India's healthcare quality gap

India's healthcare system, as I had blogged earlier, mirrors education as an example of a massive governance failure. Just as with the poor learning outcomes in education, the quality of health care is seriously compromised, as is borne out by a large and growing body of research.

This graphic from a cross-country comparison of vignettes (providers are given hypothetical cases and responses/questions compared to a checklist of essential nationally accepted set of procedures) and direct observation of the doctor-patient interaction by Jishnu Das, Jeff Hammer, and Ken Gordon is revealing,

They document the time spent, number of exams done, and medicines given across providers based on their effort levels (itself a measure of all the three).

Another study benchmarking quality of care in four countries, based on the percentage of mandatory tasks (as in a checklist) completed by the providers shows,

Shockingly, even the top quintile of Indian doctors (sample of public and private providers in clinics in Delhi), perform worse that their counterparts in Tanzania, Indonesia, and Paraguay on all the four diarrhea procedures as well as on different measures of effort. They write,

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 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. 

They construct a competence index (constructed by applying Item Response Theory to the responses of doctors to various types of patients) of providers based on their responses and finds out,

As an indicator of how poor overall competence is, a doctor in India has to be above mean competence in the sample to have a better than even chance of not harming the patient.

They compare the relative performances of three categories of doctors based on their competence and effort,

First, private doctors without an MBBS complete just over 20 percent of all essential tasks, but they are doing pretty much all they know to do—the constraint on their performance is competence. Second, private doctors with an MBBS knew 40 percent of the essential tasks, but in actual practice were completing only 25 percent of them. The constraint on their performance is effort. Third, the gap between competence and practice among public-sector doctors is even higher—these doctors knew to complete 30 percent of essential tasks, but actually completed only 8 percent. Here, the constraint on performance is clearly effort.

This dynamic is captured by the graphic below,

Just in case, one is tempted to explain away these findings claiming that the patient load in India is massive, the findings remain robust when controlled for patient case loads.