers, who usually function outside biomedicine. Practitioners in the “non-formal” domain differ from those in the “informal” domain in terms of their experience, skills, training and negotiating capacity with the biomedical world of practice. Yet in policy and research, non­formal biomedical practitioners are often considered to belong to the same category as informal non-biomedical practitioners.

Method: An operational definition was developed to identify those practitioners who function as “Non-formal biomedical prescribers and provider”. The following databases were searched: PubMed, JSTOR, SocioFile, Cochrane Library, Anthropology Plus, CINAHL and PsycINFO. Grey literature were searched in the following databases and sites: EPIC database, WHOLIS (WHO library database), the World Bank Documents and Report Repository, UN websites, The New York Academy of Medicine, the Center for Global Development, USAID, and the Digital South Asia Library. Searches were limited to papers or reports published after 1 January 2000, in English. A structured data appraisal sheet was developed following PRISMA guidelines and applied to the papers to assess their quality and relevance to the research question.

Results and discussions: Of 90 papers initially read, 25 were selected for inclusion in this review. This cadre of worker was identified in countries in South Asia (13), South East Asia (2), Africa (3), Latin America (1), and the Middle East (1). Work-based knowledge and experience within biomedical settings (e.g. as medical assistant, pharmacy sellers) were the sources of authority drawn on by NFBPs. The most frequently-reported activity was drug selling or prescribing without a prescription (15/25 studies). Dispensing on the basis of “floating” prescriptions (i.e. prescriptions that are kept by the patient and have become recurring tickets to receive medication) was also described. Five studies described NFBPs who provided health care (e.g. diarrheal illnesses, gynaecological care, and malaria diagnosis and treatment).

Socio-cultural analyses revealed that these groups operate at the margin, and occupy a liminal space, being both medical but not-medical. Their positioning within the biomedical global medicine market is indistinct, grappling with direct and indirect influence by the pharmaceutical industry, and outside the formal regulatory mechanisms that seek to constrain and direct prescribing practice. Formal biomedical practitioners are often reluctant to cede a legitimate practice space to non-formal biomedical practitioners. At the same time, the NFBP is often a pragmatic, emergent response to meet everyday primary and emergency health needs, and are imbued with community trust and reliance to provide.

Conclusion: Clear recognition of NFBPs as an emerging distinct group is needed to evaluate and engage with and develop policy that may usefully capitalise on this cadre, to ensure that patients in developing countries have accessible, appropriate and safe medical care. Sufficiently flexible and thoughtful use of socio-cultural frameworks can lead to more theoretically informed analysis of the research in systematic reviews, and to develop policy and effective interventions to capitalise on the existing roles and practices of non-formal biomedical prescribers and providers.

Keywords: Non-formal biomedical prescribers and providers, systematic review, informal providers, health care, drug sellers, prescription, liminality, communitas, developing countries.

CHAPTER ONE INTRODUCTION

Background

The research question for this thesis originated from my own personal experience observing and being treated by health care practitioners in my rural village located in the south-eastern side of Bangladesh, where I lived for 8 years (from 1993 to 2001), before moving to the capital city Dhaka. The village was farmer-dominated and underdeveloped. While staying with family in our village, I was treated by and came across many different types of health practitioners. The union health complex for primary health care and family planning was 3km away from the village and the nearest government hospital was 8km away in the district town. There was no transport except rickshaws; most of the people had to walk to the town (45 to 60 minute walk) for their subsistence and health needs as they could not afford rickshaws. There were no modem health facilities available closer to the village at that time. Only one homeopathic doctor was available in the local market which was situated 2km distant from my village.

There were two biomedical drug stores established in the late 1990s offering health care services at the local village market (25 minute walk). These drug stores sold medicines and prescribed for primary health problems. One of the owners told me of his background: he had returned to his village, quitting hisjob in a military hospital in a divisional province where he used to work as compounder for a biomedical doctor. He decided to return home and using his experience from a modern biomedical sector, he opened his own pharmacy. He became very popular in nearby villages and our family used to call him for most of our seasonal health problems even in complex cases such as, on one occasion, typhoid. The villagers used to call him ‘the Army Doctor” referencing his previous job affiliation in military hospital. He continues to serve his community, although most educated people know that he is not a qualified medical doctor. For the village, he became a dependable biomedical prescriber who also provided diagnosis and treatment for primary and maternal health care (including delivery) service in his office. He also offers an on-call home service. While, visiting my family during vacation a few years ago, I found him using a mobile phone to take home visit calls, riding his bicycle to visit patients. He refers his patients for diagnostic tests in district hospitals and review results for his patients.

Like this “Army Doctor”, there are many health care practitioners who work as prescribes and providers in many developing countries. They operate outside mainstream formal biomedicine using their working experience or training within biomedical settings [1,2]; however, they are not licensed nor authorised to prescribe medicine and practice health care. They may run their own pharmacy or practice as paid practitioners in other drug stores. In some contexts (rural or urban low income area), they are the primary source of health related information and lifesaving medicines [3, 4]. This is in fact a cadre of worker operating within the broad biomedical environment in community settings in many developing countries. They are associated with the mainstream biomedical practitioners in formal sector (e.g. working as medical assistant) as well as connected with the pharmaceutical market [1].

This thesis presents a systematic review of the work of these biomedical prescribers and providers who work outside the mainstream of biomedicine. I mount an argument that they belong to a sector that could be termed non-formal, to distinguish it from formal and informal sectors as the latter generally refers to non-biomedical providers. The primary objective is to identify and synthesize the existing knowledge on non-formal biomedical prescribers and providers who are different from two established groups: the formal biomedical practitioners and the informal health care providers (e.g. traditional or complementary and alternative practices). The sub questions explored are: What are their activities? What is their role and position in the health systems of countries in which this cadre of worker exists?

The term ‘non-formal biomedical prescribes and providers’ is non-existent in health related literature. There are two broader categorisation available: formal and informal health care sectors, where all the unregulated and illegal (non-biomedical and unlicensed/non-authorised) practices are studied as included under the informal health care category [5-7]. Informal health practitioners and providers exist in every health system but most commonly, in developing countries where the bulk of primary and other health services are provided by the informal and private sectors [8-10]. For example, across the Africa, traditional healers and pharmacy vendors have long been known to provide much of the outpatient care [11]. In many Asian countries, especially South and South-East Asia, people who are poor and living in rural areas, seek health care services form “informal biomedical practitioners”; [2, 3, 12-15]. The subject of informal providers (IPs) is yet to be thoroughly explored but there appears to be an enhanced use and contribution in community health specifically for general health problems in settings with poor resources. However, there is general acceptance that IPs provide substandard care or poor- quality of care [9]. A challenge addressed in this thesis is to disaggregate the umbrella term ‘informal’, and focus on the subsector of health care providers who work within biomedicine practice but do not hold the essential medical qualifications, as appraised by state or legislative health authorities and subsequent provisions.

In the existing literature, the informal and private practitioners are identified as encompassing a variety of practices including modern qualified biomedical practitioners, traditional healers, non-biomedical professionalized practitioners, and other non-formal groups within the biomedical system who work and use their experience from the biomedical health niche. This is a hotchpotch of practitioners, and it has proven difficult to identify ways to improve, monitor or even describe the kinds of work that are being done across this sector. Significant differences exist between informal practitioners and non-formal biomedical prescribers/providers in terms of their knowledge, experience and qualifications regarding medicine, diagnosis and treatment. The current systematic review aims to synthesize data and information on these “biomedical but not formal” providers. Research into these group has not previously been undertaken through a systematic review.

Review objectives and questions

The systematic review aims to gather and synthesize available data and outcomes of studies and interventions to look at what is known about non-formal biomedical prescribers and providers and how they are different from other informal practitioners. The hypothesis here is that the non-formal prescribers/providers have different characteristics from the ‘informal’ in terms of medical experience, knowledge of medicine and skills which are distinguishable from informal or alternative practitioners who are non-biomedical. For example, unlicensed/unregistered/unqualified medicine prescribers, drug sellers who prescribe, and medical workers who prescribe medicine as a secondary occupation appear to contribute to community health care at many levels, particularly in primary health care, neonatal care, psychotropic prescription or even chronic illness management [16, 17]. This review will also focus on literatures that discusses the quality, efficacy and acceptability of these intermediate medicine prescribers and health care providers. Therefore the key question is: what is known about the role and position of non-formal health care practitioners and how has their quality or acceptability been assessed in literature? This question will follow further sub questions as below:

1. What is known about the activities undertaken by these groups in relation to different health needs (general and complex health issues)?
2. What is known about the status of these providers and the power relations within the broader global medicine market?

Rationale for systematic review on the topic

There is lack of information in current literature about the type, role and position of non-formal biomedical prescribers, either as separate or merged with informal or private practitioners and health care providers, and information is needed to address that gap. Non-formal providers and prescribers in different contexts could be pivotal players in preventative and curative health issues regardless of the titles by which they are known in local contexts. Findings can be used to analyse the pluralist medical environment that exist in low resource settings; to measure their efficacy, acceptance and legitimacy as medical practitioners within the regulatory frameworks; and to inform further research into a cadre of health worker that is “invisible in plain sight”. Analysis can help to relate the findings for effective policy development in support and regulate the plural practices in order to develop integrated health systems that are appropriate, safe and acceptable.

Structure of this Thesis

Chapter Two describes the methods followed in the review, providing the rationale for the definition of ‘non-formal biomedical’ practices. It presents the search structure, strategy and search results, according to the PRISMA^[1] guidelines. Chapter Three presents the synthesis of the results of the studies and summarising the major findings of the review. Chapter Four and Five place the major findings in context. This thesis throws some light on methodological gaps in systematic reviews of complex health care questions, the liminal roles of non-formal biomedical prescribes and providers and their potential susceptibility to being co-opted into the globalised pharmaceutical marketing and distribution chain. Nevertheless, non-formal biomedical providers and prescribes already play a role in community health care and this thesis concludes by making recommendations to make the most of this crucial human resource for health.

CHAPTER TWO METHODS

This systematic review focuses on prescribers and providers of medications who are not formally trained or authorised to do so, who work within a biomedical paradigm. I devised the term “non-formal biomedical prescribers” to indicate these groups. However, this is not a term that is used within the literature. In this chapter, I describe the methods used to interrogate the literature to capture research on works in the broad biomedical health system who fulfil this function. The chapter begins set by setting out the conceptual framework I used to develop the operational definition of the non-formal biomedical prescriber.

Defining key terms “non-formal biomedical providers and prescribers” and a conceptual framework

In this section, I address the case for a typology of providers outside the formal medical system that enables reliable identification of those working on the edges of formal medical systems, and those working completely outside it- that is, in my terms the difference between “non­formal” and “informal”.

There is great confusion in defining health practitioners and providers in plural medical cultures in developing countries. There are two major contrasts found in research into health practitioners: formal/informal and public/private. The apposition of informal and formal is more complex than that of public and private. The formal sector is well understood across the world. Formally authorised practitioners can practice either in public or private sectors with licensing from the state’s health legislative authority [18, 19]. A practitioner may have both public and private sector practice recognised as legitimate cross practice in many countries [12, 20].

Challenges arise when looking in more detail at the heterogeneous informal sector. The literature locates the informal sector as a subset of private practice provision, and includes practitioners who are illegal, non-recognised or formally unaccepted by the scientific community such as traditional healers, shamans and alternative practitioners. The informal sector also includes providers who are located within a biomedical niche- for example, providers who have experience, training and knowledge from biomedical settings such as drug sellers, medical assistants, nurses, health workers, technicians. Some of these have positions within the formal sector, but can be found practicing out of their main occupation. Biomedical workers who are outside the formal sector are described in the literature using a range of terms: “non-doctor prescribes”, “informal allopathic doctors”, “formally trained non-doctor”, “unlicensed” or “untrained” or “unqualified” private providers, and “private practitioners without formal qualification (PPWFQ)”. Each term implies the distinctness of this group from traditional or alternative practice. The definition dilemma here is that these groups of practitioners are not formal, nor are they informal (i.e. totally non-biomedical). Rather, they exist in between formal and informal practices, and provide a strong community contribution to assisting the meeting of primary and emergency health care needs.

Neither “informal” nor “non-formal” providers are accepted by formal health authorities, and both lack legislative power to practice and face resistance from formal biomedical practitioners. However, only non-formal prescribers actually practise using concepts and deriving authority from the biomedicine. To give an example, a shaman or a faith healer is an informal prescriber who may practice based on totally non-biomedical or alternative knowledge while, a pharmacy drug seller who has worked as compounder (assistant to a doctor) is a non-formal prescriber uses working experience from biomedical setting. Although non-formal prescribers are unlicensed, they may have a significant contribution to make in community health settings, particularly in low resource countries.

This question of difference between informal and non-formal came to my attention when I came across a paper (Sudhinaraset et al., 2013) where the authors defined informal health care practitioners in developing country contexts on four criteria- training, payment, registration and regulation and, professional affiliation. These criteria resulted in the lumping together of non­biomedical practitioners (traditional healers, folk medicine and alternative practitioners) with semi qualified medical practitioners, rural medical practitioners, drug vendors, sellers and health workers and non-graduate medical practitioners [17]. I observed that there was a need to distinguish those who worked within non-biomedical frameworks from the group which worked within, or drew their claim to authority from, biomedicine. Sudhinaraset et al. did not distinguish two different levels of expertise and experience among their informal health care practitioners. One is informal and non-biomedical, often derided as being pragmatic, and not evidence-based. The other one is the emerging group of medical prescribes and providers in developing countries who work within a biomedical niche but do not possess the required qualifications. I found no developed typology to separate the non-formal group from the informal and formal categorization and that is why I provide an operational definition here to identify and sort the relevant literature.

In this thesis, I propose that “non-formal” differs from “informal” as the non-formal prescribes and providers draw on experience within the biomedical realm, and largely practises within it while, a non-formal is usually recognised as non-biomedical and informal. The non-formal biomedical providers and prescribes differ from informal health care practitioners in terms of their experience, skills, training and negotiating capacity with biomedical world of practice. They may have experience in biomedical settings such as working as doctors’ assistants, selling drugs in pharmacies, or working as pharmaceutical sales agent. I have personally observed in my home country (Bangladesh) that, people who work in different biomedical positions such as hospital workers (compounders, technicians, nurses/word staffs, lab assistants, messengers etc.) and pharmaceutical sales agents often run their own drug selling businesses as secondary occupations. They offer low cost treatment facilities including prescriptions, diagnosis and dispensing of medicines. This is also consistently reported in popular news media; medical professionals and law enforcement agencies take a position against them treating as illegal risky practice [21, 22].

These practitioners exist in the liminality [23, 24] or borderline between informal and formal biomedical practice. They have parts to play in the globalisation of biomedicine, and the distribution and uptake of pharmaceuticals and the illnesses they treat; in fact, as this thesis demonstrates, they are often the focus of pharmaceutical advertising to prospect and distribute pharmaceuticals in very poor countries. I therefore argue that these practitioners deserve to be identified properly in research and policy.

Identifying this group in existing literature is not an easy task. Specific criteria based on pattern of practice and engagement with biomedical world may be useful to help to identify the group, though not sufficient as this also captures authorised biomedical practitioners. For example, medical assistants, nurses, drug sellers/vendors, pharmaceutical sales agents or representatives, former hospital/clinic staff/workers and nurses or ward attendants may all moonlight as non­formal biomedical care givers. Unlike the informal practitioners, this non-formal group may have working experience in a web of power relations within neoliberal economies [25-27] with patients, licensed doctors, pharmacists, pharmaceutical market chain, drug wholesalers, and government agents. Of note, in some countries the state has recognised a group of providers who can prescribe for specific health care such as registered nurses or NGO health workers [28]; studies about all those were not included in this review as they are formal and authorised.

Search strategy:

The search structure and terms are presented in Figure 1 (in next page) that shows the keywords (for a full list tried see appendix 1) and MeSH terms searched in databases along with combinations and filters.

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Figure 1: Search structure and key terms development

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MeSH is a vocabulary thesaurus regulated by the National Library of Medicine, USA. It uses a hierarchical structure of sets of terms naming descriptors that helps specific searching at various levels with identification number. As ‘non-formal biomedical prescribers’ is not included in the MeSH thesaurus other key words and terms were incorporated into the search strategy. The following table represent the description and meaning of the MeSH terms2 used in this systematic review.

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Operational definitions of prescriber and provider

The UK National Health Service describes a prescriber as “a healthcare professional who can write a prescription”. Prescribers may be non-physicians who are authorised to prescribe; examples include nurses, midwives, pharmacists, podiatrists, physiotherapists, and diagnostic and therapeutic radiographers, all of whom may be “appropriate practitioners” for limited and predefined pharmacopoeia^[2]. Similar definitions are used by the World Health Organisation, who stipulate that a prescriber does need not be a doctor but could be medical assistant, nurse or midwife [29]. However, the qualification, skills and experience of prescribers vary across the cultures and different countries have different laws and authorisation relating to the power to act as a prescriber.

In many developed countries, rights to prescribe are zealously held by a limited number of practitioners, usually doctors. For example, nurses and midwives in many countries are not allowed to prescribe medicine [30-32]. These practitioners do however provide health care services, as do many unauthorized workers in the non-formal sector. In order to capture all those unauthorised workers who provide biomedical care in the non-formal sector, the term “provider” was used. To give an example of the complexity: a drug seller might be a provider but not licensed to be a prescriber. However, if licenced, a pharmacist or the practitioners located in medicine stores could be both prescriber and provider.

Database selection

The following databases were searched: PubMed, JSTOR, SocioFile, Cochrane Library, Anthropology Plus, CINAHL and PsycINFO. In addition to the database searches, I also searched as the grey literature: EPIC database, WHOLIS (WHO library database), the World Bank Documents and Report Repository, UN websites, The New York Academy of Medicine, the Center for Global Development, USAID, and the Digital South Asia Library. No papers were found from the grey literature sources that met the criteria for inclusion in this study. One reason for this is the collapsing of categories used in the grey literature. For example, reports on the WHO database merged non biomedical practice with all other informal sectors and did not distinguish non-formal biomedical workers from complementary and alternative practitioners [33, 34].

Inclusion/exclusion criteria

All types of studies were included in the initial search (i.e., randomised controlled trials, non­randomised controlled trials, longitudinal studies, cohort or case-control studies, and descriptive studies, qualitative studies, ethnography, case study, narrative based papers) as long as they addressed the identified cadre of“non-formal prescribers” providing prescriptions and selling medicine as in any form. This included patients’ medication requests or selling drugs without formal prescription or related practices by individuals or organizations, and distribution of drugs. Letters, conference papers, opinions, reports or editorials and papers from developed or high income countries were excluded. The review was limited to papers published in English since 1 January 2000.

Review procedures

Papers were subjected to a title search to exclude papers that were not relevant or were duplicates. Abstracts were then retrieved and assessed to see if they were relevant to the study. Abstracts were checked by the supervisor independently in order to verify and ensure that the appropriate strategy has been followed; this process demonstrated 100% concordance in supervisor and researcher assessments. This systematic review was registered on PROSPERO (International Prospective Register of Systematic Reviews)^[3].

Quality assessment of the papers

This systematic review followed the PRISMA^[4] guideline in assessing the quality of the papers. A check list in the form of appraisal sheet was developed to assess the quality and relevance of selected full texts for thorough review. Different types of assessment questions (see appendix 2) are used for different types of papers (e.g. quantitative, descriptive survey, randomised control trials, qualitative, ethnography etc.). Papers were included in the systematic review if they were assessed as being both relevant to the question and ofhigh quality.

Papers were assessed using the following quality criteria:

1. Goals/objectives of the study clearly stated
2. Relevant activities involved in health care service described
3. The study population clearly described
4. The data collection method clearly described including reason behind choosing particular tool (e.g. case study)
5. Statistical methods (controlling and confounding) clearly described
6. The outcomes/results clearly described
7. Unanticipated findings or data clearly described

For each of these criteria a mark of 0, 1 and 2 was given, Papers were included in the final review if they were both relevant and scored 50% and above of total score assigned; 7/14 for descriptive or quantitative and intervention studies; 12/24 for qualitative or ethnographic studies; and 9/18 for systematic reviews.

Data extraction, abstraction and analysis

After the application of appraisal sheet for data assessment relevant data and information were extracted and documented in a Microsoft Excel 2010 version and save in a data spreadsheet file.

The following data were extracted about providers discussed in the papers:

- Level of employment
- Biomedical affiliation of the research subject discussed
- Activities undertaken by non-formal providers.

Operational definitions of the categories and terms used to identify the activities by non-formal prescribers/providers are as follows:

1. ‘Providing prescription only’ refers to any non-formal prescription of medications by unlicensed or unregistered practitioners who has experience of working within biomedical niches. Examples are drugstore owners, vendors or individual practitioners who have or had working experience or observational experience of biomedical prescribing practice in clinics, hospital or under registered physicians. Dispensing of medications does not occur in the same facility.
2. ‘Selling drugs without prescriptions’ refers to non-formal prescribes who sell or dispense drugs to the patient without a recognised or licensed prescription for formal biomedical practitioner.
3. ‘Prescription and drug selling’ refers to non-formal prescribes conducting both prescription scripting and drug selling in one place or drug store mentioned in a paper.
4. ‘Prescription, testing and drug selling’ refers to complete or almost complete treatment facilities offered by non-formal providers including the practice of diagnosis, testing, giving results, and/or using diagnostic equipment offered along with the prescribing and drug selling by the same non-formal provider.
5. “Dispensing only” refers to any reference where non-formal providers do not prescribe or provide treatment other than dispensing drug.
6. Any reference of the term “Self-medication” in this paper refers to patients’ request for medicine to pharmacy or drug store and not the self-medicating activities by physician.
7. Any other related service or health care that involves prescribing practices among non­formal health care providers in developing countries will be categorised as ‘other’.

The synthesized data were tabulated in summary form. Descriptive summaries of major issues in studies were developed, collated and cross-analysed. Emerging questions and themes from the review are also presented in this thesis, to indicate the scope for future research on this topic.

Search results

Figure 2 (in next page) summarises the results of the search. Of ninety papers that were initially read, a total of 25 papers were included in the final review. Ten were descriptive studies using survey data. Three were Randomised Control Trials (RCTs) or Single Arm trials; five were systematic review, three were detailed observational or ethnographic studies and four were mixed method studies. As the term “prescriber” is rare in the literature, this review uses the broader term “provider” in place of “prescriber” to denote various actors involved at the edges of the biomedical economy of pharmaceuticals. Major observations in the results of the studies revealed from the review are described in next chapter.

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Figure 2: Flowchart of the search result from databases

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CHAPTER THREE RESULTS

The included studies spanned all regions of the developing countries across the world. The highest number studies were from South and South-east Asia (15): India (7 studies), Bangladesh (4 studies), Pakistan (1 study), Nepal (1 study), Vietnam and Thailand (2 studies). In Africa, relevant studies were set in Egypt (1 study), Sudan (1 study) and Cameroon (1 study). There was one study from the Middle East, from Lebanon. The only paper from Latin American was set in Mexico. The rest of the papers are systematic reviews (5 studies), from developing or low and middle income countries.

Study attributes

Seven studies [17, 35-40] assessed or evaluated the role, activities, performance, knowledge and efficacy of the non-biomedical providers. Different terms used to identify these workers included: informal, private or informal private providers and non-doctor prescribing practices. Five studies [41-45] described the pattern of drug dispensing or selling in pharmacy settings and the practice of drug selling without formal prescriptions. Two of these were RCTs; the first one was an assessment of a 2 year multi-component intervention on knowledge and reported practice regarding sexually transmitted diseases (STD)], acute respiratory infection (ARI), and non-prescription requests for antibiotics and steroids among the staff working in private pharmacies in Hanoi [43]. The second one was an effectiveness study of a three month multi­faceted intervention to improve prescribing practices among staff in private pharmacies in Hanoi and Bangkok [44].

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^[1] PRISMA guidelines and checklists can be accessed at http://www.prisma-statement.om/

^[2] For examples of such categories in developed countries see- http://www.nhs.uk/chq/Pages/1629.aspx?CategoryID=68&

^[3] For detail about PROSPERO and their registration process see- http://www.crd.vork.ac.uk/PROSPERO/

^[4] PRISMA guidelines and checklists are available at their website- http://www.crd.vork.ac.uk/PROSPERO/