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Quality of Medical Care in Public and Private Sectors

The development strategy over the past twenty-five years has been to increase the availability of care. Although availability remains a concern in some areas, recent evidence suggests that use of health care is high, even in countries with low per capita incomes and even among the poor.
Not surprisingly, the urgency with which countries increased the availability of health resources led to a proliferation of medical care providers with very different levels of expertise. This implies that the quality, rather than the quantity, of medical care should now form an important focus of health policy in low-income countries. However, questions relating to practice quality remain unanswered in the literature, because the quality of health care in low-income countries is difficult to measure. Traditional measures of quality have focused on "structural" quality, such as the availability of electricity, the physical condition of the clinic, or the stock of medicines. These measures tell us little about the actual quality of the medical advice patients receive when they visit a doctor.

This collection of work address this gap by examining variations in process quality across a wide range of geographical and economic settings. Six studies focus on five countries at very different stages of development spread across three continents (India and Indonesia in Asia; Tanzania in sub-Saharan Africa; and Mexico and Paraguay in Latin America). Per capita gross national income (GNI) in the poorest country studied (Tanzania), at $660 (purchasing power parity, or PPP, in 2004 international dollars), is 7 percent of that in the richest (Mexico, $8,980 in 2003).

Health care delivery is organized in very different ways, with widespread reliance on the private sector in India, semiprivate facilities operated through social security contributions in Paraguay and Mexico, and the nongovernmental organization (NGO) sector in Tanzania.

Researchers: Jishnu Das and Jeffrey Hammer (World Bank), Paul Gertler and Sarah Barber (University of California, Berkeley), and Kenneth Leonard (University of Maryland)
Contact: Jishnu Das ( )

Pilot Study in India


India has one of the largest private health sectors in the world. Public health policy discussions have mentioned the possibility of collaboration with the private sector, but little is known about how it works. This study examines both on the supply and demand of health care services.

The supply side research addresses the determinants of the quality and pricing of clinical advice, working hours, referral and marketing decisions of the providers, as well as the relationship between clinical quality measured as what doctors “know” and what doctors “do”. The difference between these two and how this wedge responds to incentives in the medical care market are important questions for policy. To evaluate what doctors "know" a series of vignettes were administered. These vignettes included a fixed set of cases presented to every provider in the sample to determine how they would evaluate the presented symptoms in terms of history, examination, and treatment.

The demand side research looks at the structure of reporting, the role that information plays in the use of health care resources, and differences between the rich and the poor in illness and health-seeking behavior. While part of this ongoing project is rooted in economic theory and methodology, researchers at the anthropology department in Johns Hopkins University are undertaking a parallel investigation using parts of the same data. To evaluate what doctors do, we observed doctor-patient interactions for the same sample of providers and collected data on 4,000 such interactions. Apart from basic information, such as the time spent and the fees charged, additional data on specific questions was also collected to match the doctors' performance directly with the vignettes.

Questionnaires (India)

These documents offer guidance about the types of questions that may be most useful to your particular situation. However, it is likely that the instruments will have to be adapted in light of the issues that require attention, and the institutional context in which the survey is to be implemented.

Provider Quality Vignettes
module| interviewer's manual 

Participant Observation       
module  | surveyor's manual 

Multi-Country Studies

Five country studies---Indonesia, Tanzania, India, Paraguay, and Mexico---document the quality of medical advice and variation in practice quality across a number of dimensions. The studies use several different measures, which are contextualized as to how they relate to each other. A three-way decomposition is used to analyze variations in the quality of care. These variations can arise from inequalities in access, inequalities in choices, or inequalities arising from discrimination.  

This series of articles discuss common elements across the studies and policy implications for future research and advocacy and were published in Web Exclusive Issue of Health Affairs 26, no. 3 (2007). These papers are freely accessible until April 10, 2007 (abstracts after that), but they will continue to be free acess after that for those in India, Indonesia and Tanzania, but not in Mexico and Paraguay.


A list of publications (by year) for this unit is available here.

Web Features

Research Digest

Policy Research Working Papers on Quality of Health Care
(Please use the free Adobe Acrobat Reader to view PDF PDF files)
The following policy research working papers are drawn from the World Bank's institutional archives. Each link opens a page with an abstract of the document and several download options.

Update: February 1, 2007


WPS3669Money for nothing : the dire straits of medical practice in Delhi, IndiaDas, Jishnu; Hammer, Jeffrey2005/07
WPS3301Which doctor? Combining vignettes and item response to measure doctor qualityDas, Jishnu; Hammer, Jeffrey2004/05
WPS3228Strained mercy : The quality of medical care in DelhiDas, Jishnu; Hammer, Jeffrey2004/03
WPS2971Short but not sweet - new evidence on short duration morbidities from IndiaDas, Jishnu; Sanchez-Paramo, Carolina2003/02

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