Regulating Private Practice

1
Regulating Private Practice

• The (In)Visible Hand of Government in the Medical
  Marketplace

2
How Bad Is Private Practice in Developing
Countries?

• Results depend on definition of the private
  sector
• A spectrum of public and private
• Moonlighting Government providers
• Fully qualified and fully private
• Any provider of medical services
• Prescribing and dispensing?

3
Is Quality Worse in the Private Sector?

• Few direct comparisons
• Vietnam1
• Public sector care higher quality
• But moonlighting Government providers were close
• Private scores pulled down by unqualified
  providers
• China2
• All subjects had limited training
• Spectrum of subsidy
• All sell drugs
• No significant differences in quality measures
• Similar subsidy requirements for preventive care

Source 1Tran Tuan et al. Comparative Quality
of Public and Private Health Services in Vietnam
(2005) 2Qingyue Meng et al Comparing the
services and quality of private and public
clinics in rural China (2000)
4
Where Quality in the Private Sector is Worse

• Many private providers lack required
  qualifications
• Dispensing providers have an incentive to
  overprescribe
• Is it any different in developed countries?
• Isolated from new developments
• It is what the patient wants/expects

5
A Bit of History

• Look back a century in US and Europe
• Not far removed from the barber/surgeon
• Typical practice fell far short of standards in
  new scientific medicine
• Force substandard doctors out of practice?
• NO
• Upgrade training requirements
• Let attrition improve average quality
• Approving and improving medical schools
• Flexner Report

6
Government and Quality Distribution

• Cut the tail off the quality curve, if
• Motivated
• Legally empowered
• Well Informed
• Adequate resources
• Not good at shifting the curve to the right

Government Action
Frequency Distribution
Quality ?
7
Making Licensing/Registration More Effective

• Taking consumer complaints seriously
• In India, consumer protection law gets providers
  attention
• Consumer education
• Resources and representation
• Public representatives on licensing boards
• Why they shoot deserters?
• Educating and Regulating
• In Laos, pharmacy practices improved with
  inspection1
• Or, was it the Hawthorne Effect?

Source 1Bo Stenson et al Private pharmacy
practice and regulation a randomized trial in
Lao PDR (2001)
8
Make Licensing/Regulation More Effective

• Prohibit the unqualified from practicing?
• License other categories to increase the supply
  of regulated providers?
• License the drug seller where there is no
  pharmacist
• Educate the consumers
• What to expect of medical care
• Part of health education curriculum
• More drugs not always better
• Injections not better than pills
• How to tell what provider is qualified?
• But who will locate among the poor
• Where there are many qualified providers
• Slums of Karachi
• Latin America

9
Shifting the Quality Distribution

• What works in the developed world1
• Continuing education a necessary, but not
  sufficient, condition
• Some interventions have little effect
• CME alone
• Published guidelines
• What works
• Feedback/academic detailing
• Evidence of impact in Bihar as well2
• Peer leaders as change agents
• Combining provider and patient interventions

Source 1Andrew Oxman et al No magic bullets a
systematic review of 102 trials of interventions
to improve professional practice (1995) 2Sarbani
Chakraborty et al. Improving private
practitioner care of sick children testing new
approaches in rural Bihar (200)
10
Shifting the Quality Curve in the Developing World

• Educating private providers
• Still a necessary condition
• Current investment in training of private
  providers does not reflect usage patterns
• Invite to Government sponsored training
• Tailor to economic realities of private practice
• Not paid to attend workshops
• Work through peer leaders and associations
• Include CME requirements in licensing

11
Accreditation---A New Avenue for Quality
Improvement

• Limit to high impact services
• HAART, Emergency Obstetrics, etc.
• Go beyond inputs to process and outcomes
• Incorporate treatment protocols
• Begin with feedback
• A carrot as well as a stick
• Free or low cost drugs
• Inclusion in referral networks
• A condition of participation in new insurance
  programs
• Public or private?
• Providers and public sector both skeptical of
  private accreditation