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The Quality of Medical Advice in Low-Income Countries

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  • Jishnu Das
  • Jeffrey Hammer
  • Kenneth Leonard

Abstract

This paper documents the quality of medical advice in low-income countries. Our evidence on health care quality in low-income countries is drawn primarily from studies in four countries: Tanzania, India, Indonesia, and Paraguay. We provide an overview of recent work that uses two broad approaches: medical vignettes (in which medical providers are presented with hypothetical cases and their responses are compared to a checklist of essential procedures) and direct observation of the doctor-patient interaction These two approaches have proved quite informative. For example, doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000-96,000 Tanzanians each year. A public-sector doctor in India asks one (and only one) question in the average interaction: "What's wrong with you?" We present systematic evidence in this paper to show that these isolated facts represent common patterns. We find that the quality of care in low-income countries as measured by what doctors know is very low, and that the problem of low competence is compounded due to low effort -- doctors provide lower standards of care for their patients than they know how to provide. We discuss how the properties and correlates of measures based on vignettes and observation may be used to evaluate policy changes. Finally, we outline the agenda in terms of further research and measurement.

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File URL: http://www.aeaweb.org/articles.php?doi=10.1257/jep.22.2.93
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Bibliographic Info

Article provided by American Economic Association in its journal Journal of Economic Perspectives.

Volume (Year): 22 (2008)
Issue (Month): 2 (Spring)
Pages: 93-114

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Handle: RePEc:aea:jecper:v:22:y:2008:i:2:p:93-114

Note: DOI: 10.1257/jep.22.2.93
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References

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  1. Das, Jishnu & Hammer, Jeffrey, 2005. "Money for nothing : the dire straits of medical practice in Delhi, India," Policy Research Working Paper Series 3669, The World Bank.
  2. Leonard, Kenneth L. & Masatu, Melkiory C., 2005. "The use of direct clinician observation and vignettes for health services quality evaluation in developing countries," Social Science & Medicine, Elsevier, vol. 61(9), pages 1944-1951, November.
  3. Björkman, Martina & Reinikka, Ritva & Svensson, Jakob, 2006. "Local Accountability," Seminar Papers 749, Stockholm University, Institute for International Economic Studies.
  4. Leonard, Kenneth & Masatu, Melkiory C., 2006. "Outpatient process quality evaluation and the Hawthorne Effect," Social Science & Medicine, Elsevier, vol. 63(9), pages 2330-2340, November.
  5. Nazmul Chaudhury & Jeffrey Hammer & Michael Kremer & Karthik Muralidharan & F. Halsey Rogers, 2006. "Missing in Action: Teacher and Health Worker Absence in Developing Countries," Journal of Economic Perspectives, American Economic Association, vol. 20(1), pages 91-116, Winter.
  6. Leonard, Kenneth L., 2008. "Is patient satisfaction sensitive to changes in the quality of care? An exploitation of the Hawthorne effect," Journal of Health Economics, Elsevier, vol. 27(2), pages 444-459, March.
  7. Kenneth L. Leonard & Melkiory C. Masatu & Alexandre Vialou, 2007. "Getting Doctors to Do Their Best: The Roles of Ability and Motivation in Health Care Quality," Journal of Human Resources, University of Wisconsin Press, vol. 42(3).
  8. Leonard, Kenneth L., 2002. "When both states and markets fail: asymmetric information and the role of NGOs in African health care," International Review of Law and Economics, Elsevier, vol. 22(1), pages 61-80, July.
  9. Harriss-White,Barbara, 2003. "India Working," Cambridge Books, Cambridge University Press, number 9780521809795, October.
  10. Harriss-White,Barbara, 2003. "India Working," Cambridge Books, Cambridge University Press, number 9780521007634, October.
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Citations

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Cited by:
  1. Bernal, Noelia & Carpio, Miguel A. & Klein, Tobias J., 2014. "The Effects of Access to Health Insurance for Informally Employed Individuals in Peru," IZA Discussion Papers 8213, Institute for the Study of Labor (IZA).
  2. Karlan, Dean & Morduch, Jonathan, 2010. "Access to Finance," Handbook of Development Economics, Elsevier.
  3. Mæstad, Ottar & Torsvik, Gaute & Aakvik, Arild, 2010. "Overworked? On the relationship between workload and health worker performance," Journal of Health Economics, Elsevier, vol. 29(5), pages 686-698, September.
  4. Mæstad, Ottar & Torsvik, Gaute & Aakvik, Arild, 2009. "Overworked? The relationship between workload and health worker performance in rural Tanzania," Working Papers in Economics 02/09, University of Bergen, Department of Economics.
  5. Beegle, Kathleen & Himelein, Kristen & Ravallion, Martin, 2012. "Frame-of-reference bias in subjective welfare," Journal of Economic Behavior & Organization, Elsevier, vol. 81(2), pages 556-570.
  6. Adhvaryu, Achyuta & Nyshadham, Anant, 2011. "Healthcare Choices, Information and Health Outcomes," Working Papers 88, Yale University, Department of Economics.
  7. Jessica Cohen & Pascaline Dupas & Simone G. Schaner, 2012. "Price Subsidies, Diagnostic Tests, and Targeting of Malaria Treatment: Evidence from a Randomized Controlled Trial," NBER Working Papers 17943, National Bureau of Economic Research, Inc.
  8. Heather Klemick & Kenneth L. Leonard & Melkiory C. Masatu, 2007. "Defining Access to Health Care: Evidence on the Importance of Quality and Distance in Rural Tanzania," American Journal of Agricultural Economics, Agricultural and Applied Economics Association, vol. 91(2), pages 347-358.
  9. Gertler, Paul & Vermeerch, Christel, 2013. "Using Performance Incentives to Improve Medical Care Productivity and Health Outcomes," Institute for Research on Labor and Employment, Working Paper Series qt9qn9q7ph, Institute of Industrial Relations, UC Berkeley.
  10. Jishnu Das, 2011. "The Quality of Medical Care in Low-Income Countries: From Providers to Markets," Working Papers id:3955, eSocialSciences.
  11. Tessa Bold & Jakob Svensson, 2013. "Policies and Institutions for Effective Service Delivery: The Need of a Microeconomic and Micropolitical Approach," Journal of African Economies, Centre for the Study of African Economies (CSAE), vol. 22(suppl_2), pages -ii38, August.
  12. Jeffrey S. Hammer, 2013. "Balancing Market and Government Failure in Service Delivery," Lahore Journal of Economics, Department of Economics, The Lahore School of Economics, vol. 18(Special E), pages 1-19, September.
  13. Fiszbein, Ariel & Ringold, Dena & Rogers, F. Halsey, 2011. "Making services work : indicators, assessments, and benchmarking of the quality and governance of public service delivery in the human development sectors," Policy Research Working Paper Series 5690, The World Bank.
  14. J. Michelle Brock & Andreas Lange & Kenneth L. Leonard, 2012. "Generosity norms and intrinsic motivation in health care provision: evidence from the laboratory and the field," Working Papers 147, European Bank for Reconstruction and Development, Office of the Chief Economist.
  15. Kjell Hausken & Mthuli Ncube, 2013. "Working Paper 172 - Political Economy of Service Delivery: Monitoring versus Contestation," Working Paper Series 468, African Development Bank.
  16. Alejandro Arrieta & Ariadna García Prado & Jorge Guillén, 2009. "The Private Health Care Sector and the Provision of Prenatal Care Services in Latin America," IDB Publications 9335, Inter-American Development Bank.
  17. Grant Miller & Kimberly Singer Babiarz, 2013. "Pay-for-Performance Incentives in Low- and Middle-Income Country Health Programs," NBER Working Papers 18932, National Bureau of Economic Research, Inc.
  18. Gertler, Paul & Vermeersch, Christel, 2012. "Using performance incentives to improve health outcomes," Policy Research Working Paper Series 6100, The World Bank.
  19. Mangham-Jefferies, Lindsay & Hanson, Kara & Mbacham, Wilfred & Onwujekwe, Obinna & Wiseman, Virginia, 2014. "What determines providers' stated preference for the treatment of uncomplicated malaria?," Social Science & Medicine, Elsevier, vol. 104(C), pages 98-106.
  20. Leonard, David K. & Bloom, Gerald & Hanson, Kara & O’Farrell, Juan & Spicer, Neil, 2013. "Institutional Solutions to the Asymmetric Information Problem in Health and Development Services for the Poor," World Development, Elsevier, vol. 48(C), pages 71-87.

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