Clinical Trial: Improving the Quality of Private Sector Health Care in West Bengal

Study Status: Completed
Recruit Status: Completed
Study Type: Interventional

Official Title: Improving the Quality of Private Sector Health Care in West Bengal

Brief Summary:

The rural healthcare market in much of the developing world is composed largely of informal private providers. These private providers often have little to no certifiable medical training. Recent studies in India using medical vignettes (or hypothetical medical situations) to measure clinical competence and direct observations of doctor-patient interactions to measure clinical practice highlight the poor quality of care that most patients receive—a problem that is clearly relevant beyond India and affects most low-income countries worldwide. For instance:

1. In rural India, standardized patients presenting with chest pain and (on further questioning) radiating pain in the arm are (correctly) diagnosed with a heart attack in less than 25 percent of cases.
2. Across 8 low and middle-income countries, health care providers completed the four necessary vital statistics for new patients in less than 4 percent of interactions: health care providers in the public sectors of many developing countries routinely spend less than 1 minute per patient.

To address these deplorably low standards in both medical knowledge and practice, the Liver Foundation in Kolkata has been working with private rural health care providers through capacity building activities to improve quality in the private sector. The program consists of multiple-week training to private rural health care providers on the basis of a well-developed curriculum in the district of Birbhum, West Bengal.

This study aims to assess the impact of this training program using a randomized evaluation, in which providers are randomly assigned to the treatment, i.e. the Liver Foundation's training program, or the control, i.e. no such training. As an independe

Detailed Summary:

The evaluation of the Liver Foundation training program for rural health care providers consists of four phases. In the first phase, the Liver Foundation will comb blocks in Birbhum district and invite 300-400 rural health care providers to participate in the program. In the second phase, all recruited providers will convene at a center in Birbhum where we, the evaluation team JPAL, will conduct a baseline study. We will then randomly allocate participating providers into two groups: the Treatment group, which will receive the Liver Foundation training within the next twelve months, and the Control group, which will not. In the third phase, the program inductees will be trained according to the curriculum put forth by the Liver Foundation. Finally, in the fourth phase, we will run an extensive endline survey to evaluate how training has affected the (1) clinical practice, (2) clinical competence, and (3) prices charged and caseload of the providers who have received the training relative to their non-trained counterparts. We detail each phase in turn.

Phase I: Provider Census in Birbhum District The Liver Foundation will identify between 300 to 400 representative private rural health care providers within the Birbhum district who are interested in the training program provided by the Liver Foundation and willing to participate in the necessary randomized selection process. All providers will be told that if they attend the baseline study, they will receive the medical training; however, how soon they will receive it will be determined through a lottery.

Phase II: Baseline Study and Randomization of Providers into Training Intervention

Bringing the providers in batches to a center established for this purpose in Birbhum, the evaluation team will run a baseline study on all 3
Sponsor: Abdul Latif Jameel Poverty Action Lab

Current Primary Outcome: Clinical Practice [ Time Frame: Endline (3-4 months after completion of intervention) ]

Original Primary Outcome: Clinical Competence [ Time Frame: Endline (one day per provider) ]

Current Secondary Outcome:

• Clinical Competence [ Time Frame: Endline (3-4 months after completion of intervention) ]
  Clinical competence will be assessed through the use of medical vignettes, which have been developed and used in a number of countries. In these medical vignettes, providers are presented with a series of symptoms related to a particular disease or medical condition and are evaluated on their ability to diagnose correctly and make the proper recommendations. The impact of the program in terms of clinical competence will be computed using a difference-in-difference estimator, which is the gain in the treatment group minus the gain in the control group in the completion of checklist items and diagnosis rates for the cases considered.
• Clinical prices and caseload [ Time Frame: Endline (3-4 months after completion of intervention) ]
  Clinical prices, or the consultation fees charged to patients, and caseload, or the number of patients a health practitioner sees per day, will be assessed using both direct observation and the standardized patients. In both cases, prices will be noted and recorded to assess the impact of the treatment.

Original Secondary Outcome:

• Clinical Practice [ Time Frame: 2 days at Endline ]
  Clinical Practice will be assessed in two ways. First, the evaluating team will sit in the providers' clinics after the completion of the intervention, observing provider-patient interactions for a full day. Information will be obtained for each provider-patient interaction on (a) consultation length, (b) history taking, (c) examinations performed, (d) information given to the patient, (e) medicines dispensed/prescribed and (f) prices charged. Second, it will be assessed using Standardized Patients, or trained professionals who present with a pre-developed set of symptoms to a provider.
• Clinical prices and caseload [ Time Frame: Endline (two days per provider) ]
  Clinical prices, or the consultation fees charged to patients, and caseload, or the number of patients a health practitioner sees per day, will be assessed using both direct observation and the standardized patients. In both cases, prices will be noted and recorded to assess the impact of the treatment.

Dates:
Date Received: January 24, 2014
Date Started: October 2012
Date Completion:
Last Updated: June 25, 2015
Last Verified: June 2015