dominic montagu based on slides developed by abi ridgway uc berkeley haas school of business...
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DOMINIC MONTAGU
Based on slides developed by Abi RidgwayUC Berkeley Haas School of Business
Exhortation and Information as Policy Tools to Improve Private-Sector Hospital Performance in
Asia
Harding-Montagu-Preker Framework: Overview
•Distribution(equity)
•Efficiency
•Quality of Care
Source: Adapted from Harding & Preker, Private Participation in Health Services, 2003.
PHSA
•Gather available information
•Identify additional needs
•In-depth studiesActivities
• Hospitals• PHC• Diagnostic labs• Producers / Distributors
Ownership
• For-profit corporate • For-profit small business
• Non-profit charitable
Formal/ Informal
Grow
Harness
Convert
StrategyAssessmentGoal Focus
Private Sector
PublicSector
Restrict
Harding-Montagu-Preker Framework: Overview
•Distribution(equity)
•Efficiency
•Quality of Care
Source: Adapted from Harding & Preker, Private Participation in Health Services, 2003.
PHSA
•Gather available information
•Identify additional needs
•In-depth studiesActivities
• Hospitals• PHC• Diagnostic labs• Producers / Distributors
Ownership
• For-profit corporate • For-profit small business
• Non-profit charitable
Formal/ Informal
Goal AssessmentFocus
Private Sector
PublicSector
Restrict
Grow
Convert
Strategy
Harness
The Problem of Quality
In South and Southeast Asia much or most hospital care is provided by the private sector.
Quality of care in private hospitals is variable and often inadequate.
Due to weak regulatory powers and small budgets, health officials in low and middle-
income countries have limited influence on the quality of care provided by private hospitals.
Traditional policies: limited applicability
Pay-for-Performance
Regulation
Accreditation
Contracting Services
#1: Persuasion
Target Audience Size
An intentional effort to change attitudes or behavior by sharing
information with hospital providers
#1: Persuasion
Criteria Ranking
Rationale
Effectiveness
Low • Lack of evidence to show effect in hospital setting• “KAP Gap” = changing knowledge is not changing
behavior• Profit motives and patient expectations also play a
role
Affordability
Medium • Depends on the size of the target audience• Inversely correlated with effectiveness
Feasibility High No new technology required Education is non-controversial• Getting physicians time is major political challenge
#2: Public Recognition
A governmental promotion of a set of standards for hospitals, followed by
public recognition of hospitals that meet those standards
Ex: Malcolm Baldrige National Quality Award Effort by US in 1980s to improve quality of
manufacturing Recognizes high quality of goods and services Xerox, Motorola, Ritz Carlton
Hospitals are included
#2: Public Recognition
Criteria Ranking
Rationale
Effectiveness
Medium Depends on market response, Baldrige winners benefit financially in term of market valuations
Creates a common set of standards• May not reach hospitals that are most likely to need
improvement
Affordability
High Government doesn’t have to provide financial reward
Only evaluate applicants Industry contributes to Baldrige award Cost-benefit ratio estimate of Baldrige = 207:1
Feasibility High Hospital voluntary participate No EHRs required, small scale data collection
#3: Public Reporting
A governmental collection of information about patient care from hospitals and dissemination of that
information to all players in the healthcare industry to facilitate better
decision-making.Ex: Hospital Compare
Pioneered in US, followed by similar effort in Europe Relies on “market” forces Is tied to financial incentives
Trickle down effect
#3: Public Reporting
Criteria Ranking
Rationale
Effectiveness
Medium Effort in the US show a change in provider behavior• Patients don’t react to public reporting data• Cherry-picking: reduced access for sicker patients• May not have long term effect
Affordability
Low • Intense data collection process• Auditing
Feasibility Low • Heavy reliance on EMRs• Probable push-back from providers
#4: Negotiation
Governments and providers make a mutual agreement for performance
improvementEx: PRACTION Study, India & Pakistan
Goal to get private provider to follow WHO recommended care for childhood illnesses (ICMI)
PRACTION had significant improvement on 16 or 21 desired behavior changes
#4: Negotiation
Criteria Ranking
Rationale
Effectiveness
Medium Face-to-face interaction shown effective in pharma-detailing
Providers actively participate, patients may also Psychological desire for consistency• Unclear if it works for teams vs. individual• Only works for common conditions
Affordability
Medium No formal training No auditing verbal case reviews• Management intensive process
Feasibility High Simple data collection method and tools Adaptable process can be used to change Providers have say and push back less
Summary of policy alternatives
PersuasionPublic
Recognition
Public Reporting
Negotiation
Effectiveness
Low Medium Medium Medium
Affordability
Medium High Low Medium
Feasibility
High High Low High
Recommendation
LMIC government should use public recognition as its primary policy tool to improve private sector care Highly affordable because doesn’t requires monitoring Politically feasible because voluntary Technical challenge is agreeing on a standards of quality
Helpful for future interventions Breaks down the separation between public and private
players
In the longer term, negotiation is the next most promising alternative PRACTION showed that effective for formal providers, but
more pushback No demonstrations yet at hospital level
Caveat
A Weak ToolAmong the policy or program options available to influence private hospitals, Exhortation and Information is both the least well documented, and the weakest.
While risks are low in the application of public recognition strategies or other Information-lined policies; the degree of changed practices is likely to be commensurately modest.
ConclusionExhortation and Information is a useful first-level intervention.
When Exhortation/Information and When Other Interventions
Effectiveness Improves the quality or equality of care
Structures and processes that reduce morbidity and mortality
Improves patient experience Improves hospital productivity
Affordability Affordable to launch and to maintain
Feasibility Technically: EMRs not yet available Politically: Support from policy-makers, patients and
providers
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