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Regulating Private Practice. The (In)Visible Hand of Government in the Medical Marketplace. How “Bad” Is Private Practice in Developing Countries?. Results depend on definition of the private sector: A spectrum of public and private Moonlighting Government providers
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Regulating Private Practice The (In)Visible Hand of Government in the Medical Marketplace
How “Bad” Is Private Practice in Developing Countries? • Results depend on definition of the private sector: • A spectrum of public and private • Moonlighting Government providers • Fully qualified and fully private • Any provider of “medical” services • Prescribing and dispensing?
Is Quality Worse in the Private Sector? • Few direct comparisons • Vietnam1 • Public sector care higher quality • But moonlighting Government providers were close • Private scores pulled down by unqualified providers • China2 • All subjects had limited training • Spectrum of subsidy • All sell drugs • No significant differences in quality measures • Similar 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 Private Sector is Worse • Many “private providers” lack required qualifications • Dispensing providers have an incentive to overprescribe • Is it any different in developed countries? • Isolated from new developments • “It is what the patient wants/expects”
A Bit of History • Look 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? • NO • Upgrade training requirements • Let attrition improve average quality • Approving and improving medical schools • Flexner Report
Government and Quality Distribution • Cut the tail off the quality curve, if: • Motivated • Legally empowered • Well Informed • Adequate resources • Not good at shifting the curve to the right Government Action Frequency Distribution Quality
Making Licensing/Registration More Effective • Taking 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 Regulating • In Laos, pharmacy practices improved with inspection1 • 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 More Effective • Prohibit the unqualified from practicing? • License other categories to increase the supply of regulated providers? • License the drug seller where there is no pharmacist • Educate the consumers • What 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? • But who will locate among the poor • Where there are many “qualified providers” • Slums of Karachi • Latin America
Shifting the Quality Distribution • What works in the developed world1 • Continuing education a necessary, but not sufficient, condition • Some interventions have little effect • CME alone • Published guidelines • What works • Feedback/academic detailing • Evidence of impact in Bihar as well2 • Peer leaders as change agents • Combining 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 in the Developing World • Educating private providers • Still a necessary condition • Current investment in training of private providers does not reflect usage patterns • Invite to Government sponsored training • Tailor to economic realities of private practice • Not paid to attend workshops • Work through peer leaders and associations • Include CME requirements in licensing
Accreditation---A New Avenue for Quality Improvement • Limit to high impact services • HAART, Emergency Obstetrics, etc. • Go beyond inputs to process and outcomes • Incorporate treatment protocols • Begin with feedback • 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? • Providers and public sector both skeptical of private accreditation