April Harding World Bank and International Finance Corporation Bali Hyatt Hotel, Sanur, Bali June 2010

2 Kimia Farma Pharmacy, Manado These women are our allies!!

3 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

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 ?

Source: Rehydration Project Can reduce use of anti- diarrheal medicine Increase early use of ORS… REDUCE DEATH

7 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

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

Remember!....private sector is responsive to patients Responsiveness: Private Sector Outperforms Public Sector Andhra Pradesh (2000)

10 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

11 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.

12 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)

13 Social 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)

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

15 Changing care preferences Changing care-seeking choices

16 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.

17 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)

18 It 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

19 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

20 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.

21 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!

22 Cambodian pharmacy accreditation program used this!

23 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.

24 Health care facilities accreditation This 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.

25 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

26 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).

27 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.

28 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?

29 Questions? Comments?