1. Measurement and Efforts to Improve Quality Gayle Martin and Zelalem Debebe June 30,2015 1 www.worldbank.org/SDIwww.SDIndicators.org

2. Measurement and Efforts to Improve Quality Gayle Martin and Zelalem Debebe June 30,2015 2 www.worldbank.org/SDIwww.SDIndicators.org Outline Large inter- and intra-country variation in key measures of quality Effectiveness requires simultaneous availability: in the same place at the same time What can be done to improve these measures of quality? Without focused effort, improvements in process quality will lag structural quality

3. Large inter- and intra-country variation in key measures of quality: Diagnostic accuracy Adherence to clinical guidelines Treatment accuracy 3 Malaria with anemia Diarrhea with severe dehydration Pneumonia Diabetes Tuberculosis

4. Large inter- and intra-country variation in key measures of quality: Diagnostic accuracy Adherence to clinical guidelines Treatment accuracy 4

5. Effectiveness requires simultaneous availability: in the same place at the same time 5

6. 6 % facilities with competent providers (46%) % facilities with steth,+sphyg+sterilizing equip (78%) Effectiveness requires simultaneous availability: in the same place at the same time

7. Even when conditions are correctly diagnosed they are not necessarily correctly treated 7

8. 8

9. Simulation results: Respiratory Infection cases correctly diagnosed and treated 15.2%

10. Simulation results: Respiratory Infection cases correctly diagnosed and treated 10 Sources: UNPOP for Population data. SDI for provider competence estimates. DHS for prevalence and utilization data. 21.9%15.2% 16.9%5.2% % of ARI cases correctly diagnosed and treated

11. 11 What can be done to improve these measures of quality? Decompose clinical guidelines and identify the relative effect of the components on the probability of successful diagnosis* Adherence to history taking and physical examination guidelines increases the probability of diagnostic accuracy by 54 % points Estimates are higher for providers with lower medical training (nurses): 36 % points versus 59% points suggesting a higher return to adhering to clinical guidelines among nurses compared to doctors and clinical officers Dep var: Probability of a correct diagnosis All Doctors/ clinical officers Nurses History taking and physical examination 0.540*** (0.153) 0.361*** (0.085) 0.591*** (0.204) Laboratory test 0.466*** (0.063) 0.326*** (0.087) 0.540*** (0.089) Observations 314513901740 R-squared 0.4190.4650.416 Number of providers 629278348 * We estimate a provider fixed effects model that enables to minimize unobserved heterogeneity due to unobserved time-invariant characteristics (such as innate abilities, intrinsic motivation etc.).

12. Without focused effort, improvements in process quality will lag structural quality 12

13. Looking to the future … 13 Providers with weakest skills are located in areas with highest mortality

14. 14 Child Health Results Chain Individual Indicators

15. Service Delivery Indicators