The Power of Informed Patients: Information Dissemination

to Enhance Private Provision

April HardingWorld Bank and

International Finance Corporation

Bali Hyatt Hotel, Sanur, Bali21-25 June 2010

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An indirect approach

Kimia Farma Pharmacy, Manado

We can effect providers….

…through changing behavior of people

These women are our allies!!

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Educated, informed people can get better results from existing health systems, including private sector

By changing care-seeking behavior

By choosing better the source of care

And by better care at home

These mechanisms work through improving peoples’ knowledge – so they can get better outcomes

Increasing knowledge is a powerful intervention

-30%

-25%

-20%

-15%

-10%

-5%

0%

- 2%Improved water

and sanitation covering 100% of

households

-3%Measures thathalve diarrhea, cough with fast breathing and

feverin every region

of the world

-13%Raising the

"Treatment" propensity in all households to the average level in Egypt

-19%Raising mother's and

father's years of schooling to levels

seen in Egypt

Source: The Power of Parents, Peter Boone, Zhengzhau Zhan, CEP Working paper 2008

Comparing impact of alternative “packages” on child mortality

How knowledge influences outcomes

Should you increase, maintain, or reduce fluids (or don’t know) for a child with

diarrhea ?

0

10

20

30

40

50

60

% a

nsw

erin

g "r

educ

e"

Informing mothers…..about ORS

Source: Rehydration Project

Can reduce use of anti-diarrheal medicine

Increase early use of ORS…

REDUCE DEATH

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There are many means of information dissemination

Posters; booklets; mass media (radio, television); education in schools; outreach/ community workers; mothers’ clubs; street theater

All means can achieve shifts in peoples’ health behaviors

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So what if we change patient behavior?

How can this enhance contribution of private sector to heath goals???

0 10 20 30 40 50

Waiting time

Doctor’s manner

Doctor’s skills

Nurse’s manner

Nurse’s skills

Explanation of care

Overall visit

Percent Satisfied or Very Satisfied

Public Private

Remember!....private sector is responsive to patients

Responsiveness: Private Sector Outperforms Public Sector

Andhra Pradesh (2000)

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Changing patient demand can support improved care quality

Some countries have ingrained preferences for injections. Ex. People in Sindh province may get as many as 14 injections a year; 90% unneeded.

• allergic reactions, abscesses, lesions, hepatitis, HIV/ AIDS and other blood-borne diseases

• patients waste 3bn+ rupees

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Changing patient behavior can support improved care quality – at home, in careseeking, and with provider

Information dissemination activities (in some countries) successfully applied posters, booklets, mass media, education in schools; and mothers’ clubs to circulate information and knowledge that have helped reduce the magnitude of the excess injection problem.

This uses patient preferences to improve quality of care.

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Information dissemination plays a role in other strategies

Information dissemination

posters, booklets, mass media, education in schools; and mothers’ clubs; street theater

Product Social Marketing

Highly strategic activities to get information to people (usually encouraging use of a product) often combined with a supply intervention (example: providing supplies at reduced rates…to encourage uptake of the product (e.g. ORS, condoms, nets)

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Information dissemination plays a role in other strategiesSocial franchising

information to people (encouraging use of franchised quality-assured service provider unit)– COMBINED with a establishing a network of quality service providers from existing providers in the community

Provider training

Often provider training is complemented by information efforts to shift patient preferences to support the new provider behavior (e.g. ORS, malaria drugs, fewer injections)

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Information dissemination plays a role in other strategies

Accreditation

People are educated as to the value of accreditation; their shift towards accredited outlets is what motivates providers to achieve accredited status

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Information dissemination influences providers through two distinct mechanisms

Changing care preferences

Changing care-seeking choices

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Mechanism 1: Changing care preferences

These interventions, when successful, improve the quality of privately provided healthcare services by educating people and shifting them to prefer good quality care practices rather than bad.  

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Mechanism 1: Changing care preferences

 

Assessment of a 10-year effort by BRAC to promote ORS use for diarrhea in Bangladesh found that: 70% of mothers knew how to prepare ORS; 60% used ORS for children’s diarrhea; and drugsellers and village doctors recommended ORS more frequently than before (Mushtaque Chowdhury et al 1997) et al  An intervention to improve shopkeepers’ treatment of malaria in Kenya included a client awareness aid, a poster specifying proper treatment of malaria, in addition to shopkeeper job aids and training (Tavrow et al. 2003) 

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Mechanism 1: Changing care preferencesIt is hard to get private providers to do things their patients don’t like, and are used to having done. And, in contrast, easier to get patients and providers to act in congruent ways.   Information dissemination strategies have successfully been applied to:• reduce unneeded use of antibiotics• increase adherence to full DOTS regime for TB• get patients to use anti-malarials for malaria

vs. antipyretics• to help patients distinguish real vs counterfeit

drugs 

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Getting better drugs delivered by private sector via information dissemination

 

Patient scratches the strip on the drug package; texts the number via mobile phone, and gets instant reply about authenticity of drug

mPedigree is working with Nigerian regulatory authorities

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Information dissemination works better when……

 

Information dissemination more effective when people clearly see the link between what they can do differently and their own benefit

COST of the changed behavior matters too. This will be discussed more in the social marketing session. 

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Mechanism 2: Changing care-seeking choices.

Private providers really like to have customers. They like it a lot.

(Distinguish with typical public providers)

Private providers are sensitive to opportunities to get more customers; and likewise sensitive to things that may make them go elsewhere.

We can use this!

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Customers look for signs of quality. Fancy certificates can attract customers.

Cambodian pharmacy accreditation program used this!

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Healthcare professionals in most countries pursue specialized recognition and certification as a means to attract patients. They know that patients look for such information as a signal of quality.

Linking achievement of better skills and expertise, with an information signal that can attract more patients – is a way of enabling market forces to deliver better outcomes with private provision of health care.

Linking better quality to increased customers is powerful

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Mechanism 2: Changing care-seeking choices

Health care facilities accreditationThis mechanism makes quality information available to people so they can choose better providers (component of accreditation and social franchising)

Providers respond, by trying to improve their scores to attract (or avoid losing) patients.

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Mechanism 2: Changing care-seeking choices

This instrument can work to motivate poor providers to improve quality to avoid losing customers. Hibbard et al, 2003 found that among Wisconsin hospitals whose performance was being reported publicly, poor performers engaged in significantly more quality improvement activities than poorly performing hospitals whose quality data was not being reported publicly

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Inights

Information dissemination is an effective strategy for improving the contribution of private providers to health outcomes..but often overlooked! You can change provider behavior MUCH more easily if patient preferences support the change (so info dissemination is often a complementary strategy for provider training).  

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Insghts

Information dissemination to consumers is a critical component of: accreditation, social marketing and social franchising strategies as well as training strategies to influence behavior of private providers Information dissemination to consumers can both influence patients’ choice of treatment, demand for services and stimulate improvement among providers themselves.

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Inights?

• Public reporting of provider performance has generated quality improvements poor providers

•   Be alert for opportunities to use markets to help achieve your goals. • Can you make it a “market advantage” for

providers to make the quality improvements you desire?

• Can you create a mechanism where providers who deliver quality can distinguish themselves in the market place from others who aren’t so committed to quality?

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Questions?

Comments?