EDITORIALS
Informal health workers to be encouraged or condemned?
Francis Omaswa
World Health Organization, 1211 Geneva 27, Switzerland (email: omaswaf@who.int)
Home-based care of patients is increasing in importance in many societies, particularly where health facilities are overwhelmed by human immune deficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and patients are returned to their homes to be cared for or to await death. Care is mostly provided by close family members who have no formal training in health care, though in some cases they may receive guidance from professional health visitors. Formal health visitors as a professional category should be rapidly expanded in order to provide needed support to the growing numbers of home-based informal caregivers.
Political and other leaders in the community, where the physical and social environments are regulated, are another group of informal health workers whose role in determining health outcomes of populations is generally understated and needs to be highlighted and brought to the fore.
In many communities, a significant proportion of health care is provided in commercial settings such as markets and shops. Vendors are regularly called upon to advise purchasers on the effects of the health products on sale and methods for their use, including potent drugs and medical equipment. In many cases these merchants and shopkeepers interrogate the buyers, take medical histories and proceed to diagnose and prescribe. In situations where formal health facilities are not available nearby or easy to access, this group of informal health workers is the first and most important point of call by people in search of health services.
The regulation and supervision of such vendors acting as informal health workers assume enormous importance, considering that many of them may trade in dangerous drugs that would normally be prescribed and supervised by qualified professionals. Storage conditions of the drugs and commodities may render them ineffective and even dangerous. Diagnoses and prescriptions may not be appropriate, as transactions are often driven by the motive to sell rather than to help the patient. In addition, inappropriate drugs may do harm on a larger scale: for example, widespread resistance of the malaria parasite to chloroquine is in large measure attributable to the role played in its dispensing by informal health workers around the world.1
In many countries there are regulations to govern these points of sale of health products, but enforcement is not easy for a number for reasons. Some are located in areas that are remote and difficult to reach, while others are protected by local leaders who value their services or even own them. One solution that is potentially effective is to increase the level of health literacy in the general population. Health education should be emphasized in primary and secondary schools and be an important subject in examinations. Health messages by radio and other media can reinforce widespread knowledge in the community and keep the informal health workers alert and up to date. Improving the performance of public health facilities in rural areas and involving the communities in their management has led to the disappearance of informal health services in some places.
Formal health workers can become informal health workers when they operate outside the rules of the health system, for example if they impose illegal charges, use employer facilities for private practice and personal gain, or practise outside the limits of their skills (such as by performing surgical procedures for which they are neither trained nor licensed). This type of informal health care is symptomatic of a poorly managed health care system often characterized by low pay and poor working conditions. However, dual employment where formal health workers undertake private practice in their free time is recognized as formal provided that the private practice is undertaken within lawful limits.
This discussion would not be complete without reference to traditional health practitioners, who are frequently the first point of consultation in many communities. Are they informal health workers or are they part of the formal health system? In countries where traditional health practitioners are regulated by laws they can be classified as part of the formal health system, but where there are no legal frameworks they may become informal health workers. One of the tricky issues in this category is the difference between witchcraft, sacrificial practices and traditional medicine. The African Union declared a decade of traditional medicine, which has made it possible for many countries to develop legal frameworks and regulate this important group of health workers.2
Informal health workers are found in every health system, and the impact of their role increases as the strength of the formal sector weakens. Informal health workers who are not breaking any regulations can be significant players in some communities and deserve to be acknowledged, encouraged and supported. These include household members, political and community leaders, vendors in shops and markets and the media. There are also informal health workers for whom increased effort needs to be made in their regulation and supervision and where members of the public need to be equipped to protect themselves through universal health literacy. 
References
1. The world health report 2000 Health systems: improving performance. Geneva: WHO; 2000.
2. Traditional medicine. Geneva: WHO; 2003. Fact Sheet 134, rev. May 2003. Available from: http://www.who.int/mediacentre/factsheets/fs134/en/