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1
Measurement and Efforts to Improve Quality
Gayle Martin and Zelalem DebebeJune 30,2015
www.worldbank.org/SDI www.SDIndicators.org
2
Measurement and Efforts to Improve Quality
Gayle Martin and Zelalem DebebeJune 30,2015
www.worldbank.org/SDI www.SDIndicators.org
Outline
• Large inter- and intra-country variation in key measures of quality
• Effectiveness requires simultaneous availability: in the same place at the same time
• What can be done to improve these measures of quality?
• Without focused effort, improvements in process quality will lag structural quality
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Large inter- and intra-country variation in key measures of quality:Diagnostic accuracyAdherence to clinical guidelines Treatment accuracy
Malaria with anemiaDiarrhea with severe dehydrationPneumoniaDiabetesTuberculosis
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Large inter- and intra-country variation in key measures of quality:Diagnostic accuracyAdherence to clinical guidelines Treatment accuracy
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Effectiveness requires simultaneous availability: in the same place at the same time
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% facilities with competent providers(46%)
% facilities with steth,+sphyg+sterilizing equip(78%)
Effectiveness requires simultaneous availability: in the same place at the same time
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Even when conditions are correctly diagnosed they are not necessarily correctly treated
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Even when conditions are correctly diagnosed they are not necessarily correctly treated
Simulation results: Respiratory Infection cases correctly diagnosed and treated
15.2%
# children with ARI
# children who sought care
# cases correctly
diagnosed
# cases correctly
diagnosed and
treated
364,950
259,114
123,338
55,632
15.2%
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Simulation results: Respiratory Infection cases correctly diagnosed and treated
Sources: UNPOP for Population data. SDI for provider competence estimates. DHS for prevalence and utilization data.
Kenya Nigeria Uganda Tanzania
512,392 560,120
973,840
364,950
112,33728,967
164,54955,632
# children with ARI
# children who sought care
# cases correctly diagnosed
# cases correctly diagnosed and treated
21.9% 15.2%16.9%5.2%
% of ARI cases correctly diagnosed and treated
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What can be done to improve these measures of quality?• Decompose clinical guidelines and identify
the relative effect of the components on the probability of successful diagnosis*
• Adherence to history taking and physical examination guidelines increases the probability of diagnostic accuracy by 54 % points
• Estimates are higher for providers with lower medical training (nurses): 36 % points versus 59% points• suggesting a higher return to adhering to
clinical guidelines among nurses compared to doctors and clinical officers
Dep var: Probability of a correct diagnosis
AllDoctors/clinical officers
Nurses
History taking and physical examination
0.540***(0.153)
0.361***(0.085)
0.591***(0.204)
Laboratory test 0.466***(0.063)
0.326***(0.087)
0.540***(0.089)
Observations 3145 1390 1740
R-squared 0.419 0.465 0.416
Number of providers 629 278 348
* We estimate a provider fixed effects model that enables to minimize unobserved heterogeneity due to unobserved time-invariant characteristics (such as innate abilities, intrinsic motivation etc.).
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Without focused effort, improvements in process quality will lag structural quality
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Looking to the future …
Providers with weakest skills are located in areas with highest mortality
Service Delivery Indicators