DOMINIC MONTAGU

Based on slides developed by Abi RidgwayUC Berkeley Haas School of Business

Exhortation and Information as Policy Tools to Improve Private-Sector Hospital Performance in

Asia

Harding-Montagu-Preker Framework: Overview

•Distribution(equity)

•Efficiency

•Quality of Care

Source: Adapted from Harding & Preker, Private Participation in Health Services, 2003.

PHSA

•Gather available information

•Identify additional needs

•In-depth studiesActivities

• Hospitals• PHC• Diagnostic labs• Producers / Distributors

Ownership

• For-profit corporate • For-profit small business

• Non-profit charitable

Formal/ Informal

Grow

Harness

Convert

StrategyAssessmentGoal Focus

Private Sector

PublicSector

Restrict

Harding-Montagu-Preker Framework: Overview

•Distribution(equity)

•Efficiency

•Quality of Care

Source: Adapted from Harding & Preker, Private Participation in Health Services, 2003.

PHSA

•Gather available information

•Identify additional needs

•In-depth studiesActivities

• Hospitals• PHC• Diagnostic labs• Producers / Distributors

Ownership

• For-profit corporate • For-profit small business

• Non-profit charitable

Formal/ Informal

Goal AssessmentFocus

Private Sector

PublicSector

Restrict

Grow

Convert

Strategy

Harness

Outline of Session

Definition

Typology

Criteria for Assessment

Conclusions

definition

The Problem of Quality

In South and Southeast Asia much or most hospital care is provided by the private sector.

Quality of care in private hospitals is variable and often inadequate.

Due to weak regulatory powers and small budgets, health officials in low and middle-

income countries have limited influence on the quality of care provided by private hospitals.

Traditional policies: limited applicability

Pay-for-Performance

Regulation

Accreditation

Contracting Services

Using information as a policy tool

Policy Alternatives

#1: Persuasion

Target Audience Size

An intentional effort to change attitudes or behavior by sharing

information with hospital providers

#1: Persuasion

Criteria Ranking

Rationale

Effectiveness

Low • Lack of evidence to show effect in hospital setting• “KAP Gap” = changing knowledge is not changing

behavior• Profit motives and patient expectations also play a

role

Affordability

Medium • Depends on the size of the target audience• Inversely correlated with effectiveness

Feasibility High No new technology required Education is non-controversial• Getting physicians time is major political challenge

#2: Public Recognition

A governmental promotion of a set of standards for hospitals, followed by

public recognition of hospitals that meet those standards

Ex: Malcolm Baldrige National Quality Award Effort by US in 1980s to improve quality of

manufacturing Recognizes high quality of goods and services Xerox, Motorola, Ritz Carlton

Hospitals are included

#2: Public Recognition

Criteria Ranking

Rationale

Effectiveness

Medium Depends on market response, Baldrige winners benefit financially in term of market valuations

Creates a common set of standards• May not reach hospitals that are most likely to need

improvement

Affordability

High Government doesn’t have to provide financial reward

Only evaluate applicants Industry contributes to Baldrige award Cost-benefit ratio estimate of Baldrige = 207:1

Feasibility High Hospital voluntary participate No EHRs required, small scale data collection

#3: Public Reporting

A governmental collection of information about patient care from hospitals and dissemination of that

information to all players in the healthcare industry to facilitate better

decision-making.Ex: Hospital Compare

Pioneered in US, followed by similar effort in Europe Relies on “market” forces Is tied to financial incentives

Trickle down effect

#3: Public Reporting

Criteria Ranking

Rationale

Effectiveness

Medium Effort in the US show a change in provider behavior• Patients don’t react to public reporting data• Cherry-picking: reduced access for sicker patients• May not have long term effect

Affordability

Low • Intense data collection process• Auditing

Feasibility Low • Heavy reliance on EMRs• Probable push-back from providers

#4: Negotiation

Governments and providers make a mutual agreement for performance

improvementEx: PRACTION Study, India & Pakistan

Goal to get private provider to follow WHO recommended care for childhood illnesses (ICMI)

PRACTION had significant improvement on 16 or 21 desired behavior changes

#4: Negotiation

Criteria Ranking

Rationale

Effectiveness

Medium Face-to-face interaction shown effective in pharma-detailing

Providers actively participate, patients may also Psychological desire for consistency• Unclear if it works for teams vs. individual• Only works for common conditions

Affordability

Medium No formal training No auditing verbal case reviews• Management intensive process

Feasibility High Simple data collection method and tools Adaptable process can be used to change Providers have say and push back less

Summary of policy alternatives

PersuasionPublic

Recognition

Public Reporting

Negotiation

Effectiveness

Low Medium Medium Medium

Affordability

Medium High Low Medium

Feasibility

High High Low High

Recommendation

LMIC government should use public recognition as its primary policy tool to improve private sector care Highly affordable because doesn’t requires monitoring Politically feasible because voluntary Technical challenge is agreeing on a standards of quality

Helpful for future interventions Breaks down the separation between public and private

players

In the longer term, negotiation is the next most promising alternative PRACTION showed that effective for formal providers, but

more pushback No demonstrations yet at hospital level

Caveat

A Weak ToolAmong the policy or program options available to influence private hospitals, Exhortation and Information is both the least well documented, and the weakest.

While risks are low in the application of public recognition strategies or other Information-lined policies; the degree of changed practices is likely to be commensurately modest.

ConclusionExhortation and Information is a useful first-level intervention.

When Exhortation/Information and When Other Interventions

Effectiveness Improves the quality or equality of care

Structures and processes that reduce morbidity and mortality

Improves patient experience Improves hospital productivity

Affordability Affordable to launch and to maintain

Feasibility Technically: EMRs not yet available Politically: Support from policy-makers, patients and

providers

QUESTIONS?

Thank you!