Write
rekort comparing the status of healthcare
facilities in red rural and urban india.
Answers
Answer:
This article reports on the quality of care delivered by private and public providers of primary health care services in rural and urban India. To measure quality, the study used standardized patients recruited from the local community and trained to present consistent cases of illness to providers. We found low overall levels of medical training among health care providers; in rural Madhya Pradesh, for example, 67 percent of health care providers who were sampled reported no medical qualifications at all. What’s more, we found only small differences between trained and untrained doctors in such areas as adherence to clinical checklists. Correct diagnoses were rare, incorrect treatments were widely prescribed, and adherence to clinical checklists was higher in private than in public clinics. Our results suggest an urgent need to measure the quality of health care services systematically and to improve the quality of medical education and continuing education programs, among other policy changes.
To improve the quality of health care in resource-poor settings, such as India, national governments, donors, and aid agencies have focused on investments in infrastructure and medical equipment, combined with expansions in the public provision of primary care services and the number of qualified health personnel.1,2 These investments have been motivated by an implicit assumption that a scarcity of qualified health providers and a lack of physical infrastructure are the primary drivers of low-quality care in resource-poor settings.
Missing from this debate is systematic evidence on the quality of care that patients actually receive when they enter a clinic. There is scant evidence linking improvements in structural aspects of quality, such as the availability of basic medical equipment and medicines, to better diagnoses and treatments for patients. Some recent studies suggest that measures of structural quality are poor proxies for the quality of care.3–5
There is also little information on the largest sector providing primary care in resource-poor settings—private providers—and no information on private providers without medical qualifications, who often provide the bulk of primary care in the rural areas of many low-income countries.
To address the gap in evidence, this article reports the first estimates of the quality of primary care services in a low-income country, as measured by 926 clinical interactions between 305 medical care providers in rural and urban India and 22 unannounced standardized patients. These patients were people recruited from the local community who were trained to present a consistent case of illness to multiple health care providers.
The use of standardized patients presents a number of advantages described below, relative to other methods of assessing quality, such as direct clinical observations, inspection of medical records where they exist, and patient exit interviews. The use of standardized patients is therefore widely regarded as the “gold standard” in quality measurement.6
First, data from standardized patients yield an assessment of provider practice that is free from observation and recall bias. That is, the use of standardized patients is a preferable methodology because the doctor does not change his or her behavior because of awareness of being observed,7 it is less vulnerable to recall bias than patient exit interviews,8 and it is more complete than what doctors might record themselves in medical records.9
Second, standardized patients permit estimates of case detection rates since illnesses are prespecified in the study design. We show below that providers’ diagnoses are often inaccurate, so that methods based on medical records or clinical observations may not yield accurate data on the true illness of the observed patients.
Finally, because all case presentations are standardized, the standardized patient methodology allows for valid quality comparisons across different types of doctors and clinics. Poorer patients or patients with more complicated symptoms might choose particular providers. Thus, data based on real patients could confound true differences in provider quality with differences in patient characteristics.
This study is unique in scale and scope. Our population-based sample of health care providers is representative of primary care facilities that serve the average household in rural Madhya Pradesh, one of India’s poorest states. The sample includes private providers with and without formal medical training. Private providers account for more than 80 percent of primary care visits in India, as is the case in many low-income countries.10–12
We supplemented our rural data with results from a convenience sample in urban Delhi, one of India’s wealthiest states. Comparisons across the rural and urban sites allowed us to better understand quality deficits and whether they arise only in particular settings