Practice-Quality Variation in Low-Income Countries

Jishnu DasDevelopment Research GroupThe World Bank

Why are the poor sick and dying?The traditional story

Poor access, poor don’t go to doctors, they visit local quacks instead

Health Centre

This is the best case scenario

That story was wrong

Sampled village with 2 private and 1 public health care provider

Village where most people go to seek careHas more than 50 health care providers

Similar Story across India

Poor people now live in villages with many health care providers to choose from and use health care providers often

Who are the providers?

80% of first-contacts (primary care) in India in private sector 77 percent of private providers in rural areas do not have medical training Contrast: All public providers are (supposedly) trained, the majority with an MBBS

77% of providers have no degree, 18% have some other degree (BAMS, BIMS, BUMS, BHMS), and only 4% have an MBBS degree (roughly equivalent to MD in the U.S.). Average village has 3.36 providers with no degree, 0.80 providers with some degree, and 0.18 providers with an MBBS degree

Emphasis now has to move from access to access with quality

Three Steps

Measure quality in many places and many ways

Understand what can work and where the problems are

Intervene and evaluate

First and most critical problem is defining the quality you want to measure

Step 1: Measuring quality

Medical Competence or Knowledge: What doctors know

Practice: What doctors doPractice: Standardized patients: How patients

are ultimately treated

Findings: Qualifications is not competence

MBBS providers in Jharkhand, Bihar, and Uttar Pradesh are less competent than providers with no degrees in Gujarat and Tamil Nadu. The variation in medical education across states could be contributing to the variation in competence of MBBS providers.

What about practice?

In a place like India, the average patient interaction lasts 3 minutes, the doctor asks 3 questions and performs 1 examination (there are no nurses to take vital signs or patient histories before the patient sees the doctor)

The picture above shows doctors in the bottom, middle and top thirds of “effort” (a composite of time, questions, and exams). The bottom third spends less than 2 minutes, asks 1 question and does no examinations

Similar results in some other countries (Tanzania, Malawi, Nigeria) but not others (Paraguay)

Findings: Diagnosis of MI, SPs

Das and others, 2012

There is no correlation between adherence to checklist and measures of facilities or equipment or patient loadThe correlation with medical training is very lowPrivate sector doctors are more likely to adhere to the checklist

Incentives are part of it

In the public sector, the same doctor is the worst in the entire system and in his/her private clinic he/she is the best in the entire system: accountability matters.

In current work, we look at public-private differences using standardized patients and find higher rates of correct treatment and adherence to checklist in the private sector For instance, in the case of unstable angina, correct treatment increases by close to 100

percent for similar doctors in the private relative to the public sector

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Den

sity

-2 -1 0 1 2Quality index

Public MBBS Public UnqualifiedPrivate MBBS Private Unqualified

Quality of care by sector (Audits 1 & 2)

Findings: Earlier study from Delhi1. As a result, practice very

different from competence; characterized by a large “know-do” gap: Providers do a lot less in practice than what they had told us they would do with a similar patient in the vignettes

2. Gap increases with competence

3. Gap consistently higher in public sector (NB: Competence essentially uncorrelated with practice in public)

4. In practice, the untrained private sector provides as good or better care than the fully trained public sector

Similar results in Tanzania, Netherlands, Canada and the U.S.

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Wha

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0 .2 .4 .6 .8 1What they said they would do

What they know W hat they Do: PrivateWhat they do: Public

Rotating The Curve

Private

Public

If providers did everything that they tell us they would do, we should observe them on the 45-degree line

Instead, the private below

And the public far below—in the public sector, practice is uncorrelated to knowledge!

What does this all mean

The fundamental finding thus far is that measures of quality that are frequently measured such as qualifications and availability of medical equipment are very poor predictors of quality of medical advice

Implications for regulation and policyMeasurements like standardized patients offer a biopsy of the system—providing a critical feedback loop for policy and interventions