The Power of Informed Patients: Information Dissemination
to Enhance Private Provision
April HardingWorld Bank and
International Finance Corporation
Bali Hyatt Hotel, Sanur, Bali21-25 June 2010
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An indirect approach
Kimia Farma Pharmacy, Manado
We can effect providers….
…through changing behavior of people
These women are our allies!!
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Educated, informed people can get better results from existing health systems, including private sector
By changing care-seeking behavior
By choosing better the source of care
And by better care at home
These mechanisms work through improving peoples’ knowledge – so they can get better outcomes
Increasing knowledge is a powerful intervention
-30%
-25%
-20%
-15%
-10%
-5%
0%
- 2%Improved water
and sanitation covering 100% of
households
-3%Measures thathalve diarrhea, cough with fast breathing and
feverin every region
of the world
-13%Raising the
"Treatment" propensity in all households to the average level in Egypt
-19%Raising mother's and
father's years of schooling to levels
seen in Egypt
Source: The Power of Parents, Peter Boone, Zhengzhau Zhan, CEP Working paper 2008
Comparing impact of alternative “packages” on child mortality
How knowledge influences outcomes
Should you increase, maintain, or reduce fluids (or don’t know) for a child with
diarrhea ?
0
10
20
30
40
50
60
% a
nsw
erin
g "r
educ
e"
Informing mothers…..about ORS
Source: Rehydration Project
Can reduce use of anti-diarrheal medicine
Increase early use of ORS…
REDUCE DEATH
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There are many means of information dissemination
Posters; booklets; mass media (radio, television); education in schools; outreach/ community workers; mothers’ clubs; street theater
All means can achieve shifts in peoples’ health behaviors
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So what if we change patient behavior?
How can this enhance contribution of private sector to heath goals???
0 10 20 30 40 50
Waiting time
Doctor’s manner
Doctor’s skills
Nurse’s manner
Nurse’s skills
Explanation of care
Overall visit
Percent Satisfied or Very Satisfied
Public Private
Remember!....private sector is responsive to patients
Responsiveness: Private Sector Outperforms Public Sector
Andhra Pradesh (2000)
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Changing patient demand can support improved care quality
Some countries have ingrained preferences for injections. Ex. People in Sindh province may get as many as 14 injections a year; 90% unneeded.
• allergic reactions, abscesses, lesions, hepatitis, HIV/ AIDS and other blood-borne diseases
• patients waste 3bn+ rupees
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Changing patient behavior can support improved care quality – at home, in careseeking, and with provider
Information dissemination activities (in some countries) successfully applied posters, booklets, mass media, education in schools; and mothers’ clubs to circulate information and knowledge that have helped reduce the magnitude of the excess injection problem.
This uses patient preferences to improve quality of care.
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Information dissemination plays a role in other strategies
Information dissemination
posters, booklets, mass media, education in schools; and mothers’ clubs; street theater
Product Social Marketing
Highly strategic activities to get information to people (usually encouraging use of a product) often combined with a supply intervention (example: providing supplies at reduced rates…to encourage uptake of the product (e.g. ORS, condoms, nets)
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Information dissemination plays a role in other strategiesSocial franchising
information to people (encouraging use of franchised quality-assured service provider unit)– COMBINED with a establishing a network of quality service providers from existing providers in the community
Provider training
Often provider training is complemented by information efforts to shift patient preferences to support the new provider behavior (e.g. ORS, malaria drugs, fewer injections)
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Information dissemination plays a role in other strategies
Accreditation
People are educated as to the value of accreditation; their shift towards accredited outlets is what motivates providers to achieve accredited status
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Information dissemination influences providers through two distinct mechanisms
Changing care preferences
Changing care-seeking choices
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Mechanism 1: Changing care preferences
These interventions, when successful, improve the quality of privately provided healthcare services by educating people and shifting them to prefer good quality care practices rather than bad.
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Mechanism 1: Changing care preferences
Assessment of a 10-year effort by BRAC to promote ORS use for diarrhea in Bangladesh found that: 70% of mothers knew how to prepare ORS; 60% used ORS for children’s diarrhea; and drugsellers and village doctors recommended ORS more frequently than before (Mushtaque Chowdhury et al 1997) et al An intervention to improve shopkeepers’ treatment of malaria in Kenya included a client awareness aid, a poster specifying proper treatment of malaria, in addition to shopkeeper job aids and training (Tavrow et al. 2003)
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Mechanism 1: Changing care preferencesIt is hard to get private providers to do things their patients don’t like, and are used to having done. And, in contrast, easier to get patients and providers to act in congruent ways. Information dissemination strategies have successfully been applied to:• reduce unneeded use of antibiotics• increase adherence to full DOTS regime for TB• get patients to use anti-malarials for malaria
vs. antipyretics• to help patients distinguish real vs counterfeit
drugs
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Getting better drugs delivered by private sector via information dissemination
Patient scratches the strip on the drug package; texts the number via mobile phone, and gets instant reply about authenticity of drug
mPedigree is working with Nigerian regulatory authorities
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Information dissemination works better when……
Information dissemination more effective when people clearly see the link between what they can do differently and their own benefit
COST of the changed behavior matters too. This will be discussed more in the social marketing session.
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Mechanism 2: Changing care-seeking choices.
Private providers really like to have customers. They like it a lot.
(Distinguish with typical public providers)
Private providers are sensitive to opportunities to get more customers; and likewise sensitive to things that may make them go elsewhere.
We can use this!
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Customers look for signs of quality. Fancy certificates can attract customers.
Cambodian pharmacy accreditation program used this!
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Healthcare professionals in most countries pursue specialized recognition and certification as a means to attract patients. They know that patients look for such information as a signal of quality.
Linking achievement of better skills and expertise, with an information signal that can attract more patients – is a way of enabling market forces to deliver better outcomes with private provision of health care.
Linking better quality to increased customers is powerful
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Mechanism 2: Changing care-seeking choices
Health care facilities accreditationThis mechanism makes quality information available to people so they can choose better providers (component of accreditation and social franchising)
Providers respond, by trying to improve their scores to attract (or avoid losing) patients.
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Mechanism 2: Changing care-seeking choices
This instrument can work to motivate poor providers to improve quality to avoid losing customers. Hibbard et al, 2003 found that among Wisconsin hospitals whose performance was being reported publicly, poor performers engaged in significantly more quality improvement activities than poorly performing hospitals whose quality data was not being reported publicly
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Inights
Information dissemination is an effective strategy for improving the contribution of private providers to health outcomes..but often overlooked! You can change provider behavior MUCH more easily if patient preferences support the change (so info dissemination is often a complementary strategy for provider training).
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Insghts
Information dissemination to consumers is a critical component of: accreditation, social marketing and social franchising strategies as well as training strategies to influence behavior of private providers Information dissemination to consumers can both influence patients’ choice of treatment, demand for services and stimulate improvement among providers themselves.
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Inights?
• Public reporting of provider performance has generated quality improvements poor providers
• Be alert for opportunities to use markets to help achieve your goals. • Can you make it a “market advantage” for
providers to make the quality improvements you desire?
• Can you create a mechanism where providers who deliver quality can distinguish themselves in the market place from others who aren’t so committed to quality?
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Questions?
Comments?