1. DOMINIC MONTAGU Based on slides developed by Abi Ridgway UC Berkeley Haas School of Business Exhortation and Information as Policy Tools to Improve Private-Sector Hospital Performance in Asia

2. 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 studies PHSA Gather available information Identify additional needs In-depth studies Activities Hospitals PHC Diagnostic labs Producers / Distributors Ownership For-profit corporate For-profit small business Non-profit charitable Formal/ Informal Activities Hospitals PHC Diagnostic labs Producers / Distributors Ownership For-profit corporate For-profit small business Non-profit charitable Formal/ Informal Grow Harness Convert Strategy Assessment Goal Focus Private Sector Public Sector Restrict

3. 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 studies PHSA Gather available information Identify additional needs In-depth studies Activities Hospitals PHC Diagnostic labs Producers / Distributors Ownership For-profit corporate For-profit small business Non-profit charitable Formal/ Informal Activities Hospitals PHC Diagnostic labs Producers / Distributors Ownership For-profit corporate For-profit small business Non-profit charitable Formal/ Informal Goal Assessment Focus Private Sector Public Sector Restrict Grow Convert Strategy Harness

4. Outline of Session Definition Typology Criteria for Assessment Conclusions definition

5. 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.

6. Traditional policies: limited applicability Pay-for-Performance Regulation Accreditation Contracting Services

7. Using information as a policy tool Collect From ProvidersPublicBest Practices Disseminate To Providers Public

8. Policy Alternatives Persuasion Public Recognition Public Reporting Negotiation

9. #1: Persuasion Academic Detailing ORT, Indonesia Group training sessions Hyderabad, India TB Dissemination of best practices Preventive Pediatrics, India Target Audience Size An intentional effort to change attitudes or behavior by sharing information with hospital providers

10. #1: Persuasion CriteriaRankingRationale EffectivenessLow 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 AffordabilityMedium Depends on the size of the target audience Inversely correlated with effectiveness FeasibilityHigh No new technology required Education is non-controversial Getting physicians time is major political challenge

11. #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

12. #2: Public Recognition CriteriaRankingRationale EffectivenessMedium 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 AffordabilityHigh Government doesn’t have to provide financial reward Only evaluate applicants Industry contributes to Baldrige award Cost-benefit ratio estimate of Baldrige = 207:1 FeasibilityHigh Hospital voluntary participate No EHRs required, small scale data collection

13. #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

14. #3: Public Reporting CriteriaRankingRationale EffectivenessMedium 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 AffordabilityLow Intense data collection process Auditing FeasibilityLow Heavy reliance on EMRs Probable push-back from providers

15. #4: Negotiation Governments and providers make a mutual agreement for performance improvement Ex: 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 Verbal Case Reviews Share data and desired behavior AgreementFollow-up

16. #4: Negotiation CriteriaRankingRationale EffectivenessMedium 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 AffordabilityMedium No formal training No auditing verbal case reviews Management intensive process FeasibilityHigh Simple data collection method and tools Adaptable process can be used to change Providers have say and push back less

17. Summary of policy alternatives Persuasion Public Recognition Public Reporting Negotiation Effectiveness LowMedium Affordability MediumHighLowMedium Feasibility High LowHigh

18. 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

19. Caveat A Weak Tool Among 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. Conclusion Exhortation and Information is a useful first-level intervention.

20. 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

21. QUESTIONS? Thank you!