Reforming medical education admission and training in low- and middle-income countries: who gets admitted and why it matters.

Recent studies reveal public-sector healthcare providers in low- and middle-income countries (LMICs) are frequently absent from work, solicit informal payments for service delivery, and engage in disrespectful or abusive treatment of patients. While extrinsic factors may foster and facilitate these negative practices, it is not often feasible to alter the external environment in low-resource settings. In contrast, healthcare professionals with strong intrinsic motivation and a desire to serve the needs of their community are less likely to engage in these negative behaviors and may draw upon internal incentives to deliver a high quality of care. Reforming medical education admission and training practices in LMICs is one promising strategy for increasing the prevalence of medical professionals with strong intrinsic motivation.

Validity of the Food Insecurity Experience Scale for Use in Sub-Saharan Africa and Characteristics of Food-Insecure Individuals.

BACKGROUND: The Food Insecurity Experience Scale (FIES) is a UN FAO-Voices of the Hungry project (FAO-VoH) metric of food insecurity (FI). The FAO-VoH tested the psychometric properties of FIES with the use of global 2014 Gallup World Poll (GWP) data. However, similarities in its psychometric structure in sub-Saharan Africa (SSA) to allow aggregation of SSA results were untested. OBJECTIVES: We aimed to 1) assess the validity of FIES for use in SSA, 2) determine the prevalence of FI by country, age group, and gender, and 3) examine the sociodemographic and economic characteristics of individuals with FI. METHODS: The Rasch modeling procedure was applied to data collected by GWP in 2014 and 2015 on 57,792 respondents aged ≥19 y in SSA. RESULTS: FIES largely met the Rasch model assumptions of equal discrimination and conditional independence. However, 34.3% of countries had high outfits (≥2.0) for the item "went without eating for a whole day." Four countries had significant correlations for the items "were hungry but did not eat" and "ran out of food." The overall prevalence of severe FI (SFI) was 36.4%, ranging from 6.0% in Mauritius to 87.3% in South Sudan. Older adults were at significantly higher risk of SFI than younger adults (38.6% and 35.8%, respectively, P < 0.0001), and women more than men (37.3% and 35.4%, respectively, P < 0.0001). Higher proportions of individuals with SFI were rural residents, less educated, lower income, unemployed, and lived in households with many children under the age of 15 y. CONCLUSIONS: FIES has acceptable levels of internal validity for use in SSA. However, the item "went without eating for a whole day" may need cognitive testing in a few SSA countries. For countries with correlated items, 1 of the items may be excluded.

Giving and promising gifts: Experimental evidence on reciprocity from the field.

We test the value of unconditional non-monetary gifts as a way to improve health worker performance in a low income country health setting. We randomly assigned health workers to different gift treatments within a program that visited health workers, measured performance and encouraged them to provide high quality care for their patients. We show that unconditional non-monetary gifts improve performance by 20 percent over a six-week period, compared to the control group. We compare the impact of the unconditional gift to one in which a gift is offered conditional on meeting a performance target and show that only the unconditional gift results in a statistically significant improvement. This demonstrates that organizations can improve the performance of health workers in the medium term without using financial incentives.

Changing health care provider performance through measurement.

Can the quality of care be improved by repeated measurement? We show that measuring protocol adherence repeatedly over ten weeks leads to significant improvements in quality immediately and up to 18 months later without any additional training, equipment, supplies or material incentives. 96 clinicians took part in a study which included information, encouragement, scrutiny and repeated contact with the research team measuring quality. We examine protocol adherence over the course of the study and for 45 of the original clinicians 18 months after the conclusion of the project. Health workers change their behavior significantly over the course of the study, and even eighteen months later demonstrate a five percentage point improvement in quality. The dynamics of clinicians' reactions to this intervention suggest that quality can be improved by the repeated measurement by external peers in a way that provides reminders of expectations.

Protocol for the evaluation of a quality-based pay for performance scheme in Liberia.

BACKGROUND: Improving the quality of care at hospitals is a key next step in rebuilding Liberia's health system. In order to improve the efficiency, effectiveness, and quality of care at the secondary hospital level, the country is developing a system to upgrade health worker skills and competencies, and shifting towards improved provider accountability for results, including a Graduate Medical Residency Program (GMRP) and provider accountability for improvements in quality through performance-based financing (PBF) at the hospital level. METHODS/DESIGN: This document outlines the protocol for the impact evaluation of the hospital improvement program. The evaluation will provide an estimate of the impact of the project and investigate the mechanism for success in a way that can provide general lessons about the quality of health care in low-income countries. The evaluation aims 1) to provide the best possible estimate of program impact and 2) to quantitatively describe the changes that took place within facilities as a result of the program. In particular, the impact evaluation focuses on the changes in human resources within the hospitals. As such, we use a three-period intensive evaluation of treated and matched comparison hospitals to see how services change in treated hospitals as well as a continuous data collection effort to track the activities of individual health workers within treated hospitals. DISCUSSION: We are particularly interested in understanding how facilities met quality targets. Did they bring in new health workers with higher qualifications? Did they improve the knowledge or competence of their existing staff? Did they improve the availability of medicines and equipment so that the capacities of existing health workers were improved? Did they address the motivation of health workers so that individuals with the same competence and capacity were able to provide higher quality? And, if they did improve quality, did patients notice?

Active patients in rural African health care: implications for research and policy.

We introduce the 'active patient' model, which we claim is a better way to describe health-seeking behaviour in low-income countries. Active patients do not automatically seek health care at the closest or lowest cost provider, but rather seek high-quality care (even at higher cost) when they estimate that such care will significantly improves outcomes. We show how the active patient can improve his or her health even when access to adequate quality care is insufficient and that the empirical literature supports this model, particularly in Africa. Finally, we demonstrate the importance, in analysing health care policy, of recognizing patients' efforts to improve health outcomes by seeking quality care.

Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania.

Professionalism can be defined generally as adhering to the accepted standards of a profession and placing the interests of the public above the individual professional's immediate interests. In the field of medicine, professionalism should lead at least some practitioners in developing countries to effectively care for their patients despite the absence of extrinsic incentives to do so. In this study we examine the behavior of 80 practitioners from the Arusha region of Tanzania for evidence of professionalism. We show that about 20% of these practitioners behave professionally, and almost half of those who do so practice in the public sector. These professional health care workers provide high quality care even when they work in an environment that does not reward this effort, a finding that has important implications for the use of performance-based incentives.

Idle chatter or learning? Evidence of social learning about clinicians and the health system from rural Tanzania.

We examine data from the rural Arusha region in Tanzania in which households are asked to recall the illness episodes of randomly chosen other households in their village. We interviewed 502 randomly selected households from 22 villages in 20 wards of Arusha. We analyze the probability that a household can recall another illness episode as a function of the characteristics of the illness, the location and type of health care chosen and the outcome experienced. We found that households are more likely to recall severe illnesses, illnesses for which good quality care is important, illnesses that resulted in visits to hospitals and illnesses when the patient was not cured. In addition, households are more likely to recall illnesses that resulted in a visit to a facility where the average tenure of clinicians is less than two years. The results suggest that households deliberately collect information in order to learn about clinicians and facilities in their local area. We show evidence that households use this information when they choose whether to visit new health care providers. In particular, households are less likely to visit a new provider when they hear of bad outcomes and more likely to do so when they hear of good outcomes.

Is patient satisfaction sensitive to changes in the quality of care? An exploitation of the Hawthorne effect.

We introduce a new instrument to evaluate the impact of behavior on outcomes when the behavior may be a function of unobserved variables that also affect outcomes. The instrument is introduced through a test of patient sensitivity to increases in the quality of care provided by doctors. We utilize the Hawthorne effect, in which the very presence of a research team causes doctors to provide measurably superior quality care for any type of patient to show that patients respond to this increased quality and are more likely to be very satisfied. Using the Hawthorne effect as an instrument allows us to examine the responsiveness of satisfaction to improvements in quality despite the fact that patient satisfaction is subjective and jointly produced with quality during the course of a consultation.

Variations in the quality of care accessible to rural communities in Tanzania.

The government of Tanzania has made access to health care a priority. In particular, it has made great efforts to increase the number of facilities available to the rural population. By examining one such rural area, we find that although facilities exist and are staffed with competent clinicians, the quality of care received by patients visiting government facilities is subpar, especially that received by the poor in rural areas compared with urban areas. Importantly, nongovernmental organization (NGO) facilities provide better and more consistent care across the rural-urban divide. Access to high-quality care is inequitable, and this inequality is not inevitable.

The use of direct clinician observation and vignettes for health services quality evaluation in developing countries.

This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality.

Outcome versus service based payments in health care: lessons from African traditional healers.

We compare the more common physician compensation method of fee-for-service to the less common payment-for-outcomes method. This paper combines an investigation of the theoretical properties of both of these payment regimes with a unique data set from rural Cameroon in which patients can choose between outcome and service based payments. We show that consideration of the role of patient effort in the production of health leads to important differences in the performance of these contracts. Theory and empirical evidence show that when illnesses require (or are responsive to) large amounts of both patient and practitioner effort, outcome based payment schemes are superior to effort based schemes. The traditional healer--a practitioner who offers health services on an outcome-contingent basis--is advanced as an important example of how patient effort can be better understood and tapped in health care.