It’s no secret that top-down monitoring and accreditation isn’t always a successful mechanism to ensure the quality of care in health facilities. Outdated licenses, sparse monitoring, corruption, misaligned incentives and other ills plague the health care infrastructure—both public and private—around the world. In a chaotic marketplace, provider behavior ranging from patients seen, to time spent per patient and decisions regarding diagnosis and treatment, are guided by a variety of forces, including medical knowledge, regulatory environment, revenue calculations, and a host of intrinsic motivations.
Last week, Results for Development hosted Ken Leonard, agricultural economist at the University of Maryland, and Jishnu Das, senior economist at the World Bank to discuss their recent work on care quality among public and private providers in Tanzania and India, and the influences that shape provider behavior. The following are just a few of the many fascinating findings coming out of this work.
Do providers practice what they know? In most settings, service quality is largely equated with provider knowledge. While this is true to an extent—some baseline of knowledge is essential for basic diagnosis and treatment—recent evidence from the two countries shows that quality is one part knowledge and three parts effort. In a recent study of provider behavior in the public and non-state sectors in Tanzania, Ken Leonard and colleagues found a significant know-do gap among health care providers. Mapping competence against performance in a field setting, the team found that a considerable number of providers performed well below their level of knowledge. Results of a study in the Indian state of Madhya Pradesh underline the same conclusion. In fact, untrained private sector providers performed better than their qualified public sector counterparts, even though they were less knowledgeable, simply because they exerted more effort.
Are patients ignorant? With such a disparity in provider quality, can patients tell the difference? According to many, the answer is no. While asymmetries of information certainly exist between patients and providers that put patients at a disadvantage, the “ignorant patient” theory may have some holes. In Tanzania, researchers found a distinct decrease in patient satisfaction with the services they received in line with a decrease in service quality (measured by adherence to protocol). Among private providers in India, the market appeared to efficiently price service quality—providers that exerted the most effort were also more expensive, indicating that patients were willing to pay more for better quality care.
How to improve service quality? Recognizing that traditional accreditation and monitoring may not always work effectively, what other instruments are available to incentivize quality? In Tanzania, Ken Leonard and his team focused on measuring the impact of peer monitoring on service quality. They found that the same providers that initially performed below their level of knowledge immediately improved their practice when a member of the research team walked into the room. (It may be interesting to note this provider reverted back to old practices when he became accustomed to—or bored with—the individual.) In addition to direct observations, the study team found that simple encouragement from a fellow doctor had an even greater effect on service quality several weeks after the encouraging talk was given. In India, the study in Madhya Pradesh highlighted the effect of customer accountability on provider behavior. Amazingly the same provider was found to be the worst in the entire system when practicing in the public sector, and the best when in a private practice. What was the difference? In the latter case, the provider’s income depended entirely on patient loyalty and trust.
These findings hold some interesting implications for interventions aimed at improving service quality. In a world heavily focused on improving provider knowledge through continuous training, perhaps the real key to better quality is encouraging greater effort among providers. How should this be done? That, dear readers, remains the silver bullet.