Publication: The Quality of Medical Advice in Low-Income Countries
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Date
2008
ISSN
08953309
Published
2008
Author(s)
Leonard, Kenneth
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Abstract
This paper documents the quality of medical advice in low-income countries. Our evidence on health care quality in low-income countries is drawn primarily from studies in four countries: Tanzania, India, Indonesia, and Paraguay. We provide an overview of recent work that uses two broad approaches: medical vignettes (in which medical providers are presented with hypothetical cases and their responses are compared to a checklist of essential procedures) and direct observation of the doctor--patient interaction These two approaches have proved quite informative. For example, doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000-96,000 Tanzanians each year. A public-sector doctor in India asks one (and only one) question in the average interaction: "What's wrong with you?" We present systematic evidence in this paper to show that these isolated facts represent common patterns. We find that the quality of care in low-income countries as measured by what doctors know is very low, and that the problem of low competence is compounded due to low effort--doctors provide lower standards of care for their patients than they know how to provide. We discuss how the properties and correlates of measures based on vignettes and observation may be used to evaluate policy changes. Finally, we outline the agenda in terms of further research and measurement.
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Publication The Quality of Medical Advice in Low-Income Countries(World Bank, Washington, DC, 2008-01)This paper provides an overview of recent work on quality measurement of medical care and its correlates in four low and middle-income countries-India, Indonesia, Tanzania, and Paraguay. The authors describe two methods-testing doctors and watching doctors-that are relatively easy to implement and yield important insights about the nature of medical care in these countries. The paper discusses the properties of these measures, their correlates, and how they may be used to evaluate policy changes. Finally, the authors outline an agenda for further research and measurement.Publication Strained Mercy: The Quality of Medical Care in Delhi(World Bank, Washington, D.C., 2004-03)The quality of medical care is a potentially important determinant of health outcomes. Nevertheless, it remains an understudied area. The limited research that exists defines quality either on the basis of drug availability or facility characteristics, but little is known about how provider quality affects the provision of health care. The authors address this gap through a survey in Delhi with two related components. They evaluate "competence" (what providers know) through vignettes and practice (what providers do) through direct clinical observation. Overall quality as measured by the competence necessary to recognize and handle common and dangerous conditions is quite low, albeit with tremendous variation. While there is some correlation with simple observed characteristics, there is still an enormous amount of variation within such categories. Further, even when providers know what to do they often do not do it in practice. This appears to be true in both the public and private sectors though for very different, and systematic, reasons. In the public sector providers are more likely to commit errors of omission-they are less likely to exert effort compared with their private counterparts. In the private sector, providers are prone to errors of commission-they are more likely to behave according to the patient's expectations, resulting in the inappropriate use of medications, the overuse of antibiotics, and increased expenditures. This has important policy implications for our understanding of how market failures and failures of regulation in the health sector affect the poor.Publication Weak Links in the Chain II : A Prescription for Health Policy in Poor Countries(World Bank, Washington, DC, 2002-01)This article presents an approach to public policy in health that comes directly from the literature on public economics. It identifies two characteristic market failures in health. The first is the existence of large externalities in the control of many infectious diseases that are mostly addressed by standard public health interventions. The second is the widespread breakdown of insurance markets that leave people exposed to catastrophic financial losses. Other essential considerations in setting priorities in health are the degree to which policies address poverty and inequality and the practicality of implementing policies given limited administrative capacities. Priorities based on these criteria tend to differ substantially from those commonly prescribed by the international community.Publication The Impact of Recall Periods on Reported Morbidity and Health Seeking Behavior(2011-08-01)Between 2000 and 2002, the authors followed 1621 individuals in Delhi, India using a combination of weekly and monthly-recall health questionnaires. In 2008, they augmented these data with another 8 weeks of surveys during which households were experimentally allocated to surveys with different recall periods in the second half of the survey. This paper shows that the length of the recall period had a large impact on reported morbidity, doctor visits, time spent sick, whether at least one day of work/school was lost due to sickness, and the reported use of self-medication. The effects are more pronounced among the poor than the rich. In one example, differential recall effects across income groups reverse the sign of the gradient between doctor visits and per-capita expenditures such that the poor use health care providers more than the rich in the weekly recall surveys but less in monthly recall surveys. The authors hypothesize that illnesses -- especially among the poor -- are no longer perceived as "extraordinary events" but have become part of "normal" life. They discuss the implications of these results for health survey methodology, and the economic interpretation of sickness in poor populations.Publication Money for Nothing : The Dire Straits of Medical Practice in Delhi, India(World Bank, Washington, DC, 2005-07)The quality of medical care received by patients varies for two reasons: differences in doctors' competence or differences in doctors' incentives. Using medical vignettes, the authors evaluated competence for a sample of doctors in Delhi. One month later, they observed the same doctors in their practice. The authors find three patterns in the data. First, what doctors do is less than what they know they should do-doctors operate well inside their knowledge frontier. Second, competence and effort are complementary so that doctors who know more also do more. Third, the gap between what doctors do and what they know responds to incentives: doctors in the fee-for-service private sector are closer in practice to their knowledge frontier than those in the fixed-salary public sector. Under-qualified private sector doctors, even though they know less, provide better care on average than their better-qualified counterparts in the public sector. These results indicate that to improve medical services, at least for poor people, there should be greater emphasis on changing the incentives of public providers rather than increasing provider competence through training.
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