Exploring the roles of informal healthcare providers in urban settings to improve access and quality of care for the urban poor: experience from Bangladesh, Ghana, Nepal, and Nigeria.

Though informal healthcare providers (IHPs), often defined as unregistered and not formally trained, are heavily utilized by low-income urban residents and present an opportunity to address the urban primary care gap, these providers are rarely prioritized or integrated into health systems. This paper explores IHPs' role in urban settings across four rapidly urbanizing low- and middle-income countries: Bangladesh, Nepal, Nigeria, and Ghana, to enhance understanding of their potential within health systems and promote their integration to improve access and quality of care for the urban poor. We studied published and unpublished articles and policy documents to compare informal provider types, roles, services, and target populations in each country. We then present case studies illustrating how these providers support healthcare for urban poor. A narrative synthesis was applied to describe the included documents/literature and results, while quantitative data were analysed using STATA version 16. OpenStreetMap basemaps were employed to illustrate informal providers' locations within urban areas. Our findings show that across the four countries, there is substantial evidence that informal providers contribute significantly to health service delivery by bridging the care gap, particularly for socially and economically disadvantaged urban populations. They serve as the first point of contact, offering a wide range of health services, including preventive, curative, and restorative services. However, they are loosely defined and lack robust standards, protocols, professional training, and accreditation. Informal providers play a critical, though varied, role in the delivery of healthcare across the countries studied, facilitating access to care where it might otherwise be unavailable or unaffordable. Initiatives to strengthen the informal sector, e.g. linking or integrating with the formal sector, have the potential to improve healthcare access and quality for the urban poor.