When we talk about strengthening health care systems in developing countries, we often mean building hospitals, hiring more staff or stocking up on medications. But one topic has been noticeably missing: the quality of doctors and nurses.
That may seem baffling, given that the quality of medical professionals – the very people taking care of the sick – can mean life or death for patients, and that their salaries take up the bulk of a health system’s budget. And surely, governments, donors, development institutions and non-governmental organizations want the best results for their investment.
The problem arises in part because the quality of care is a hard thing to measure. Every patient is different, and even with the same broad category of diagnosis, they may warrant different treatment, which makes it difficult to compare health outcomes. In addition, patients may not be able to follow an optimal treatment plan, especially when it’s expensive.
The new study led by World Bank economist Jishnu Das, along with Manoj Mohanan of the Duke Global Health Institute and Duke Sanford School of Public Policy and others, those issues are resolved by using “standardized patients,” or local people who are recruited to memorize and present consistent symptoms of an illness during unannounced visits to multiple health care providers. The methodology is considered the gold standard in quality measurement.
The study, published Monday in the journal Health Affairs, recruited 22 such patients in India, trained them for at least 150 hours and had them make 926 visits to 305 providers in India. They presented symptoms for unstable angina (chest pain), asthma, and dysentery (intestinal inflammation) – which all come with well-known, textbook treatment plans. That makes it easier to compare treatment – and providers – across the board.
What they find is surprising. First, most providers – for example, 67% in rural Madhya Pradesh, one of India’s poorest states – don’t have medical degrees. Second, the overall quality is low. Each visit in the state averaged 3.6 minutes, 33% of the providers gave a diagnosis at all and just 12% of those were correct. Only 30.4% of the visits led to correct treatment, but 41.7% of the visits led to unnecessary or harmful treatment. The numbers are a little better in Delhi, one of India’s wealthiest states, with visits averaging 5.3 minutes and 48 percent of providers giving the correct treatment.
In addition, the study shows there aren’t big differences between trained and untrained doctors in areas such as sticking to clinical checklists, signaling the need for better medical education. Perhaps as a result of that, public clinics didn’t fare better in the study. In fact, when it comes to following medical guidelines, public providers were worse than their untrained, private counterparts.
The study could help policy makers make evidence-based decisions. In November, the government announced a five-year plan to triple health spending and improve the quality of health services. In 2010, India spent 4% of gross domestic product on health expenditures, compared with an average of 10% in developed countries. Out-of-pocket expenditures account for 70 percent of the nation’s overall health care costs.
“This study is significant not only because of our findings, but also because we were able to demonstrate how this method of rigorous quality assessment can be developed and implemented on a large scale in urban and rural settings,” said Mohanan, assistant professor of public policy and global health. “Based on the success of our efforts, similar quality assessment methods and tools are being adopted in other studies including my project in Bihar, as well as in other countries.”
Mohanan was a co-investigator who helped develop the study, the locally adapted scripts, and recruitment and training of the standardized patients.
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