Related Resources

@article{Kwan2022,

title = {Implementing Quality of Care Measures: Lessons from a Standardized Patient Study in Seven Provinces of China},

author = {Ada Kwan},

url = {https://www.qutubproject.org/wp-content/uploads/2017/09/Kwan-AJPH-2022.pdf},

year  = {2022},

date = {2022-04-28},

urldate = {2022-01-01},

journal = {American Journal of Public Health},

number = {0},

pages = {e1--e3},

publisher = {American Public Health Association},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Xu2022,

title = {Improving Data Surveillance Resilience Beyond COVID-19: Experiences of Primary heAlth Care quAlity Cohort In China (ACACIA) Using Unannounced Standardized Patients},

author = {Dong Xu and Yiyuan Cai and Xiaohui Wang and Yaolong Chen and Wenjie Gong and Jing Liao and Jifang Zhou and Zhongliang Zhou and Nan Zhang and Chengxiang Tang and Baibing Mi and Yun Lu and Ruixin Wang and Qing Zhao and Wenjun He and Huijuan Liang and Jinghua Li and Jay Pan},

url = {https://www.qutubproject.org/wp-content/uploads/2017/09/Xu-AJPH-2022.pdf},

year  = {2022},

date = {2022-04-28},

urldate = {2022-04-28},

journal = {American Journal of Public Health},

number = {0},

pages = {e1--e10},

publisher = {American Public Health Association},

abstract = {We analyzed COVID-19 influences on the design, implementation, and validity of assessing the quality of primary health care using unannounced standardized patients (USPs) in China. Because of the pandemic, we crowdsourced our funding, removed tuberculosis from the USP case roster, adjusted common cold and asthma cases, used hybrid online–offline training for USPs, shared USPs across provinces, and strengthened ethical considerations.



With those changes, we were able to conduct fieldwork despite frequent COVID-19 interruptions. Furthermore, the USP assessment tool maintained high validity in the quality checklist (criteria), USP role fidelity, checklist completion, and physician detection of USPs. Our experiences suggest that the pandemic created not only barriers but also opportunities to innovate ways to build a resilient data collection system.



To build data system reliance, we recommend harnessing the power of technology for a hybrid model of remote and in-person work, learning from the sharing economy to pool strengths and optimize resources, and dedicating individual and group leadership to problem-solving and results.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Rosapep2022c,

title = {Tuberculosis care quality in urban Nigeria: A cross-sectional study of adherence to screening and treatment initiation guidelines in multi-cadre networks of private health service providers},

author = {Lauren A Rosapep and Sophie Faye and Benjamin Johns and Bolanle Olusola-Faleye and Elaine M Baruwa and Micah K Sorum and Flora Nwagagbo and Abdu A Adamu and Ada Kwan and Christopher Obanubi and Akinyemi Olumuyiwa Atobatele},

url = {https://journals.plos.org/globalpublichealth/article/file?id=10.1371/journal.pgph.0000150&type=printable},

year  = {2022},

date = {2022-01-06},

urldate = {2022-01-01},

journal = {PLoS Global Public Health},

volume = {2},

number = {1},

pages = {e0000150},

publisher = {Public Library of Science San Francisco, CA USA},

abstract = {Nigeria has a high burden of tuberculosis (TB) and low case detection rates. Nigeria’s large private health sector footprint represents an untapped resource for combating the disease. To examine the quality of private sector contributions to TB, the USAID-funded Sustaining Health Outcomes through the Private Sector (SHOPS) Plus program evaluated adherence to national standards for management of presumptive and confirmed TB among the clinical facilities, laboratories, pharmacies, and drug shops it trained to deliver TB services. The study used a standardized patient (SP) survey methodology to measure case management protocol adherence among 837 private and 206 public providers in urban Lagos and Kano. It examined two different scenarios: a “textbook” case of presumptive TB and a treatment initiation case where SPs presented as referred patients with confirmed TB diagnoses. Private sector results were benchmarked against public sector results. A bottleneck analysis examined protocol adherence departures at key points along the case management sequence that providers were trained to follow. Except for laboratories, few providers met the criteria for fully correct management of presumptive TB, though more than 70% of providers correctly engaged in TB screening. In the treatment initiation case 18% of clinical providers demonstrated fully correct case management. Private and public providers’ adherence was not significantly different. Bottleneck analysis revealed that the most common deviations from correct management were failure to initiate sputum collection for presumptive patients and failure to conduct sufficiently thorough treatment initiation counseling for confirmed patients. This study found the quality of private providers’ TB case management to be comparable to public providers in Nigeria, as well as to providers in other high burden countries. Findings support continued efforts to include private providers in Nigeria’s national TB program. Though most providers fell short of desired quality, the bottleneck analysis points to specific issues that TB stakeholders can feasibly address with system- and provider-level interventions.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Kovacs2021,

title = {Can patients improve the quality of care they receive? Experimental evidence from Senegal},

author = {Roxanne J Kovacs and Mylene Lagarde and John Cairns},

url = {https://www.sciencedirect.com/science/article/pii/S0305750X21003557},

year  = {2021},

date = {2021-11-12},

urldate = {2022-01-01},

journal = {World Development},

volume = {150},

pages = {105740},

publisher = {Elsevier},

abstract = {Providers in many low and middle-income countries (LMICs) often fail to correctly diagnose and treat their patients, even though they have the clinical knowledge to do so. Against the backdrop of many failed attempts to increase provider effort, this study examines whether quality of care can be improved by encouraging patients to be more active during consultations. We design a simple experiment with undercover standardised patients who randomly vary how much information they disclose about their symptoms. We find that providers are 27% more likely to correctly manage a patient who volunteers several key symptoms of their condition at the start of the consultation, compared to a typical patient who shares less information. Lower performance in the control group is not due to providers’ lack of knowledge, an incapacity to ask the right questions, or a response to time or resource constraints. Instead, providers’ low motivation seems to limit their ability to adapt their effort to patients’ inputs in the consultation. Our findings provide proof-of-concept evidence that interventions making patients more active in their consultations could significantly improve the quality of care in LMICs.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Zawahir2021,

title = {Standardised patient study to assess tuberculosis case detection within the private pharmacy sector in Vietnam},

author = {Shukry Zawahir and Hien Le and Thu Anh Nguyen and Justin Beardsley and Anh Dang Duc and Sarah Bernays and Kerri Viney and Thai Cao Hung and Shannon McKinn and Hoang Huy Tran and Son Nguyen Tu and Kavindhran Velen and Tan Luong Minh and Hung Tran Thi Mai and Nhung Nguyen Viet and Ha Nguyen Viet and Van Nguyen Thi Cam and Thanh Nguyen Trung and Stephen Jan and Ben J Marais and Joel Negin and Guy B Marks and Gregory Fox},

url = {https://gh.bmj.com/content/bmjgh/6/10/e006475.full.pdf?with-ds=yes},

year  = {2021},

date = {2021-10-06},

urldate = {2021-01-01},

journal = {BMJ Global Health},

volume = {6},

number = {10},

pages = {e006475},

publisher = {BMJ Specialist Journals},

abstract = {Background

Of the estimated 10 million people affected by (TB) each year, one-third are never diagnosed. Delayed case detection within the private healthcare sector has been identified as a particular problem in some settings, leading to considerable morbidity, mortality and community transmission. Using unannounced standardised patient (SP) visits to the pharmacies, we aimed to evaluate the performance of private pharmacies in the detection and treatment of TB.



Methods

A cross-sectional study was undertaken at randomly selected private pharmacies within 40 districts of Vietnam. Trained actors implemented two standardised clinical scenarios of presumptive TB and presumptive multidrug-resistant TB (MDR-TB). Outcomes were the proportion of SPs referred for medical assessment and the proportion inappropriately receiving broad-spectrum antibiotics. Logistic regression evaluated predictors of SPs’ referral.



Results

In total, 638 SP encounters were conducted, of which only 155 (24.3%) were referred for medical assessment; 511 (80·1%) were inappropriately offered antibiotics. A higher proportion of SPs were referred without having been given antibiotics if they had presumptive MDR-TB (68/320, 21.3%) versus presumptive TB (17/318, 5.3%; adjusted OR=4.8, 95% CI 2.9 to 7.8). Pharmacies offered antibiotics without a prescription to 89.9% of SPs with presumptive TB and 70.3% with presumptive MDR-TB, with no clear follow-up plan.



Conclusions

Few SPs with presumptive TB were appropriately referred for medical assessment by private pharmacies. Interventions to improve appropriate TB referral within the private pharmacy sector are urgently required to reduce the number of undiagnosed TB cases in Vietnam and similar high-prevalence settings.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{xue2018quality,

title = {The Quality of Tuberculosis Care in Urban Migrant Clinics in China},

author = {Hao Xue and Jennifer Hager and Qi An and Kai Liu and Jing Zhang and Emma Auden and Bingyan Yang and Jie Yang and Hongyan Liu and Jingchun Nie and others},

url = {https://www.mdpi.com/1660-4601/15/9/2037/htm},

year  = {2018},

date = {2018-09-18},

journal = {International journal of environmental research and public health},

volume = {15},

number = {9},

pages = {2037},

publisher = {Multidisciplinary Digital Publishing Institute},

abstract = {Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14–46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28–72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Das2018,

title = {Rethinking assumptions about delivery of healthcare: implications for universal health coverage},

author = {Jishnu Das and Liana Woskie and Ruma Rajbhandari and Kamran Abbasi and Ashish Jha},

url = {https://www.qutubproject.org/wp-content/uploads/2018/05/2018-05-DasJ-BMJ.pdf, Full article},

year  = {2018},

date = {2018-05-23},

journal = {BMJ},

volume = {361},

pages = {k1716},

abstract = {Key Messages

• Availability of health advisers is not the main problem in most countries

• Simply providing access to trained medical staff and facilities does not guarantee universal access to quality care

• A weak link between medical qualifications and medical knowledge implies that providers without any formal medical training can provide higher quality care than fully trained doctors

• In many countries large gaps exist between what doctors know and what they actually do

• New approaches are needed to tackle systems that produce medical professionals who are poorly trained, undermotivated, and underused},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Christian2018b,

title = {Measuring Quality Gaps in TB Screening in South Africa Using Standardised Patient Analysis},

author = {Carmen S Christian and Ulf-G Gerdtham and Dumisani Hompashe and Anja Smith and Ronelle Burger},

url = {http://www.mdpi.com/1660-4601/15/4/729/htm, Full article},

year  = {2018},

date = {2018-04-12},

journal = {International Journal of Environmental Research and Public Health},

volume = {15},

number = {4},

pages = {729},

publisher = {Multidisciplinary Digital Publishing Institute},

abstract = {This is the first multi-district Standardised Patient (SP) study in South Africa. It measures the quality of TB screening at primary healthcare (PHC) facilities. We hypothesise that TB screening protocols and best practices are poorly adhered to at the PHC level. The SP method allows researchers to observe how healthcare providers identify, test and advise presumptive TB patients, and whether this aligns with clinical protocols and best practice. The study was conducted at PHC facilities in two provinces and 143 interactions at 39 facilities were analysed. Only 43% of interactions resulted in SPs receiving a TB sputum test and being offered an HIV test. TB sputum tests were conducted routinely (84%) while HIV tests were offered less frequently (47%). Nurses frequently neglected to ask SPs whether their household contacts had confirmed TB (54%). Antibiotics were prescribed without taking temperatures in 8% of cases. The importance of returning to the facility to receive TB test results was only explained in 28%. The SP method has highlighted gaps in clinical practice, signalling missed opportunities. Early detection of sub-optimal TB care is instrumental in decreasing TB-related morbidity and mortality. The findings provide the rationale for further quality improvement work in TB management.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Das2017,

title = {Standardized patient method in tuberculosis research},

author = {Jishnu Das and Ada Kwan and Benjamin Daniels and Srinath Satyanarayana and Ramnath Subbaraman and Sofi Bergkvist and Ranendra K Das and Veena Das and Madhukar Pai},

url = {http://www.nmji.in/article.asp?issn=0970-258X;year=2017;volume=30;issue=4;spage=210;epage=211;aulast=Grace, Full article},

year  = {2017},

date = {2017-11-17},

journal = {The National Medical Journal of India},

volume = {30},

number = {4},

pages = {210-211},

abstract = {India contributes to almost a quarter of the global burden of tuberculosis (TB).[1] The majority of patients are treated either in the government sector or in the highly unregulated private sector.[2] Using the technique called ‘standardized patient’ (SP), Das et al. and Satyanarayana et al. assessed the practices of healthcare providers and pharmacies when patients with symptoms suggestive of TB consult them. The first study used the SP method to assess the quality of care delivered to patients with TB. The SP method has been used for diseases such as diabetes and pneumonia. Das et al. were the first to use this approach for TB. This pilot study aimed to validate the SP method to assess how healthcare providers manage patients presenting with symptoms of TB. Individuals were recruited as employees and trained intensively to present as SPs to different types of private practitioners. This study was done in low- and middle-income areas of New Delhi. The convenience sampling method was used to recruit 100 private healthcare providers, of which 40% were practitioners of alternative medicine, 29% were practitioners of allopathic medicine and 31% were informal healthcare providers. The authors developed four types of case scenarios: (i) patient of presumed TB; (b) patient of presumed TB not responding to a course of antibiotics; (iii) patient presenting with evidence suggestive of bacteriologically confirmed TB such as a positive sputum smear result; and (iv) recurrence of TB in a previously treated patient. Correct case management was defined as per the Standards for TB Care in India. Of the 250 SP healthcare provider interactions, correct case management was seen in only 21%. The detection rate of SPs by private practitioners was minimal (5%) in this study. The authors recommend that the SP method can be used successfully to assess the quality of healthcare provided to patients with TB.



The authors used a similar technique in another study to assess the practices of pharmacies when patients with symptoms suggestive of presumed TB and microbiologically confirmed TB approached them for advice and medicines. Satyanarayana et al. conducted this multi- centric survey in Patna, Mumbai and the initial validation phase in New Delhi. Expected case management was defined as per the guidelines from the Indian Pharmaceutical Association and Central TB Division, Government of India. Similar to the first study, SPs were trained intensively. Mock interviews and dry runs were conducted in the field under supervision. Two case descriptions were adopted to assess the guidance given to the patients and medicines dispensed to them by the pharmacists. Case 1 SPs were trained to present to the pharmacist with 2–3 weeks’ duration of cough and fever. Case 2 SPs had a positive sputum smear result for acid-fast bacilli (in addition to the presentation of symptoms). Convenience sampling was used for the pilot phase in Delhi and random sampling for the pharmacies in Patna and Mumbai. Of the 622 pharmacies sampled, 93% of the scheduled SP–pharmacist interactions were completed for both case scenarios. Ideal case management was noted in 13% of case 1 presentations and 62% of case 2 presentations. First-line anti-TB drugs were not dispensed to any of the SP. The fluoroquinolone group of drugs was given to 7% and steroids to 5% of the total interactions; this has relevance not only for TB, but also for other community-acquired infections. The second study complemented the first one by using the SP technique to assess inappropriate use of antibiotics by pharmacists.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Miller2017,

title = {Do chain pharmacies perform better than independent pharmacies? Evidence from a standardised patient study of the management of childhood diarrhoea and suspected tuberculosis in urban India},

author = {Rosalind Miller and Catherine Goodman},

url = {http://gh.bmj.com/content/2/3/e000457.full.pdf, Full article},

year  = {2017},

date = {2017-09-22},

journal = {BMJ Global Health},

volume = {2},

number = {3},

pages = {e000457},

publisher = {BMJ Specialist Journals},

abstract = {Introduction

Pharmacies and drug stores are frequently patients’ first point of care in many low-income and middle-income countries, but their practice is often poor. Pharmacy retailing in India has traditionally been dominated by local, individually owned shops, but recent years have seen the growth of pharmacy chains. In theory, lower-powered profit incentives and self-regulation to preserve brand identity may lead to higher quality in chain stores. In practice, this has been little studied.



Methods

We randomly selected a stratified sample of chain and independent pharmacies in urban Bengaluru. Standardised patients (SPs) visited pharmacies and presented a scripted case of diarrhoea for a child and suspected tuberculosis (TB). SPs were debriefed immediately after the visit using a structured questionnaire. We measured the quality of history taking, therapeutic management and advice giving against national (Government of India) and international (WHO) guidelines. We used Pearson’s χ2 tests to examine associations between pharmacy type and case management.



Findings

Management of childhood diarrhoea and suspected TB was woefully substandard. History taking of the SP was limited; unnecessary and harmful medicines, including antibiotics, were commonly sold; and advice giving was near non-existent. The performance of chains and independent shops was strikingly similar for most areas of assessment. We observed no significant differences between the management of suspected TB in chains and independents. 43% of chains and 45% of independents managed the TB case correctly; 17% and 16% of chains and independents, respectively, sold antibiotics. We found that chains sold significantly fewer harmful antibiotics and antidiarrhoeals (35% vs 48%, p=0.029) and prescription-only medicines (37% vs 49%, p=0.048) for the patient with diarrhoea compared with independent shops. Not a single shop managed the patient with diarrhoea correctly according to guidelines.



Conclusion

Our results from Bengaluru suggest that it is unlikely that chains alone can solve persisting quality challenges. However, they may offer a potential vehicle through which to deliver interventions. Future intervention research should consider recruiting chains to see whether effectiveness of interventions differ among chains compared with independents.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Mohanan2016,

title = {Providers' knowledge of diagnosis and treatment of tuberculosis using vignettes: evidence from rural Bihar, India},

author = {Manoj Mohanan and Jeremy D Goldhaber-Fiebert and Soledad Giardili and Marcos Vera-Hernández},

url = {http://gh.bmj.com/content/1/4/e000155.full.pdf, Full article},

year  = {2016},

date = {2016-12-16},

journal = {BMJ global health},

volume = {1},

number = {4},

pages = {e000155},

publisher = {BMJ Specialist Journals},

abstract = {Background

Almost 25% of all new cases of tuberculosis (TB) worldwide are in India, where drug resistance and low quality of care remain key challenges.



Methods

We conducted an observational, cross-sectional study of healthcare providers' knowledge of diagnosis and treatment of TB in rural Bihar, India, from June to September 2012. Using data from vignette-based interviews with 395 most commonly visited healthcare providers in study areas, we scored providers' knowledge and used multivariable regression models to examine their relationship to providers' characteristics.



Findings

80% of 395 providers had no formal medical qualifications. Overall, providers demonstrated low levels of knowledge: 64.9% (95% CI 59.8% to 69.8%) diagnosed correctly, and 21.7% (CI 16.8% to 27.1%) recommended correct treatment. Providers seldom asked diagnostic questions such as fever (31.4%, CI 26.8% to 36.2%) and bloody sputum (11.1%, CI 8.2% to 14.7%), or results from sputum microscopy (20.0%, CI: 16.2% to 24.3%). After controlling for whether providers treat TB, MBBS providers were not significantly different, from unqualified providers or those with alternative medical qualifications, on knowledge score or offering correct treatment. MBBS providers were, however, more likely to recommend referrals relative to complementary medicine and unqualified providers (23.2 and 37.7 percentage points, respectively).



Interpretation

Healthcare providers in rural areas in Bihar, India, have low levels of knowledge regarding TB diagnosis and treatment. Our findings highlight the need for policies to improve training, incentives, task shifting and regulation to improve knowledge and performance of existing providers. Further, more research is needed on the incentives providers face and the role of information on quality to help patients select providers who offer higher quality care.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Das2016,

title = {Quality and Accountability in Health Care Delivery: Audit-Study Evidence from Primary Care in India},

author = {Jishnu Das and Alaka Holla and Aakash Mohpal and Karthik Muralidharan},

url = {https://www.qutubproject.org/wp-content/uploads/2017/09/Das-American-Economic-Review-2016-Das.pdf, Full article},

year  = {2016},

date = {2016-12-01},

journal = {American Economic Review},

volume = {106},

number = {12},

pages = {3765-99},

abstract = {We present unique audit-study evidence on health care quality in rural India, and find that most private providers lacked medical qualifications, but completed more checklist items than public providers and recommended correct treatments equally often. Among doctors with public and private practices, all quality metrics were higher in their private clinics. Market prices are positively correlated with checklist completion and correct treatment, but also with unnecessary treatments. However, public sector salaries are uncorrelated with quality. A simple model helps interpret our findings: Where public-sector effort is low, the benefits of higher diagnostic effort among private providers may outweigh costs of potential overtreatment.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Das2016,

title = {The impact of training informal health care providers in India: A randomized controlled trial},

author = {Jishnu Das and Abhijit Chowdhury and Reshmaan Hussam and Abhijit V Banerjee},

url = {https://www.qutubproject.org/wp-content/uploads/2017/09/Das-Science-2016.pdf, Full article},

year  = {2016},

date = {2016-10-07},

journal = {Science},

volume = {354},

number = {6308},

pages = {aaf7384},

publisher = {American Association for the Advancement of Science},

abstract = {INTRODUCTION

In rural India, health care providers without formal medical training and self-declared “doctors” are sought for up to 75% of primary care visits. The frequent use of such informal providers, despite legal prohibitions on their practices, in part reflects the absence of trained medical professionals in rural locations. For example, in the majority of villages in the Indian states of Rajasthan, Madhya Pradesh, and West Bengal, informal providers are the only proximate source of health care.



RATIONALE

The status of informal providers in the complex Indian health system is the subject of a highly charged debate among policy-makers and the medical establishment. The official view of the establishment is that fully trained providers are the only legitimate source of health care, and training informal providers legitimizes an illegal activity and worsens population health outcomes. In contrast, given the lack of availability of trained providers and the fact that informal providers are tightly linked with the communities that they serve, others believe that training can serve as a stopgap measure to improve health care in tandem with better regulation and reform of the public health care system. However, despite the policy interest and important ramifications for the country, there is little evidence regarding the benefits (or lack thereof) of training informal providers.



We report on the impact of a multitopic training program for informal providers in the Indian state of West Bengal that provided 72 sessions of training over 9 months. We used a randomized controlled trial design, together with visits by unannounced standardized patients (“mystery clients”), to measure the extent to which training could improve the clinical practice of informal providers over the range of conditions that they face. The conditions presented by standardized patients were blinded from program implementers. Therefore, we view the evaluation of this multitopic training program as a measure of impact on primary care in general. Standardized patient data are accompanied by data from day-long clinical observations, providing a comprehensive picture of provider practice. Our study also benchmarks the impact of training against the performance of doctors in public primary health centers serving the same region. Lastly, it explores whether the training affected patient demand for informal providers.



RESULTS

Mean attendance at each training session was 56% [95% confidence interval (CI): 51, 62%], with no contamination from the control group. Using standardized patient data, we find that providers allocated to the training group were 4.1 (1.7, 6.5) percentage points, or 15.2%, more likely to adhere to condition-specific checklists than those in the control group. The training increased rates of correct case management by 7.9 (0.4, 15.5) percentage points, or 14.2%, and patient caseload by 0.8 to 1.8 (0.13, 3.57) patients per day, or 7.6 to 17.0%. Data from clinical observations show similar patterns. Although correct case management among doctors in public clinics was 14.7 (–0.1, 30.4) percentage points, or 28.3%, higher than among untrained informal providers, the training program reduced this gap by half for providers with mean attendance and reduced the gap almost entirely for providers who completed the full course. However, the training had no effect on the use of unnecessary medicines and antibiotics, although both training- and control-group informal providers prescribed 18.8 (7.7, 28.9) percentage points, or 28.2%, fewer unnecessary antibiotics than public-sector providers.



CONCLUSION

Training informal providers increased correct case management rates but did not reduce the use of unnecessary medicines or antibiotics. At the same time, training did not lead informal providers to violate rules with greater frequency or worsen their clinical practice, both of which are concerns that have been raised by representatives of the Indian Medical Association. Our findings thus suggest that multitopic medical training may offer an effective short-run strategy to improved health care provision and complement critical investments in the quality of public care.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Kruk2016,

title = {Time for a quality revolution in global health},

author = {Margaret E Kruk and Elysia Larson and Nana AY Twum-Danso},

url = {http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(16)30131-0.pdf, Full article},

year  = {2016},

date = {2016-09-01},

journal = {The Lancet Global health},

volume = {4},

number = {9},

pages = {e594--e596},

publisher = {Elsevier},

abstract = {The beginning of 2016 marked a major transition in global health: from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). The core strategy used to reduce mortality from MDG health conditions was expansion of coverage of a short list of eff ective but relatively simple health interventions. Indeed, success on many of the MDGs was measured through coverage (eg, proportion of births with skilled attendants). There are two reasons to think that the utilisation strategy will not deliver the Sustainable Development Goals (SDGs).},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Mohanan2015,

title = {The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India},

author = {Manoj Mohanan and Marcos Vera-Hernández and Veena Das and Soledad Giardili and Jeremy D Goldhaber-Fiebert and Tracy L Rabin and Sunil S Raj and Jeremy I Schwartz and Aparna Seth},

url = {http://jamanetwork.com/journals/jamapediatrics/fullarticle/2118580, Full article},

year  = {2015},

date = {2015-02-16},

journal = {JAMA pediatrics},

volume = {169},

number = {4},

pages = {349--357},

publisher = {American Medical Association},

abstract = {Importance

In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners’ knowledge of appropriate care and the actual care delivered (the know-do gap).



Objective

To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India.



Design, Setting, and Participants

We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs).



Main Outcomes and Measures

For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners’ characteristics. We also examined correct treatment recommended by practitioners with both methods.



Results

Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia.



Conclusions and Relevance

Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Das2014,

title = {Quality of primary care in low-income countries: Facts and economics},

author = {Jishnu Das and Jeffrey Hammer},

url = {https://www.qutubproject.org/wp-content/uploads/2017/09/Das-Hammer-Annurev-economics-2014.pdf, Full article},

year  = {2014},

date = {2014-08-01},

journal = {Annual Review of Economics},

volume = {6},

number = {1},

pages = {525--553},

publisher = {Annual Reviews},

abstract = {New research on the quality of care in public and private primary care facilities has significantly enriched our understanding of how health care is delivered in low- and middle-income countries. First, this article summarizes recent advances in the measurement of quality, distinguishing between measurements of provider knowledge and provider effort. Second, it looks at the determinants of practice quality variation in low-income settings, highlighting the limited role of structural constraints such as infrastructure, the supply of materials including drugs, and provider training—the mainstay of much of global health policy today. In contrast, practice quality variation is clearly linked to provider effort, an aspect of provider behavior that can be altered through a variety of means. Third, it provides a broad economic framework to interpret the findings. We look for evidence of specific market failures in the provision of primary care and emphasize that the key difficulty is (and always was) the transaction-specific nature of medical advice. Providers can do too much or too little (or both), and the extent of either depends on the specific patient and the specific disease. We document specific ways in which it is difficult for both consumers and governments to monitor every transaction to detect potentially errant behavior.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{Das2012,

title = {In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps},

author = {Jishnu Das and Alaka Holla and Veena Das and Manoj Mohanan and Diana Tabak and Brian Chan},

url = {http://content.healthaffairs.org/content/31/12/2774.full.pdf+html, Full article},

year  = {2012},

date = {2012-12-01},

journal = {Health Affairs},

volume = {31},

number = {12},

pages = {2774--2784},

publisher = {Health Affairs},

abstract = {This article reports on the quality of care delivered by private and public providers of primary health care services in rural and urban India. To measure quality, the study used standardized patients recruited from the local community and trained to present consistent cases of illness to providers. We found low overall levels of medical training among health care providers; in rural Madhya Pradesh, for example, 67 percent of health care providers who were sampled reported no medical qualifications at all. What’s more, we found only small differences between trained and untrained doctors in such areas as adherence to clinical checklists. Correct diagnoses were rare, incorrect treatments were widely prescribed, and adherence to clinical checklists was higher in private than in public clinics. Our results suggest an urgent need to measure the quality of health care services systematically and to improve the quality of medical education and continuing education programs, among other policy changes.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}