Health Policy and Planning Advance Access originally published online on January 23, 2006
Health Policy and Planning 2006 21(2):101-109; doi:10.1093/heapol/czj009
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Original article |
Provider-specific report cards: a tool for health sector accountability in developing countries
Center for Delivery, Organization and Markets, US Agency for Healthcare Research and Quality, Rockville, MD, USA
Correspondence: Peggy McNamara, Senior Policy Analyst, Center for Delivery, Organization and Markets, US Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301/427–1440; Fax: +1 301/427–1430; E-mail: pmcnamar{at}ahrq.gov
In most health care systems in most countries, providers are not adequately held accountable – by governments, purchasers, provider professional associations or civil society – for the quality of care. One approach to improve provider accountability that is being debated and implemented in a subset of developed countries and a smaller group of developing countries is provider-specific comparative performance reporting. This review discusses universal design options for report cards, summarizes the evidence base, presents developing country examples, reviews challenges and outlines implementation steps. The ultimate aim is to provoke thoughtful debate about if and how comparative performance reporting fits within a developing country's broader framework of strategies to promote quality of care.
Key Words: provider report cards, consumer reports, performance reports, provider profiles, comparative quality reports, league tables, provider accountability
1Some of the text in the following three paragraphs is drawn from McNamara (2005b).
2Public reporting of environmental sector performance, being pursued by a number of developing countries and communities, represents an important body of experience relevant to the discussion of health sector report cards. Faced with widespread violation of pollution prohibitions, for example, Sao Paulo in 1991 began public reporting of the violators. As a result of the public reporting and imposition of fines, 95% of the violators installed waste treatment units. Similarly, Indonesia's environmental protection agency began publicly rating industry compliance with environmental standards, which brought about spectacular improvements in pollution abatement. According to advocates of environmental performance reports, exposing the worst performers has proven to be a powerful way of pressuring companies to provide better services. By focusing political attention on service quality, benchmarking can also help to shield regulators from political interference (Kingdom and Jagannathan 2001).
3Donabedian identifies two basic elements of quality performance: technical and interpersonal performance. Technical performance depends on clinical knowledge and judgement used in arriving at an appropriate strategy of care and on the skill in implementing that strategy. Interpersonal performance, the vehicle by which technical care is implemented, depends on the management of processes that relate to privacy, confidentiality, informed choice, concern, empathy, honesty, tact and sensitivity. Information from which inferences can be drawn about quality of care – be it technical quality or interpersonal quality – can be grouped into three categories: structure, process and outcomes. Structure refers to attributes of the setting in which care occurs. For technical quality, this includes attributes of material resources (e.g. facilities, equipment, supplies), of human resources (e.g. number and qualifications of personnel), and of organizational structure (e.g. infection control system, staff payment system). For interpersonal quality, structure indicators include, for example, complaint registries, satisfaction surveys, ombudsman programmes. Process refers to what is being done in giving care. For technical quality, process includes provider activities in making a diagnosis and implementing treatment. For interpersonal quality, process includes, for example, provider practices to involve patients in decision-making about their care. Outcome, for technical quality, refers to the effect of care on the health status of the patient. For interpersonal quality, outcome refers, for example, to patient satisfaction level, bypass patterns, waiting times (Donabedian 1988.).
4Some of the text in the following three paragraphs is drawn from McNamara (2005a).
5McNamara (2003) reports on a review of a small convenience sample of four facility surveys, which suggests they are particularly adept at capturing data on technical structure and interpersonal structure, and a review of a small convenience sample of four household surveys, which suggests they are suited to providing information on a broader range of technical and interpersonal performance.