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  • Strained Mercy:
    The Quality of Medical Care in Delhi
    Jishnu Das
    Development Research Group, World Bank
    jdas1@worldbank.org
    Jeffrey Hammer
    Development Research Group, World Bank
    Jhammer@worldbank.org
    with
    The Institute of Socio-Economic Research on Development and Democracy
    Delhi
    World Bank Policy Research Working Paper 3228, March 2004
    The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the
    exchange of ideas about development issues. An objective of the series is to get the findings out quickly,
    even if the presentations are less than fully polished. The papers carry the names of the authors and should
    be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely
    those of the authors. They do not necessarily represent the view of the World Bank, its Executive Directors,
    or the countries they represent. Policy Research Working Papers are available online at
    http://econ.worldbank.org.
    _____________________________________
    The modules used in this study were designed in consultation with Dr. Tejvir Singh Bubba Khurana and
    many discussions with Ken Leonard and Asim Khwaja. The pilot and survey was implemented by Jishnu
    Das and Jeffrey Hammer with N. Deepak, Pritha Dasgupta, Sourabh Priyadarshi, Poonam Kumari and
    Sarasij Majumdar, all members of The Institute of Socio-Economic Research on Development and
    Democracy Delhi (ISERDD). Further support from Purshottam, Rajan Kumar and Simi Bajaj, often under
    trying circumstances, is gratefully acknowledged. We also thank Dr. Arvind Taneja, Veena Das, and R. K.
    Das for comments and suggestions; to the panel of physicians led by Dr. Jonathan Ellen and Dr. Zahida
    Khwaja for their cooperation in evaluating treatments; and to Shruti Haldea for excellent research
    assistance. Finally, the project would not have been possible without the cooperation and enthusiasm of the
    participating providers as well as administrators of the various public sector facilities surveyed. The
    research was funded by a research grant from the World Bank.
  • ii
    Abstract
    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. We address this
    gap through a survey in Delhi with two related components. We 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 don’t do it in practice. This
    appears to be true in both the public and private sectors but for very different, and
    systematic, reasons. In the public sector providers are more likely to commit errors of
    omission—exert less effort compared to 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.
    Contents
    I. Introduction 1
    II. What Does Quality Mean? Understanding Competence and Practice 5
    III. Measuring Quality: The Method and Implications 7
    III.1. Sampling 7
    III.2. Assessing Competence: Methodology 8
    III.3. Assessing Competence: Benchmarking 11
    III.4. What Does the Distribution of Competence Imply for Care? 12
    IV. What Providers Do: The Relationship between Competence and Practice? 15
    IV.1. Competence and Practice: Is There a Difference? 16
    IV.2. Incentives and the “Wedge”: Evidence from Public/Private Providers 19
    V. Discussion and Conclusion 24
    Bibliography 26
  • 1
    I. Introduction
    For all its acknowledged importance, the quality of medical care in India is not well
    understood. Many studies of the demand for medical services identify quality as a major
    determinant of facility selection and use, and that such use should contribute to
    improvements in health status. However, quality of care is not clearly defined beyond
    easily observable facility characteristics such as the availability of medicines or
    functioning equipment (Collier, Dercon, and Mackinnon 2003; Lavy and Germain
    1994).
    1
    What is less well understood, but has greater relevance for both the use and
    outcomes of services, is the quality of the actual advice given in clinical settings.
    Medicine can be bought over the counter and is not specific to particular facilities or
    providers. But good advice from a provider with knowledge and experience is a service
    that patients cannot easily obtain by themselves.
    2
    While clearly important, it is understandable why the clinical quality of medical
    advice is not well studied. It is not easy to define what should be measured and even with
    a clear definition, measurement is hard to implement in practice. Our paper addresses this
    gap and presents results of research on different dimensions of quality as applied to
    medical caregivers in Delhi. We distinguish between quality measured as “What do
    medical care providers know?” and as “What do medical care providers do?” We refer to
    the first as “competence” and the second as “practice.” The wedge between competence
    and practice—the relation between what they know and what they do—then raises
    important theoretical and empirical questions related to the structure of the health care
    market.
    3
    1
    This observation is restricted to research in economics—there is a large literature on the quality of
    prescriptions and medication in India, starting with Greenhalgh (1987) and with more recent contributions
    by Kamat and Nichter (1998) and Phadke (1998). These studies, which document the patterns of
    prescription and self-medication in the Indian health environment, suffer from two related problems. First
    (with the notable exception of Phadke 1998) there is little information linking the prescription to the
    characteristics of the provider. Second (partly as a result of this omission) there is little that can be said
    from these studies on how prescription practices can be improved, i.e., does the dramatic overuse of
    antibiotics stem from patient demand, overall uncertainty in the health environment, or other factors such as
    doctor/patient ignorance? Understanding the mechanisms that give rise to observed patterns of medication
    is a necessary first step in framing policy in the health sector.
    2
    Theoretically this refers to the difference between goods that can be traded and those that cannot. If
    medicine is not available in the hospital, individuals can buy it from the pharmacist. Human capital on the
    other hand is harder to trade—advice cannot be purchased without the presence of the doctor. Thus while
    free medication will lead to greater use of the facility (equivalent to a pharmacist who “sells” his medicines
    free of cost), the impact on health outcomes depends entirely on the quality of care imparted.
    3
    This article summarizes findings in two recent papers: Das and Hammer (2003a, and 2003b)

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Download Strained Mercy: The Quality of Medical Care in Delhi

Download Strained Mercy: The Quality of Medical Care in Delhi 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. Das and Hammer 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. This paper—a product of Public Services, Development Research Group—is part of a larger effort in the group to understand the delivery of basic services by the government and private sector in low-income countries. The study was funded by the Research Support Budget under the research project “Health Care Providers and Markets in Delhi.”

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