Quality and Accountability in Health: Audit Evidence From Primary Care Providers

Abstract

Private primary care providers routinely account for more than 50 percent of first-contacts in low-income settings, rising to 80 percent in countries like India. The majority of these providers operate in single provider clinics with little regulatory oversight or government subsidies. No patients have health insurance beyond the free care that they can access in the public sector. These key features offer a unique opportunity to evaluate the relative benefits (or lack thereof) of a market model of primary care provision, relative to provision through the public sector. We report results from audit studies, where standardized patients presented to primary care providers in a representative sample of rural public and private providers in the Indian state of Madhya Pradesh. Across all audit studies, public providers spent less time with patients, completed fewer items on a checklist of essential history and examination items, and were either no different or worse in their treatment and diagnostic accuracy. In one dramatic example, public providers in their private practice were 32 percentage points more likely to provide the correct treatment for unstable angina relative to in their public practice. Our results, that customer accountability in an unregulated, unsubsidized and uninsured private market results in better primary care relative to the administrative accountability in the public sector, is further supported by a strong positive correlation between the prices charged to the standardized patients and the quality of care received. These results suggest a trade-off between poor administrative accountability in the public sector and market failures arising from (potentially) misplaced quality judgments on the part of patients in the private sector. However, hedonic pricing in the private market also suggests that financial constraints may prevent the poor from accessing higher quality care. ( with Alaka Holla, Michael Kremer and Karthik Muralidharan ).