Incentives for Accurate Diagnosis: Improving Health Care Quality in Mali

Finding ways to deliver high-quality health care to low-income populations in developing countries is a critical policy challenge. Our initial ESRC-funded project found that reducing user fees (by providing primary health care for free) does substantially increase Malian households' use of this care. However, we also find evidence that much of this care may be unnecessary or mis-targeted: our data suggest that children seeking care in government-run community clinics (CSCOMs) are frequently prescribed antimalarials and antibiotics when they do not need the treatment. This is particularly striking for malaria, since the Malian government has mandated that malaria diagnoses be confirmed by diagnostic testing. Our findings are consistent with a large body of economic literature, which on the one hand provides theoretical underpinnings for the problem of over-prescription and over-treatment, and on the other documents low levels of doctor effort and quality of care in both the public and private sectors across the developing world. Our implementing partner, Mali Health, has indicated that the increase in program costs due to over-prescription and the need for close monitoring and quality checks are a key barrier to scaling up the free-care intervention.

We propose to conduct a follow-on project to identify the leading causes behind over-treatment, and test whether alternative incentive regimes can improve care outcomes without producing unnecessary costs. Our analytical framework is motivated by economic models of an "informed expert" selling "a credence good": the doctor has knowledge about the patient's illness and need for treatment that is not verifiable, and the patient must buy the treatment without knowing if it is truly what he or she needs. The model clarifies how doctor incentives, patient incentives, observability of diagnostic test results, and beliefs about test accuracy interact to produce care outcomes in this context.

This analysis informs the design of a randomized controlled trial (RCT), which we will use to empirically test the model (as well as alternative theories for over-treatment) and identify promising strategies for improving care outcomes in the Malian public sector. Our primary application will be malaria, since high-quality, low-cost rapid diagnostic tests for the disease are readily available. However, given the striking rates of antibiotic use in our data, we also propose to use part of the new grant to conduct additional scoping work and expand the project to include bacterial illness if possible.

The RCT will be conducted at 48 CSCOMs in the Bamako area and will allow us to evaluate the relative importance of test verifiability, provider beliefs about diagnostic test accuracy, and patient education about testing; provider incentives to diagnose and adhere to test results; and patient incentives to follow doctor advice and purchase medications. Over the course of the RCT we will construct a unique dataset that captures detailed information about patient demographic characteristics, symptoms, and treatment outcomes (tests and prescriptions given, medications purchased). We will also conduct home-based follow-up surveys to obtain information about patients' true malaria status, compliance with treatment, and provider satisfaction. This will allow us to estimate how alternative incentive and information regimes impact over-treatment and care outcomes in the public sector.

We propose to forge a close collaboration with Malian health officials, to ensure that our project has maximal policy impact. Aside from its immediate relevance for the Malian public health system, this project will be of broad interest to researchers and policymakers working in the fields of economic development and public health.

Ensuring cost-efficient, high quality health care in developing countries has been a worldwide policy goal since the establishment of the United Nations Millennium Development Goals in 2000.Yet greater access to powerful drugs in regions with low regulatory oversight has contributed to overuse of these drugs and the resulting growth of new resistant strains of parasites and bacteria.

Our research project speaks to a need for policy approaches that can tackle the over-treatment problem in developing country contexts, which cannot rely on large-scale centralized monitoring efforts. By providing information on the causes over-treatment and under-diagnosis, our results will contribute directly to the design of such policies.

Our research will have an impact for four groups of beneficiaries. First, we expect the project to make significant contributions in the academic fields of public health, development economics, and demography. Second, we expect that our research will help local and national governmental bodies to design and implement effective public sector healthcare policies to address over-treatment problems. The citizens of these countries will also benefit through better quality, lower cost healthcare. Third, policy organizations working to promote better access to health care in the developing world will benefit from our work, especially those that work on malaria prevention, like the President's Malaria Initiative. By helping to improve the efficiency of the programs run by these organizations, our research will increase their capacity to provide aid, benefiting those covered by the resulting expansion. Fourth, the clients of the community health clinics we are planning on working with will benefit from higher quality care, better use of diagnostics for the prescription of antimalarials and antibiotics, and lower healthcare costs as a result.

Our primary strategy for maximizing impact will be to disseminate our results to policymakers and health providers in an accessible, informative way. Mali Health will use the results of our study to optimize their programs and adjust their current work on health system strengthening in collaborating CSCOMs. Mali Health also plays a key role in our strategy to influence national and regional policymakers. The organization has an established set of contacts at institutions involved in providing health care throughout Mali. At an international level, Mali Health is part of several networks of aid organizations such as Partners in Health which can be used to disseminate results.

A second pillar in our strategy for dissemination of results to policymakers is Dr. Seydou Doumbia, a senior investigator on the project. Dr. Doumbia is Professor and Dean of the Faculty of Medicine at the University of Bamako, and has been involved in several community-based research projects designed to improve the health system in Mali. His department provides support to the Ministry of Health and tests feasibility of scaling up new health intervention strategies, providing a direct channel to policymakers within Mali.

Our third dissemination channel is IPA and its sister organization, the Abdul Latif Jameel Poverty Action Lab (JPAL). Both organizations have the shared mission to promote the use of rigorous impact evaluations in policy-making. They publicize the design and results of all their projects on their website and regularly host large regional conferences and local dissemination workshops. IPA and JPAL work actively at the global level to promote the scale-up of successful interventions and to disseminate information to policy makers.

Finally, the PIs of this study plan on disseminating their research results through academic conferences and peer-reviewed publications, which in turn will influence policy. We also intend to disseminate our work in a format that is more directly accessible and relevant to policy makers, for example by presenting our work in policy forums.