1. Regulating Private Practice The (In)Visible Hand of Government in the Medical Marketplace

2. How “Bad” Is Private Practice in Developing Countries? Results depend on definition of the private sector:Results depend on definition of the private sector: –A 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?

3. Is Quality Worse in the Private Sector? Few direct comparisonsFew direct comparisons Vietnam 1Vietnam 1 –Public sector care higher quality –But moonlighting Government providers were close –Private scores pulled down by unqualified providers China 2China 2 –All subjects had limited training –Spectrum of subsidy –All sell drugs –No significant differences in quality measures –Similar subsidy requirements for preventive care Source: 1 Tran Tuan et al. “Comparative Quality of Public and Private Health Services in Vietnam” (2005) 2 Qingyue Meng et al “Comparing the services and quality of private and public clinics in rural China” (2000)

4. Where Quality in the Private Sector is Worse Many “private providers” lack required qualificationsMany “private providers” lack required qualifications Dispensing providers have an incentive to overprescribeDispensing providers have an incentive to overprescribe –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”

5. A Bit of History Look back a century in US and EuropeLook back a century in US and Europe –Not far removed from the barber/surgeon –Typical practice fell far short of standards in new “scientific medicine” –Force “substandard” doctors out of practice? NONO Upgrade training requirementsUpgrade training requirements –Let attrition improve average quality –Approving and improving medical schools Flexner ReportFlexner Report

6. Government and Quality Distribution Cut the tail off the quality curve, if:Cut the tail off the quality curve, if: –Motivated –Legally empowered –Well Informed –Adequate resources Not good at shifting the curve to the rightNot good at shifting the curve to the right Quality  Frequency Distribution Government Action

7. Making Licensing/Registration More Effective Taking consumer complaints seriouslyTaking consumer complaints seriously –In India, consumer protection law gets provider’s attention –Consumer education –Resources and representation –Public representatives on licensing boards –Why they shoot deserters? Educating and RegulatingEducating and Regulating –In Laos, pharmacy practices improved with inspection 1 Or, was it the “Hawthorne Effect”?Or, was it the “Hawthorne Effect”? Source: 1 Bo Stenson et al “Private pharmacy practice and regulation: a randomized trial in Lao PDR” (2001)

8. Make Licensing/Regulation More Effective Prohibit the unqualified from practicing?Prohibit the unqualified from practicing? –License other categories to increase the supply of regulated providers? License the drug seller where there is no pharmacistLicense the drug seller where there is no pharmacist –Educate the consumers What to expect of medical careWhat to expect of medical care –Part of health education curriculum –More drugs not always better –Injections not better than pills How to tell what provider is qualified?How to tell what provider is qualified? –But who will locate among the poor Where there are many “qualified providers”Where there are many “qualified providers” –Slums of Karachi –Latin America

9. Shifting the Quality Distribution What works in the developed world 1What works in the developed world 1 –Continuing education a necessary, but not sufficient, condition –Some interventions have little effect CME aloneCME alone Published guidelinesPublished guidelines What worksWhat works –Feedback/academic detailing Evidence of impact in Bihar as well 2Evidence of impact in Bihar as well 2 –Peer leaders as change agents –Combining provider and patient interventions Source: 1 Andrew Oxman et al “No magic bullets: a systematic review of 102 trials of interventions to improve professional practice” (1995) 2 Sarbani Chakraborty et al. “Improving private practitioner care of sick children; testing new approaches in rural Bihar” (200)

10. Shifting the Quality Curve in the Developing World Educating private providersEducating private providers –Still a necessary condition –Current investment in training of private 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 workshops Work through peer leaders and associationsWork through peer leaders and associations Include CME requirements in licensingInclude CME requirements in licensing

11. Accreditation---A New Avenue for Quality Improvement Limit to high impact servicesLimit to high impact services –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 drugs –Inclusion in referral networks –A condition of participation in new insurance programs Public or private?Public or private? –Providers and public sector both skeptical of private accreditation