The Governance of Informal Healthcare Providers in Noncommunicable Disease Care in Informal Settlements: A Policy Analysis from Sierra Leone

In cities across the developing world, the line between a formal hospital and a neighborhood shop is often blurry. In these crowded, low-income neighborhoods, known as informal settlements, people frequently turn to local figures for medical help before, or instead of, visiting a clinic. These figures include traditional healers who use herbs, faith-based leaders who offer spiritual care, and street vendors who sell medicines. While these providers are often the first people a sick neighbor calls, they operate outside the official rules of the national health system. This creates a difficult situation for governments: they need to ensure these providers do not harm patients, but they also need to recognize that these providers are often the only source of care available. The challenge is particularly acute for noncommunicable diseases, such as high blood pressure and diabetes. Unlike infections that can be cured quickly, these conditions require long-term management, regular check-ups, and consistent medication. When the formal health system is stretched thin or too far away, the informal network becomes the backbone of daily care, yet the rules governing how these two worlds interact remain unclear and often contradictory.

A team of researchers set out to understand exactly how this system works in Freetown, the capital of Sierra Leone. They focused on three specific neighborhoods where people live in crowded, makeshift housing. The researchers wanted to know how the government views these informal providers and how those views translate into real-world rules. They did not just look at written laws; they spoke with the people who make the rules, the doctors working in clinics, and the informal providers themselves. They asked how the government treats a traditional healer compared to a street vendor selling pills, and how these different approaches affect the care people with diabetes and heart disease receive. The study found that the government does not treat all informal providers the same way. Instead, the rules change depending on who the provider is and what kind of risk the government thinks they pose.

The researchers discovered that the official government documents, which are supposed to guide the entire health system, barely mention these informal providers at all. When the Ministry of Health writes a plan for fighting diabetes or high blood pressure, it focuses on hospitals and clinics, leaving out the traditional healers and medicine sellers who are actually seeing patients every day. This silence creates a gap between what the government plans and what happens on the ground. Because the policies do not clearly say how to work with these providers, different government departments handle them in very different ways. Some are seen as partners to be managed, while others are seen as threats to be stopped.

For traditional healers, who use plants and herbs, the government has started to create a new kind of space. These healers are not fully part of the official system, but they are not completely banned either. The government is working on a new policy that would allow them to practice, provided they follow certain rules and refer serious cases to doctors. This is a "hybrid" approach, where the healers are allowed to work but are kept under a loose form of supervision. The government recognizes that these healers are trusted by the community and can help spread health messages, especially during crises like disease outbreaks. However, the path to becoming a registered, legal healer is difficult and expensive, which keeps many of them on the margins.

In stark contrast, the government treats street vendors who sell medicines very harshly. These individuals are often called "quacks" by officials because they sell prescription drugs without a license or a doctor's note. The government views them as a major danger to public health, fearing they sell fake or expired drugs and give the wrong treatment for serious conditions like high blood pressure. As a result, the main way the government deals with them is through enforcement. Police and health inspectors regularly raid their stalls, seize their goods, and arrest them. The goal is to drive them out of business entirely. However, the researchers found that this approach is not working as intended. Because the formal clinics are often out of medicine or too far away, people continue to buy from these vendors. The vendors themselves say they try to be careful, asking customers for prescriptions, but they feel harassed rather than helped by the constant raids.

Then there are the faith-based healers, such as pastors and religious scholars, who offer spiritual comfort and advice. For this group, the government has almost no rules at all. Officials generally believe that spiritual healing is a matter of faith and not something that can be measured or regulated by a medical board. They see these healers as operating in a separate world that does not overlap with the science of medicine. Consequently, there is no formal way to train them or check their work. Yet, in practice, many people visit these healers alongside doctors, mixing spiritual prayers with medical pills. The healers often encourage their followers to see a doctor for physical illnesses, acting as a bridge to the formal system, but the government does not have a plan to officially include them in the health strategy.

The study highlights that this patchwork of rules is not just a bureaucratic issue; it directly affects the health of people living in these neighborhoods. When the government focuses only on arresting drug sellers, it does not solve the problem of why people need to buy from them in the first place: a lack of affordable, accessible care in the formal system. When the government ignores faith healers, it misses an opportunity to use their influence to encourage people to take their medication. The researchers concluded that the current approach is too fragmented. To improve care for diseases like diabetes and heart disease, the government needs to move beyond simple enforcement and start building a system that acknowledges the reality of these neighborhoods. This means creating clear, fair rules that allow informal providers to work safely alongside doctors, rather than trying to eliminate them or leaving them to operate without any guidance. The goal is to turn a collection of separate, often conflicting efforts into a coordinated network that actually reaches the people who need it most.