Measuring the Quality of Private Providers in Myanmar: a cohort study

1. Measuring the Quality of Private Providers in Myanmar: a cohort study Tin Aung, Willi McFarland, Kim Longfield, May Sudhinaraset and Dominic Montagu

2. A method combining components of direct observation, clinical vignettes, and medical mannequins • Validated by direct observation of true patients • More time efficient than direct observation of true patients • Closer to reality than clinical vignettes and medical mannequins Observed Simulated Patient

3. Study Overview • Intervention: recruitment and franchising of rural community-level providers. Providers receive regular support visit and a limited set of primary care focused branded commodities. • Study Objective: to see if provider quality improvements are sustained six months after training

4. Study Overview • Methodology: Observed Simulated Patient (OSP) Instrument used immediately prior to training (winter 2011), and at six months. OSP has previously been validated in comparison to direct observation of pediatric malaria diagnosis and treatment among private practitioners in Myanmar (Aung et al 2012). • Providers were visited at their home and asked to conduct a patient consultation for an ill child (simulated by a life-size-doll). An observer scored the providers against a detailed list of best practices for malaria diagnosis and treatment.

5. Providercharacteristics

6. Scoring of OSP • Questions developed from PSI protocols, themselves developed based on WHO treatment guidelines • Differential weighting of binary questions • 61 points for diagnosis • (applicable to both positive and negative RDT result) • 39 points for treatment • (positive RDT only) • Revised instruments were reviewed by Infectious Disease Faculty of the Yangon Institute of Medicine • Prof. Chit Soe • Prof. Khin May Ohn • Dr. Soe Aung (Malariologist)

7. Consulting OSP

8. Explaining to OSP

9. Baseline to 6 months Importance to Health Average percent correct

10. OSP performance vs. provider characteristics

11. Trained nurses/CHWs recognize severe malaria & take vital signs

12. Using RDTs in normal practices is correlated with using RDTs during OSP

13. Using RDTs in normal practice is correlated with quality medical care during OSP

14. Using ACTs in normal practice is correlated with good medical care during OSP

15. Summary of Findings • All newly trained providers improved in all dimensions • Nurses/Midwifes improved most at taking vital signs and checking for serve malaria • Providers who improved the most in prescribing and testing were those who performed the most tests and treatment normally

16. Implications for Measuring Franchising Quality • Quality can be both complex and costly to measure • Our study provides insights into provider attributes that are associated with quality improvement • Measure attributes as proxies for quality and quality potential • OSP allows franchisors to identify likely high and low quality providers

17. THANK YOU Tin Aung Strategic Information Director PSI/Myanmar taung@psimyanmar.org