Regulating Private Regulating Private PracticePractice

The (In)Visible Hand of The (In)Visible Hand of Government in the Medical Government in the Medical

MarketplaceMarketplace

How “Bad” Is Private How “Bad” Is Private Practice in Developing Practice in Developing

Countries?Countries?• Results depend on definition of the Results depend on definition of the

private sector:private sector:– A spectrum of public and privateA spectrum of public and private

• Moonlighting Government providersMoonlighting Government providers• Fully qualified and fully privateFully qualified and fully private• Any provider of “medical” servicesAny provider of “medical” services

• Prescribing and dispensing?Prescribing and dispensing?

Is Quality Worse in the Is Quality Worse in the Private Sector?Private Sector?

• Few direct comparisonsFew direct comparisons• VietnamVietnam11

– Public sector care higher qualityPublic sector care higher quality– But moonlighting Government providers were But moonlighting Government providers were

closeclose– Private scores pulled down by unqualified Private scores pulled down by unqualified

providersproviders• ChinaChina22

– All subjects had limited trainingAll subjects had limited training– Spectrum of subsidySpectrum of subsidy– All sell drugsAll sell drugs– No significant differences in quality measuresNo significant differences in quality measures– Similar subsidy requirements for preventive careSimilar subsidy requirements for preventive care

Source:1Tran Tuan et al. “Comparative Quality of Public and Private Health Services in Vietnam” (2005)2Qingyue Meng et al “Comparing the services and quality of private and public clinics in rural China”

(2000)

Where Quality in the Where Quality in the Private Sector is WorsePrivate Sector is Worse

• Many “private providers” lack Many “private providers” lack required qualificationsrequired qualifications

• Dispensing providers have an Dispensing providers have an incentive to overprescribeincentive to overprescribe– Is it any different in developed countries?Is it any different in developed countries?

• Isolated from new developmentsIsolated from new developments• ““It is what the patient wants/expects”It is what the patient wants/expects”

A Bit of HistoryA Bit of History

• Look back a century in US and EuropeLook back a century in US and Europe– Not far removed from the barber/surgeonNot far removed from the barber/surgeon– Typical practice fell far short of standards in Typical practice fell far short of standards in

new “scientific medicine”new “scientific medicine”– Force “substandard” doctors out of practice?Force “substandard” doctors out of practice?

• NONO

• Upgrade training requirementsUpgrade training requirements– Let attrition improve average qualityLet attrition improve average quality– Approving and improving medical schoolsApproving and improving medical schools

• Flexner ReportFlexner Report

Government and Quality Government and Quality DistributionDistribution

• Cut the tail off the Cut the tail off the quality curve, if:quality curve, if:– MotivatedMotivated– Legally empoweredLegally empowered– Well InformedWell Informed– Adequate resourcesAdequate resources

• Not good at Not good at shifting the curve shifting the curve to the rightto the right

Quality

Fre

quen

cy D

istr

ibut

ion Government

Action

Making Making Licensing/Registration Licensing/Registration

More EffectiveMore Effective• Taking consumer complaints seriouslyTaking consumer complaints seriously

– In India, consumer protection law gets In India, consumer protection law gets provider’s attentionprovider’s attention

– Consumer educationConsumer education– Resources and representationResources and representation– Public representatives on licensing boardsPublic representatives on licensing boards– Why they shoot deserters?Why they shoot deserters?

• Educating and RegulatingEducating and Regulating– In Laos, pharmacy practices improved with In Laos, pharmacy practices improved with

inspectioninspection11

• Or, was it the “Hawthorne Effect”?Or, was it the “Hawthorne Effect”?Source:1Bo Stenson et al “Private pharmacy practice and regulation: a randomized trial in Lao PDR” (2001)

Make Licensing/Regulation Make Licensing/Regulation More EffectiveMore Effective

• Prohibit the unqualified from practicing?Prohibit the unqualified from practicing?– License other categories to increase the License other categories to increase the

supply of regulated providers?supply of regulated providers?• License the drug seller where there is no pharmacistLicense the drug seller where there is no pharmacist

– Educate the consumersEducate the consumers• What to expect of medical careWhat to expect of medical care

– Part of health education curriculumPart of health education curriculum– More drugs not always betterMore drugs not always better– Injections not better than pillsInjections not better than pills

• How to tell what provider is qualified?How to tell what provider is qualified?– But who will locate among the poorBut who will locate among the poor

• Where there are many “qualified providers”Where there are many “qualified providers”– Slums of KarachiSlums of Karachi– Latin AmericaLatin America

Shifting the Quality Shifting the Quality DistributionDistribution

• What works in the developed worldWhat works in the developed world11

– Continuing education a necessary, but not Continuing education a necessary, but not sufficient, conditionsufficient, condition

– Some interventions have little effectSome interventions have little effect• CME aloneCME alone• Published guidelinesPublished guidelines

• What worksWhat works– Feedback/academic detailingFeedback/academic detailing

• Evidence of impact in Bihar as wellEvidence of impact in Bihar as well22

– Peer leaders as change agentsPeer leaders as change agents– Combining provider and patient interventionsCombining provider and patient interventions

Source:1Andrew Oxman et al “No magic bullets: a systematic review of 102 trials of

interventions to improve professional practice” (1995)2Sarbani Chakraborty et al. “Improving private practitioner care of sick

children; testing new approaches in rural Bihar” (200)

Shifting the Quality Curve Shifting the Quality Curve in the Developing Worldin the Developing World

• Educating private providersEducating private providers– Still a necessary conditionStill a necessary condition– Current investment in training of private Current investment in training of private

providers does not reflect usage patterns providers does not reflect usage patterns • Invite to Government sponsored trainingInvite to Government sponsored training• Tailor to economic realities of private practiceTailor to economic realities of private practice

– Not paid to attend workshopsNot paid to attend workshops

• Work through peer leaders and associationsWork through peer leaders and associations• Include CME requirements in licensingInclude CME requirements in licensing

Accreditation---A New Accreditation---A New Avenue for Quality Avenue for Quality

ImprovementImprovement• Limit to high impact servicesLimit to high impact services

– HAART, Emergency Obstetrics, etc.HAART, Emergency Obstetrics, etc.• Go beyond inputs to process and outcomesGo beyond inputs to process and outcomes• Incorporate treatment protocolsIncorporate treatment protocols• Begin with feedbackBegin with feedback• A “carrot” as well as a “stick”A “carrot” as well as a “stick”

– Free or low cost drugsFree or low cost drugs– Inclusion in referral networksInclusion in referral networks– A condition of participation in new insurance A condition of participation in new insurance

programsprograms• Public or private?Public or private?

– Providers and public sector both skeptical of Providers and public sector both skeptical of private accreditationprivate accreditation