High-performance cost efficient simultaneous wireless information and power transfers deploying jointly modulated amplifying programmable metasurface.

Programmable metasurfaces present significant capabilities in manipulating electromagnetic waves, making them a promising candidate for simultaneous wireless information and power transfer (SWIPT), which has the potential to enable sustainable wireless communication in complex electromagnetic environments. However, challenges remain in terms of maximum power transmission distance and stable phase manipulation with high-power scattered waves. Additionally, waveform limitations restrict average scattered power and rectifier conversion efficiency, affecting data transmission rates and energy transmission distance. Here we show an amplifying programmable metasurface (APM) and a joint modulation method to address these challenges. The APM mitigates the peak-to-average power ratio and improves maximum power, phase response stability, average output power, and rectifier conversion efficiency. Through experimental validation, we demonstrate the feasibility of the SWIPT system, showcasing simultaneous LED array powering and movie video transmission. This innovative SWIPT system holds promise for diverse applications, including 6 G wireless communications, IoT, implanted devices, and cognitive radio networks.

Factors Influencing Adoption and Use of Telemedicine Services in Rural Areas of China: Mixed Methods Study.

BACKGROUND: The shortage of medical resources in rural China reflects the health inequity in resource-limited settings, whereas telemedicine could provide opportunities to fill this gap. However, evidence of patient acceptance of telemedicine services from low- and middle-income countries is still lacking. OBJECTIVE: We aimed to understand the profile of patient end-user telemedicine use and identify factors influencing telemedicine service use in rural China. METHODS: Our study followed a mixed methods approach, with a quantitative cross-sectional survey followed by in-depth semistructured interviews to describe telemedicine use and its associated factors among rural residents in Guangdong Province, China. In the quantitative analysis, explanatory variables included environmental and context factors, household-level factors, individual sociodemographic factors, access to digital health care, and health needs and demand factors. We conducted univariate and multivariate analyses using Firth logistic regression to examine the correlations of telemedicine uptake. A thematic approach was used, guided by the Social Cognitive Theory for the qualitative analysis. RESULTS: A total of 2101 households were recruited for the quantitative survey. With a mean age of 61.4 (SD 14.41) years, >70% (1364/2101, 72.94%) of the household respondents were male. Less than 1% (14/2101, 0.67%) of the respondents reported experience of using telemedicine. The quantitative results supported that villagers living with family members who had a fever in the past 2 weeks (adjusted odds ratio 6.96, 95% CI 2.20-21.98; P=.001) or having smartphones or computers (adjusted odds ratio 3.71, 95% CI 0.64-21.32; P=.14) had marginally higher telemedicine uptake, whereas the qualitative results endorse these findings. The results of qualitative interviews (n=27) also supplemented the potential barriers to telemedicine use from the lack of knowledge, trust, demand, low self-efficacy, and sufficient physical and social support. CONCLUSIONS: This study found extremely low use of telemedicine in rural China and identified potential factors affecting telemedicine uptake. The main barriers to telemedicine adoption among rural residents were found, including lack of knowledge, trust, demand as well as low self-efficacy, and insufficient physical and social support. Our study also suggests strategies to facilitate telemedicine engagement in low-resource settings: improving digital literacy and self-efficacy, building trust, and strengthening telemedicine infrastructure support.

Evaluation of a village-based digital health kiosks program: A protocol for a cluster randomized clinical trial.

Background: To address disparities in healthcare quality and access between rural and urban areas in China, reforms emphasize strengthening primary care and digital health utilization. Yet, evidence on digital health approaches in rural areas is lacking. Objective: This study will evaluate the effectiveness of Guangdong Second Provincial General Hospital's Digital Health Kiosk program, which uses the Dingbei telemedicine platform to connect rural clinicians to physicians in upper-level health facilities and provide access to artificial intelligence-enabled diagnostic support. We hypothesize that our interventions will increase healthcare utilization and patient satisfaction, decrease out-of-pocket costs, and improve health outcomes. Methods: This cluster randomized control trial will enroll clinics according to a partial factorial design. Clinics will be randomized to either a control arm with clinician medical training, a second arm additionally receiving Dingbei telemedicine training, or a third arm with monetary incentives for patient visits conducted through Dingbei plus all prior interventions. Clinics in the second and third arm will then be orthogonally randomized to a social marketing arm that targets villager awareness of the kiosk program. We will use surveys and Dingbei administrative data to evaluate clinic utilization, revenue, and clinician competency, as well as patient satisfaction and expenses. Results: We have received ethical approval from Guangdong Second Provincial General Hospital (IRB approval number: GD2H-KY IRB-AF-SC.07-01.1), Peking University (IRB00001052-21007), and the University of North Carolina at Chapel Hill (323385). Study enrollment began April 2022. Conclusions: This study has the potential to inform future telemedicine approaches and assess telemedicine as a method to address disparities in healthcare access.Trial registration number: ChiCTR2100053872.

Factors Associated with Vaccination Intention against the COVID-19 Pandemic: A Global Population-Based Study.

Several vaccines have been developed for COVID-19 since the pandemic began. This study aimed to evaluate the factors associated with COVID-19 vaccination intention. A global survey was conducted across 26 countries from October, 2020 to December, 2021 using an online self-administered questionnaire. Demographic information, socio-economic status, and clinical information were collected. A logistic regression examined the associations between vaccine intention and factors such as perceptions and the presence of chronic physical and mental conditions. The sample included 2459 participants, with 384 participants (15.7%) expressing lower COVID-19 vaccination intent. Individuals who identified as female; belonged to an older age group; had a higher level of education; were students; had full health insurance coverage; or had a previous history of influenza vaccination were more willing to receive vaccination. Conversely, those who were working part-time, were self-employed, or were receiving social welfare were less likely to report an intention to get vaccinated. Participants with mental or physical health conditions were more unwilling to receive vaccination, especially those with sickle cell disease, cancer history within the past five years, or mental illness. Stronger vaccination intent was associated with recommendations from the government or family doctors. The presence of chronic conditions was associated with lower vaccine intention. Individuals with health conditions are especially vulnerable to health complications and may experience an increased severity of COVID-19 symptoms. Future research should evaluate the effectiveness of interventions targeting the vaccine perceptions and behaviours of at-risk groups. As such, public awareness campaigns conducted by the government and proactive endorsement from health physicians may help improve COVID-19 vaccination intention.

Does school shutdown increase inequality in academic performance? Evidence from COVID-19 pandemic in China.

The school shutdown due to the global pandemic of coronavirus disease 2019 (COVID-19) can lead to an increase in educational inequality through disproportionately affecting disadvantaged children. We use data from a unique survey of 7202 junior high school students and their parents from Shaanxi province to explore whether the school shutdown enlarged the educational gap between students with different parental socioeconomic statuses (SES) during the pandemic. We find that students with more highly educated parents experienced an increase in relative test rankings after the shutdown period. A 1-year increase in parents' education led to a relative 0.18-percentile increase in students' rankings of total test scores. We also identify the mechanisms behind the enlarged gap by means of heterogeneity analyses. We show that parents' education mainly affected children's academic performance through parents' engagement in their children's homeschooling, mitigating the negative impacts of Internet addiction on students, and serving as substitutes for teachers who were unable to teach well online.

The Effect of Governance on Industrial Wastewater Pollution in China.

Water pollution not only aggravates the deterioration of the ecological environment and endanger human health, but also has a significantly negative impact on economic growth and social development. It is crucial to investigate the relationship between industrial wastewater governance and industrial wastewater pollution on the path to reduce water pollution. In this paper, we studied whether industrial wastewater governance affected industrial wastewater pollution using the panel fixed effect model and system generalized moment estimation model (SYS-GMM) with the panel data of 30 provinces from 2005 to 2020 in China. This is the only empirical analysis of the relationship between industrial wastewater governance and industrial wastewater pollution. We proxied industrial wastewater pollution by organic pollutants and inorganic pollutants and measured the per capita investment in industrial wastewater governance. The results shed light on the positive correlation between the per capita investment in industrial wastewater governance and industrial wastewater pollution. The increase in per capita investment in industrial wastewater governance promoted the increase of pollutant emissions from industrial wastewater. The estimation also indicated that there was an inverted U-shaped relationship between per capita GDP and inorganic /organic pollutants in industrial wastewater. Our empirical research shows that it is necessary to increase investment in industrial wastewater treatment and optimize the investment structure of environmental treatment, so as to pave the way for the comprehensive utilization of a variety of environmental treatment solutions.

The assessment of spirituality between cancer and chronic inpatients: a cross-sectional study.

PURPOSE: Spiritual well-being had a protective effect on quality of life in cancer, due to the cultural, regional, and custom differences; it was rarely been discussed between cancer and chronic diseases in Chongqing, China. We aimed at comparing the level of spirituality in two groups and discussing its factors of subjects with cancer at county regions. METHODS: A cross-sectional questionnaire survey was distributed to 630 inpatients who received treatment between January and December 2020 in Chongqing University Three Gorges Hospital. In addition to basic demographic data, spirituality was measured using the Chinese version of Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12). The mean, standard deviation, independent t-tests, ANOVA, and multiple regression were used for statistical description and analysis. RESULTS: Significant differences were found between cancer and chronic diseases in total scores of FACIT-Sp-12 and each domain (P < 0.05). The meaning, peace, faith, and total scores in cancer were 11.21 ± 3.38, 10.66 ± 4.46, 11.43 ± 3.54, and 33.3 ± 10.35, respectively, which were lower than chronic diseases (13.00 ± 3.21, 12.95 ± 4.76, 12.66 ± 3.64, 38.61 ± 10.88, respectively). The spiritual well-being had significant differences in gender, character, and emotional with spouse for cancer (P < 0.05). The male and extravert character were significantly associated with a greater spiritual well-being. CONCLUSION: The study shows a medium level of spiritual well-being in cancer, which stands the population with lower economic and education in county regions. It suggests that under the current nursing mode, we should provide specifically spiritual care to the female, introvert, and those with poor relationship with spouses and create a harmonious doctor-patient environment to improve the spiritual well-being.

Measurements of quality of village-level care and patients' healthcare-seeking behaviors in rural China.

BACKGROUND: Although the progress in global health initiatives has improved the availability of primary health care (PHC), unqualified healthcare remains a serious challenge in low- and middle-income countries, where PHC is often underutilized. This study examines factors associated with patients' healthcare-seeking behaviors in rural Chin-seeking healthcare at village-level PHC providers, at higher-level health facilities, self-medicating, and refraining from seeking medical help. We focus on provider-side factors, including (1) the unobservable quality indicator, (2) the observable quality indicator, and (3) the observable signal indicator. METHODS: We analyzed 1578 episodes of healthcare-seeking behaviors of patients with diarrhea or cough/runny nose symptom from surveys conducted in July 2017 and January 2018 in 114 villages of the Yunnan province. We investigated the correlation between quality-related factors with patients' healthcare-seeking behaviors by multinomial logit regression. RESULTS: We found that rural patients were insensitive to the unobservable quality of healthcare providers, as measured by standardized clinical vignettes, which might be attributable to the credence nature of PHC. The observable quality indicator, whether the clinician has received full-time junior college formal medical education, was associated with patients' healthcare choices. Patients, however, were more likely to select healthcare based on the observable signal indicator, which was measured by the availability of medicines. Additionally, the observable signal indicator had no significant association with two quality indicators. Notably, socioeconomically-disadvantaged patients relied more on the village-level PHC, which emphasized the role of PHC in promoting the welfare of rural populations. CONCLUSIONS: Our study found an inconsistency between objective quality of healthcare provided by providers and subjective quality perceived by patients. Patients could not identify the actual quality of PHC precisely, while they were more likely to make decisions based on the observable signal indicator. Therefore, the quality of PHC should be more observable to patients. This study not only supplements the literature on healthcare-seeking choices by examining four types of behaviors simultaneously but also clarifies rural patients' perceptions of the quality of PHC for policy decision-making on increasing the utilization of PHC and improving the medical welfare of the vulnerable.

Health, economic, and social implications of COVID-19 for China's rural population.

This study examines the effects of local and nationwide COVID-19 disease control measures on the health and economy of China's rural population. We conducted phone surveys with 726 randomly selected village informants across seven rural Chinese provinces in February 2020. Four villages (0.55%) reported infections, and none reported deaths. Disease control measures had been universally implemented in all sample villages. About 74% of informants reported that villagers with wage-earning jobs outside the village had stopped working due to workplace closures. A higher percentage of rural individuals could not work due to transportation, housing, and other constraints. Local governments had taken measures to reduce the impact of COVID-19. Although schools in all surveyed villages were closed, 71% of village informants reported that students were attending classes online. Overall, measures to control COVID-19 appear to have been successful in limiting disease transmission in rural communities outside the main epidemic area. Rural Chinese citizens, however, have experienced significant economic consequences from the disease control measures.

[Bioavailability and Ecological Risk Assessment of Cadmium in the Sea-Land Interaction Sediments of the Pearl River Delta].

Cadmium (Cd) pollution poses a threat to human health, and research on Cd bioavailability as well as its ecological risk assessment can help prevent and mitigate Cd hazards. The enrichment characteristics and variability of Cd were investigated in sea-land interaction soil fractions and the associated environmental and ecological risks were evaluated using the accumulation index (Igeo), potential ecological hazard index (Er), and risk assessment coding (RAC). The results showed that:① The Cd content of miscellaneous fill material was typically lower than 0.3 mg·kg-1 and that of plain full was higher than 0.3 mg·kg-1. The Cd content of marine sediment was significantly higher than that of continental sediments, averaging 0.36 and 0.10 mg·kg-1, respectively. The concentration of Cd in marine sediments buried at shallow depths (<5 m) was generally higher than at greater depths (>5 m). ② There was a moderate correlation between Cd and CEC in artificial fill (Q4ml; correlation coefficient=0.52, P<0.05). There was a weak correlation between Cd and organic matter in the marine sediments (correlation coefficient=0.49, P<0.05). Total cadmium and the physical and chemical properties of soil had a significant influence on the fraction of soil cadmium. ③ The Igeo of artificially fill and marine sediment was dominated by the relationship 1 < Igeo < 2, which indicated a moderate level of pollution. The Er of artificial fill and marine sediment was mainly 80 < Er < 160, indicating a high potential ecological hazard. Soil acid-extractable Cd accounted for more than 50% of the total Cd in each drill hole, which generally indicated a very high potential ecological risk. These results provide a basis for environmental and agricultural decision-making and provide theoretical guidance for soil pollution investigations and remediation.

Sigma metrics application for validated and non-validated detecting systems performance assessment.

BACKGROUND: Sigma metrics provide an objective and quantitative methodology for analytical quality evaluation of clinical laboratory. This study investigated the testing performance of validated systems and non-validated systems based on sigma metrics, and explored the major parameters affecting the system performance. METHODS: Sigma metrics were evaluated by six biochemistry assays based on Beckman and Mindray validated and non-validated systems through crossing the reagents and analyzers. Imprecision and bias were assessed for all assays based on trueness programs organized by National Centre for Clinical Laboratory. Total error allowance obtained from the Chinese Ministry of Health Clinical Laboratory Centre Industry Standard (WS/T403-2012). RESULTS: The imprecision for all systems meets the quality specifications except TP assay (2.19%) detected by Mindray non-validated system, and the bias for four assays measured by non-validated systems cannot fulfill the criterion, including lactate dehydrogenase (LDH), total protein (TP), triglycerides (TG), and glucose (GLU). Higher biases were detected in six assays at different levels among non-validated and validated systems. Systems performed poorly or unacceptably for TP assay with sigma metrics lower than 3 except Mindray non-validated system. The sigma metrics for other assays with four systems were greater than 3 except the LDH evaluated on Mindray non-validated systems. CONCLUSION: Non-validated systems may introduce performance uncertainty compared with validated systems based on sigma metrics evaluation, and lower bias was provided by validated systems. The performance of non-validated systems should be evaluated thoroughly in the clinical laboratory before they were adopted for routine use.

Opportunistic upper endoscopy during colonoscopy as a screening strategy for countries with intermediate gastric cancer risk.

BACKGROUND AND AIM: Screening upper endoscopy can detect esophagogastric (OG) cancers early with improved outcomes. Recent cost-utility studies suggest that opportunistic upper endoscopy at the same setting of colonoscopy might be a useful strategy for screening of OG cancers, and it may be more acceptable to the patients due to cost-saving and convenience. We aim to study the diagnostic performance of this screening strategy in a country with intermediate gastric cancer risk. METHODS: A retrospective cohort study using a prospective endoscopy database from 2015 to 2017 was performed. Patients included were individuals age > 40 who underwent opportunistic upper endoscopy at the same setting of colonoscopy without any OG symptoms. Neoplastic OG lesions are defined as cancer and high-grade dysplasia. Pre-neoplastic lesions include Barrett's esophagus (BE), intestinal metaplasia (IM), and atrophic gastritis (AG). RESULTS: The study population involved 1414 patients. Neoplastic OG lesions were detected in five patients (0.35%). Pre-neoplastic lesions were identified in 174 (12.3%) patients. IM was found in 146 (10.3%) patients with 21 (1.4%) having extensive IM. The number needed to scope to detect a neoplastic OG lesion is 282.8 with an estimated cost of USD$141 400 per lesion detected. On multivariate regression, age ≥ 60 (RR: 1.84, 95% CI: 1.29-2.63) and first-degree relatives with gastric cancer (RR: 1.64, 95% CI: 1.06-2.55) were independent risk factors for neoplastic or pre-neoplastic OG lesion. CONCLUSION: For countries with intermediate gastric cancer risk, opportunistic upper endoscopy may be an alternative screening strategy in a selected patient population. Prospective trials are warranted to validate its performance.

Combating HIV stigma in low- and middle-income healthcare settings: a scoping review.

INTRODUCTION: Nearly 40 years into the HIV epidemic, the persistence of HIV stigma is a matter of grave urgency. Discrimination (i.e. enacted stigma) in healthcare settings is particularly problematic as it deprives people of critical healthcare services while also discouraging preventive care seeking by confirming fears of anticipated stigma. We review existing research on the effectiveness of stigma interventions in healthcare settings of low- and middle-income countries (LMIC), where stigma control efforts are often further complicated by heavy HIV burdens, less developed healthcare systems, and the layering of HIV stigma with discrimination towards other marginalized identities. This review describes progress in this field to date and identifies research gaps to guide future directions for research. METHODS: We conducted a scoping review of HIV reduction interventions in LMIC healthcare settings using Embase, Ovid MEDLINE, PsycINFO and Scopus (through March 5, 2020). Information regarding study design, stigma measurement techniques, intervention features and study findings were extracted. We also assessed methodological rigor using the Joanna Briggs Institute checklist for systematic reviews. RESULTS AND DISCUSSION: Our search identified 8766 studies, of which 19 were included in the final analysis. All but one study reported reductions in stigma following the intervention. The studies demonstrated broad regional distribution across LMIC and many employed designs that made use of a control condition. However, these strengths masked key shortcomings including a dearth of research from the lowest income category of LMIC and a lack of interventions to address institutional or structural determinants of stigma. Lastly, despite the fact that most stigma measures were based on existing instruments, only three studies described steps taken to validate or adapt the stigma measures to local settings. CONCLUSIONS: Combating healthcare stigma in LMIC demands interventions that can simultaneously address resource constraints, high HIV burden and more severe stigma. Our findings suggest that this will require more objective, reliable and culturally adaptable stigma measures to facilitate meaningful programme evaluation and comparison across studies. All but one study concluded that their interventions were effective in reducing healthcare stigma. Though encouraging, the fact that most studies measured impact using self-reported measures suggests that social desirability may bias results upwards. Homogeneity of study results also hindered our ability to draw substantive conclusions about potential best practices to guide the design of future stigma reduction programmes.

Economic Implications of Chinese Diagnosis-Related Group-Based Payment Systems for Critically Ill Patients in ICUs.

OBJECTIVES: To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay. DESIGN: A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database. SETTING: Twenty-two public hospitals in Sanming, Southern China. PATIENTS: All patients admitted to ICUs from January 1, 2017, to December 31, 2018. INTERVENTION: The implementation of Chinese diagnosis-related group-based payments on January 1, 2018. MEASUREMENTS AND MAIN RESULTS: Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay. CONCLUSIONS: Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group-based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.

Risk assessment of the total testing process based on quality indicators with the Sigma metrics.

Background Evidence-based evaluation of laboratory performances including pre-analytical, analytical and post-analytical stages of the total testing process (TTP) is crucial to ensure patients receiving safe, efficient and effective care. To conduct risk assessment, quality management tools such as Failure Mode and Effect Analysis (FMEA) and the Failure Reporting and Corrective Action System (FRACAS) were constantly used for proactive or reactive analysis, respectively. However, FMEA and FRACAS faced big challenges in determining the scoring scales and failure prioritization in the assessment of real-world cases. Here, we developed a novel strategy, by incorporating Sigma metrics into risk assessment based on quality indicators (QIs) data, to provide a more objective assessment of risks in TTP. Methods QI data was collected for 1 year and FRACAS was applied to produce the risk rating based on three variables: (1) Sigma metrics for the frequency of defects; (2) possible consequence; (3) detection method. The risk priority number (RPN) of each QI was calculated by a 5-point scale score, where a value of RPN > 50 was rated as high-risk. Results The RPNs of two QIs in post-analytical phase (TAT of Stat biochemistry analyte and Timely critical values notification) were above 50 which required rigorous monitoring and corrective actions to eliminate the high risks. Nine QIs (RPNs between 25 and 50) required further investigation and monitoring. After 3 months of corrective action the two identified high-risk processes were successfully reduced. Conclusions The strategy can be implemented to reduce identified risk and assuring patient safety.

Risk analysis and assessment based on Sigma metrics and intended use.

INTRODUCTION: In order to ensure the quality in clinical laboratories and meet the low risk requirements of patients and clinicians, a risk analysis and assessment model based on Sigma metrics and intended use was constructed, based on which differential sigma performance (σ) expectations of 42 analytes were developed. MATERIALS AND METHODS: Failure mode and effects analysis was applied to produce an analytic risk rating based on three factors, each test of which was graded as follows: 1) Sigma metrics; 2) the severity of harm; 3) intended use. By multiplying the score of Sigma metrics by the score of severity of harm by the score of intended use, each was assigned a typical risk priority number (RPN), with RPN ≤ 25 rated as low risk. Low risk was defined as acceptable standards; the sigma performance expectations were calculated. RESULTS: Among the 42 analytes, tests with σ ≥ 6, 5 ≤ σ < 6, 4 ≤ σ < 5, 3 ≤ σ < 4, σ < 3 were 21, 5, 5, 6, and 5, respectively; there were 7 high-risk tests, 8 of them medium risk tests. According to the risk assessment conclusion, 13 tests had sigma performance expectations ≥ 6; 15 test items had sigma performance expectations ≥ 5, while 3 test items had sigma performance expectations ≥ 4; 11 test items had sigma performance expectations ≥ 3. CONCLUSIONS: Constructing the risk analysis and assessment model based on Sigma metrics and intended use will help clinical laboratories to identify the high-risk tests more objectively and comprehensively. Such model can also be used to establish the sigma performance expectations and meet the low risk requirements of patients and clinicians.

Survey using incognito standardized patients shows poor quality care in China's rural clinics.

Over the past decade, China has implemented reforms designed to expand access to health care in rural areas. Little objective evidence exists, however, on the quality of that care. This study reports results from a standardized patient study designed to assess the quality of care delivered by village clinicians in rural China. To measure quality, we recruited individuals from the local community to serve as undercover patients and trained them to present consistent symptoms of two common illnesses (dysentery and angina). Based on 82 covert interactions between the standardized patients and local clinicians, we find that the quality of care is low as measured by adherence to clinical checklists and the rates of correct diagnoses and treatments. Further analysis suggests that quality is most strongly correlated with provider qualifications. Our results highlight the need for policy action to address the low quality of care delivered by grassroots providers.