Distribution and characteristics of non-government health practitioners in a rural area of Bangladesh

In August–September 1978, a survey was undertaken of all non-government health practitioners residing in an area containing a study population of 263,000 in rural Bangladesh. The aim of the survey was to elucidate the type, pattern, distribution, characteristics of practice of non-government practitioners in one rural area of Bangladesh. The quality of data on this study population is considered unique because of 15 years of longitudinal demographic surveillance undertaken by the International Centre for Diarrhoeal Disease Research, Bangladesh.

Altogether, 1292 practitioners were identified, giving a practitioner density of 4.7 per 1000 population. Allopathic and homeopathic practitioners constituted 14.9 and 3.3%, respectively, of the total. Very few of these two practitioner categories were officially registered (1.8% of total). Kobiraj, totka (an indigenous healer), and other categories comprised 15.3, 60.5, and 6.0, respectively. Allopaths and homeopaths were younger, better educated, and predominately male in comparison to the more numerous kobiraj, totka, and other practitioners, who tended to be older, less educated, and more often women. Most of the latter group of practitioners learned their skills by apprenticeship while the former group more frequently attended schools.

The geographic distribution of allopaths and homeopaths was thinner than the more numerous kobiraj, totka, and other groups. Most practitioners reported unrestricted, full-time availability to clients in homes and offices without time limitations. Although most non-allopathic practitioners denied the use of allopathic drugs, indepth interviews suggested that this response was biased due to fear of regulatory violations. Allopaths and homeopaths averaged 18 patients daily, while kobiraj, totkas, and others averaged fewer than 10 patients daily.

When practitioners and clients were asked about specialization, a disease-specific utilization pattern emerged. For some diseases, all types of practitioners were employed; but for others, specific practitioner types were utilized. In general, there appeared to be good correspondence between the reported specialization of practitioners and the reported utilization pattern of clients. An attempt was also made to estimate the financial resources involved in non-government health systems. Crude estimations of reported income by practitioners was ten-fold lower than income estimated by client reports of cost and frequency of consultations.

The paper concludes by hypothesizing that, despite high financial costs, the non-government systems are utilized heavily because of availability, social access, and social perceptions of illness causation. Government services are not yet competitive because of poor availability, access, quality, and cost. Although information was not obtained on the biomedical effectiveness of native pharmacopoeias, perceived effectiveness was sufficiently high to attract heavy utilization of high costs. Finally, the prospect of integrating non-governmental traditional medical systems into state-sanctioned medical bureaucracies is discussed with a view toward rationalizing health services in Bangladesh.