Improving the Quality of Private Sector Health Care in West Bengal
Condition: Myocardial Infarction; Diarrhea (Dysentery); Asthma
MeSH terms: Dysentery; Myocardial Infarction; Infarction; Diarrhea
Study type: Interventional

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 independent outside evaluation
      team, we will run a baseline survey for all providers (through a third party data collection
      agency), monitor the application of and compliance in the Liver Foundation's training
      intervention, and conduct a final endline study. By comparing the treatment and control
      groups on a variety of measures developed to capture competence in provider knowledge and
      practice, we can rigorously assess whether such a training program for informal rural health
      care providers is an effective means of improving provider medical knowledge and practice in
      the short run. It is worth noting that this study will not be able to capture long run
      effects , such as price or location changes, on health care for the rural poor.
    

Detailed description: 
      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 300 participants over the course of three
      weeks. The baseline study will consist of two parts:

        1. Baseline provider survey: this survey asks basic questions about training, socioeconomic
           background, work practices, etc.

        2. Vignette testing: Teams of trained vignette testers will test each doctor's competence
           through a series of five medical vignettes.

      After having completed the above two steps of the baseline survey, the evaluation team will
      randomly allocate these providers into two groups: the "Treatment" group, which will receive
      the training, and the "Control" group, which will not. Note that those individuals selected
      for the control group will be informed that they will receive training at a later time due to
      limited resources; thus we will phase them in one year later, after the evaluation of the
      first treatment group is complete.

      Phase III: Training Intervention The primary objective of the Liver Foundation's training
      program will be capacity building through theoretical information in health sciences,
      training in proper referral techniques during emergencies, and maternal and child health care
      priorities in rural areas. The training will be in the form of two three-hour classes per
      week and will continue for nine months, with three mid-term exams administered every three
      months as per the Liver Foundation curriculum. During this time, the evaluation team will
      only collect the rosters of the attendees of the training classes and conduct sporadic random
      visits to the sessions to gain a better sense of the training methods and attendance rates.

      Phase IV: Endline survey After the intervention has run its course for at least nine months,
      we will wrap up the evaluation with an extensive endline survey. Unlike the baseline survey,
      which can be completed in the one central location at which the providers meet, the endline
      survey must be done at each providers' own place of work. We expect that the process of
      locating and evaluating each of the 300 providers at his or her place of work will require
      approximately three months.
    

Intervention name(s): Training; Control
Intervention type(s): Other; Other
Intervention description(s): (please see Arm Description); This group will not receive any training from the Liver Foundation; they will simply be evaluated at baseline and endline.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research