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Improving Quality of Care
Jishnu Das(World Bank, Washington DC and
Centre for Policy Research, New Delhi)Institute of Medicine, January 2015
Problem
• Improve quality of care “at scale” in a cost-effective manner
• Six Strategies: Service based, facility and context specific labor intensive methodologies
– RCT evidence not available
– Key questions about what constitutes quality of care
Here
Three Issues
Policy or Product
Health Related
Non-health related
Study Population
What is measured
How is it evaluated
Further observations
• Overarching: How much does it cost
• Question: What are the implicit assumptions for scaled up quality improvement efforts
• Caveat: Most results here from India and primary care
Current Situation
• 4.4 providers per village, 77% with no formal medical training, <10% public
• 40% of public doctors absent on any given day, 2-3% decline over 10 years
• 4% of patients get the correct treatment “only”, fully trained doctors give the correct treatment “plus” 40% of the time, give at least one incorrect treatment 75% of the time
Data are from the Medical Advice, Quality and Availability in Rural India (MAQARI) project, joint with AlakaHolla (World Bank), Karthik Muralidharan (UCSD), Michael Kremer (Harvard University) and Aakash Mohpal(Michigan)
Current Situation
Health care providers appear to do what they say they would do around half the timeCorrect treatment increases with effort, and knowledgeReplicated in Tanzania, Rwanda, Canada, Netherlands
Current Situation: Data
Standardized patients for asthma (young adult), angina (older man), diarrhea (child, at home). In public health facilities, records don’t match what patients came or what they reported with. Most private facilities in our sample don’t have patient records.
Symptoms Indicative of Case Presented
Symptoms Listed
SP Listed
SP VisitsTotal, 231
(100%)
Yes, 171 (74%)
Yes, 75 (32%)
Yes, 57 (25%)
No, 18 (8%)
No, 96 (42%)
No, 60 (26%)
Question: What can be done• Five asks
–Private Sector: no de facto regulation
– Informal providers without formal training
–Multiple topics
– Evaluate under and over treatment
–Costs less than $150 per provider
• Attempt training intervention, with AbhijitBanerjee and Reshmaan Hussam (MIT) and Abhijit Chowdhury (P.G. Hospital, Kolkata)
Start simple but relevant
Quality: When a patient goes to a health care provider he/she receives the correct diagnosis and treatment (could include referral) and a minimum level of guaranteed safety. He/she should not receive treatments that are not required, or worse, harmful.
Use Standardized patients: People recruited from local community and extensively trained (120 hours) by a cross-disciplinary team to depict the same medical condition to multiple providers. Debriefed with a structured questionnaire after interaction, allows to elicit whether providers did what they were supposed to and did not do what they were not supposed to
Evaluation and Design
• Multi-topic, long duration training among 304 participating providers, randomized into a treatment group (offered training) and a control group (not offered training)
– Liver Foundation, West Bengal
– 2 days a week, 4 hours a day, 9 months
– Multiple trainers, multiple approaches
• Standardized patients for asthma, angina and childhood dysentery sent 3 months after completion (6 months after topics were taught)
• Compare providers allocated to training to control group
• Compare providers in study (from 203 villages) to full census of 11 public health centers in these villages
• Implementers firewalled from evaluators
• Implementers did not know what (trained) providers would be evaluated on
Attendance
Preliminary Results from: “The Impact of Training Informal Providers on Medical Practice in West Bengal, India: A Randomized Controlled Trial”, joint with Abhijit Banerjee (MIT), Abhijit Chowdhury (PG Hospital, Kolkata and Liver Foundation) and ReshmaanHusssam (MIT)
Process outcomes• Likelihood of correct treatment for SPs increased 7-8
percentage points (Intention to treat) on base of 52%– 13-14 percentage points (Instrumental variables)
• Adherence to checklist increased by 4-7 percentage points (ITT and IV) on base of 27 percent
• No change in “things that they should not do”– Antibiotic use, polypharmacy, injection use
• 2000+ patient observations confirm more examinations and history taking
• Cost of intervention of $175 per provider could be fully recovered within 6 months as demand increased by 2 patients per day
Preliminary Results from: “The Impact of Training Informal Providers on Medical Practice in West Bengal, India: A Randomized Controlled Trial”, joint with Abhijit Banerjee (MIT), Abhijit Chowdhury (PG Hospital, Kolkata and Liver Foundation) and ReshmaanHusssam (MIT)
Process Outcomes
PHC Control Treatment
Checklist - All 0.202 0.273 0.313
Correct Treatment 0.667 0.520 0.594
Average Quality Treatment 0.182 0.114 0.174
Correct Diagnosis 0.182 0.136 0.188
Consultation Length (Mins) 1.735 3.252 3.495
Gave Antibiotics 0.667 0.477 0.480
Antibiotics (Asthma and MI) 0.636 0.331 0.332
Offered injection 0.045 0.011 0.019
Treatment - Polypharmacy 2.758 2.162 2.208
Preliminary Results from: “The Impact of Training Informal Providers on Medical Practice in West Bengal, India: A Randomized Controlled Trial”, joint with Abhijit Banerjee (MIT), Abhijit Chowdhury (PG Hospital, Kolkata and Liver Foundation) and ReshmaanHusssam (MIT)
Evaluation lessons
• Possible to evaluate in an RCT context a complex, long-duration, multi-topic training intervention
• One benchmark for QI as costs were $175 per provider
– 12-13 percentage point increase in correct treatment (Instrumental variables estimates)
– Closes gap with public sector in treatment, which was in 11 of 203 villages where providers came from
• Informal providers performed better on all other measures without training
Preliminary Results from: “The Impact of Training Informal Providers on Medical Practice in West Bengal, India: A Randomized Controlled Trial”, joint with Abhijit Banerjee (MIT), Abhijit Chowdhury (PG Hospital, Kolkata and Liver Foundation) and ReshmaanHusssam (MIT)
Implicit assumptions in USAID programs?
• Problem has been correctly diagnosed as a front-line issue that is independent of potential policy changes or changes in institutional structure
• Public sector interventions carry over to private sector OR will shrink private sector
• Costs are sufficiently low for large and sustained scale-up within country budgets
• There is sufficient capacity and external validity for scale-up