Joint Learning Network for Universal Health Coverage

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Provider Motivation and Quality of Care

A Health Systems Brown Bag

When we think about universal health coverage, we often define it along three axes: breadth – the proportion of people who enjoy coverage, depth – the range of services included, and height – the proportion of costs covered. Though increasing access to a number of services is a critical step forward, there is another dimension to consider – that of the quality. We can’t improve health outcomes if individuals don’t get safe, appropriate care – effective coverage. The question of how to assure quality care is one that every country continues to grapple with, and as part of the JLN, we are thinking critically about the ways payers can drive quality improvements in their systems through mechanisms like accreditation, public reporting, provider payments mechanisms, citizen accountability, and continuous quality improvement. But what if the answer lies in intrinsic motivation of the provider? Can these external interventions make a difference? Or do they need to appeal to intrinsic drivers? This concept of delineating intrinsic and extrinsic motivation is one that is difficult to articulate and even harder to measure. Last week, at a brown bag session held at the Center for Global Development, Ken Leonard and Jishnu Das shared some fascinating observations about what motivates providers to perform well.

Termed the “know-do” gap, Ken described the concept that a provider may know how to do 90% of the appropriate things, but may do the right thing only 40% of the time, leaving a 50% gap between what is known and what is done. In order to determine whether or not this gap could be closed, the speakers conducted lab and field-based experiments that looked at intrinsic provider generosity, and the effect of encouragement by another physician as well as peer observation. The providers that were more generous in the laboratory experiment generally offered better quality care in the field, suggesting that they are perhaps more intrinsically driven to provide higher quality care. Two field-based interventions were tested: (1) peer scrutiny where a peer was invited to observe the provider and (2) peer encouragement where a well-respected physician engaged the provider in a motivational conversation. Providers responded most favorably to peer encouragement and also showed increasing levels of improvement in response to repeated peer scrutiny (traditionally known as the Hawthorne effect). What was interesting to observe were the differences between sectors – public, private, and NGO. Private providers did not respond favorably to either peer scrutiny or peer encouragement and in fact showed less effort when these interventions were introduced. The performance of those in the NGO sector remained the same, while the performance of those in the public sector improved. These findings suggest that there is opportunity to close the “know-do” gap, but the baseline levels of motivation across sectors need to be considered.

Jishnu then challenged some of our existing perceptions of quality and availability of providers by sharing results from the Medical Advice, Quality, and Availability in Rural India (MAQARI) Project (soon to be published, we hope!). Though we often think that geographic access is a key barrier to seeking quality care, Jishnu shared that the number of providers in rural India is on par with other similar countries and in fact, the rural villages with the highest human development index had the fewest number of providers.

How good are these providers though? The vast majority of providers being utilized are untrained (76% of primary care providers, 65% of self-identified physicians). If people are primarily accessing the services of untrained providers, there is a definite need to assess the quality of care they are receiving.

Several video clips that were recorded as part of the MAQARI project revealed varying levels of care being delivered by rural providers. What was fairly astonishing was that in comparing the performance of public and private, trained and untrained providers, the untrained, private providers beat out the public sector providers. The private sector evidently exerted greater effort. What was even more surprising was that the same doctor, who performed the worst in the public sector, performed the best in the private sector.

If the very same provider can perform at such drastically different levels when placed in different sectors, it is clear that there are a number of environmental factors at play and we must focus on this enabling environment in order to improve quality of care. Given the improved performance of that same provider in the private sector, perhaps we need to ask the question of how we can make the public sector look more like the private sector. What other extrinsic factors differ between sectors? If payment is not at the root of the difference, how can we use non-financial incentives such as systematic peer observation or encouragement to motivate providers to close their own quality gap? As the JLN’s quality track continues to identify the most effective interventions that can be used by financing agencies, it should take into consideration the power of intrinsic motivation and identify ways to incorporate it into quality strategies moving forward.

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