In Urban And Rural India , A Standardized Patient Study Showed Low Levels Of Chan

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. T o improve the quality of health care in resource-poor settings, such as India, national governments, donors, and aid agencies have focused on investments in infrastructure and medical equipment, combined with expansions in the public provision of primary care services and the number of qualified health personnel. These investments have been motivated by an implicit assumption that a scarcity of qualified health providers and a lack of physical infrastructure are the primary drivers of lowquality care in resource-poor settings. Missing from this debate is systematic evidence on the quality of care that patients actually receive when they enter a clinic. There is scant evidence linking improvements in structural aspects of quality, such as the availability of basic medical equipment and medicines, to better diagnoses and treatments for patients. Some recent studies suggest that measures of structural quality are poor proxies for the quality of care. There is also little information on the largest sector providing primary care in resource-poor settings—private providers—and no information on private providers without medical qualifications, who often provide the bulk of primary care in the rural areas of many low-income countries. To address the gap in evidence, this article reports the first estimates of the quality of primary care services in a low-income country, as measured by 926 clinical interactions between 305 medical care providers in rural and urban India and 22 unannounced standardized patients. Thesepatientswerepeople recruited from the local communitywhowere trained to present a consistent case of illness tomultiplehealth care providers. The use of standardized patients presents a number of advantages described below, relative to other methods of assessing quality, such as direct clinical observations, inspection of medical records where they exist, and patient exit doi: 10.1377/hlthaff.2011.1356