Mid-level providers online forum

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1 Mid-level providers online forum Digest of day 5 (quality of care with mid-level providers) Responses by Francis Kamwendo First of all I want to thank the respondents who have so far responded to day 5 discussions on quality of care by mid-level health providers. These discussions bring out all the important issues of quality in health care. 1. Should MLPs quality of health care be measured on their merit using the above criteria for quality in health care, or should their performance be compared to doctors (Medical Officers/Specialists)? Respondents have differing views. Contributor from Malaysia feels that MLPs quality of care should be measured on their own merit using the standard criteria proposed (responsive, causing no harm, evidence-based and appropriate, timely, without unnecessary tests and procedures, and non-discriminatory) because MLPs have their given scope of work different from that of Doctors or Specialists. The contributor emphasises the fact that clients in Malaysia are satisfied with the services provided by Assistant Medical Officers. Contribution from Angola, takes the view that quality of care by MLPs should be the same as that for Physicians and therefore can be compared in spite of different scope of training and practice. The contributor quotes the example of surgical technicians in Mozambique whose quality of care is as good as that provided by Physicians. The contributor from Portugal, links the access to care and quality debates through a health economics perspective. In this context Physicians and Specialists who serve urban population do have the largest share of the health budget and would therefore provide better health care quality than MLPs who serve the rural population due to less resources. The fourth contributor, South Africa brings in structure and outcome as measures of quality. As such MLPs and Physicians will be measured by similar standards. 2. Are there studies done or ongoing in your country measuring the quality of care by MLPs in the process of task shifting? Contributors from Malaysia, Angola and Portugal did not know of any such studies. The South African contributor pointed to a completed and ongoing study in Malawi on Midlevel providers in emergency obstetric and newborn health care, factors affecting their performance and retention within the Malawian Health System. My summary All agree that providers of health care should be supervised and monitored to make sure they provide the right type of care timely and equally to everybody. If quality of care is measured by the standards listed above, it would not matter whether the provider is MLP

2 or Physician. The comparison of quality of care between MLPs and Physicians/Specialists, becomes necessary only in the context of shifting tasks from Physicians to MLPs. As for research done or ongoing, it is good to know what Malawi has and is planning to do. However, there is urgent need to measure quality using outcomes of morbidity and mortality. I, therefore, encourage countries and institutions to embark on quality of care research for MLPs.

3 Summary of postings by participants. Sarasivathy Eddiah (Malaysia) suggests that quality of care provided by MLP should be assessed solely on the basis of the standard criteria proposed (responsive, causing no harm, evidence-based and appropriate, timely, without unnecessary tests and procedures, and non-discriminatory) and not be compared to the performance of doctors. Given that MLP's scope of practice is more limited than doctors', a comparison between these different type of cadres is not feasible. Eddiah reports that there have been no studies conducted on MLP in Malaysia, but there is anecdotal evidence of MLP assuming leadership positions in health services management, and widespread general public satisfaction with the services provided by Assistant Medical Officers. Alfonso Tavares (Angola) offers a different perspective: he acknowledges that the scope of practice of MLP is more limited than doctors', but within the range of services that fall within their training curricula and scope of practice, there should be no difference in quality of care between MLP and physicians. If quality differences were accepted, this might create political tensions and ethical dilemmas, and the general public might shun services provided by MLP. The positive experience of surgical technicians in Mozambique, who provide care of quality standards comparable to doctors', offers an interesting example for countries with a similar health system context, like Angola. Giuliano Russo (Research fellow in health economics and policy; Instituto de Higiene e Medicina Tropical, Lisbon, Portugal) links the access to care and quality debates through a health economics perspective. Russo cautions against the establishment of two-tier health care systems, with services in urban areas provided by physicians, and lower quality care provided by MLP in rural and disadvantaged areas. Beyond the equity and quality concerns, such a system would be prone to skewed allocation of financial resources, as the urban-based medical elite would be likely to capture a larger proportion of public funds, entrenching inequality. Marco Gomes (Center for Health Policy and Innovation, South Africa) suggests that MLP performance should be evaluated according to a framework that comprises three criteria: 1) structure (e.g. health system infrastructure and inputs, such as facilities, supplies, levels of funding and staffing); 2) processes (e.g. the interaction between caregivers and patients); 3) health outcomes (health status, patient satisfaction, etc.) Gomes suggests that quality of care can be improved best by focusing evaluation on processes. He also reports that a study is being conducted in Malawi looking at quality of care, performance and retention of MLP in providing obstetric and newborn care.

4 Full text of contributions received on day 5 (quality of care with MLP). 1. Should MLPs quality of health care be measured on their merit using the above criteria for quality in health care, or should their performance be compared to doctors (Medical Officers/Specialists)? MLP's quality of health care should be based on merit and the criteria below for quality in health care and not be compared with doctors. Fit the needs of the client Not cause harm to the client Be right for the client (give correct diagnosis and treatment, i.e. evidence based) Be given without unnecessary delays Include only the necessary medical tests and procedures for the specific diagnosis and treatment Be fair and not affected by gender, religion, language, age or income Both the scope of responsibilities and scope of work is varied and different. In Malaysia, MLP's like Assistant Medical Officers are trained to treat patients with minor illness and refer the other patients to the doctor. There is no way we can compare them to the doctors. If they can meet the above criteria, then they have achieved their objectives. 2. Are there studies done or ongoing in your country measuring the quality of care by MLPs in the process of task shifting? There has been no study being done, but the roles of the MPL's has been diversified and we have had MLP's (Assistant Medical Officers and Nurses) been promoted to be directors of hospitals replacing the doctors. The quality of care is always evaluated based on the numbers of complains received. The One Malaysia Clinics run solely by the Assistant Medical Officer all over Malaysia has received tremendous response by the public. Sarasivathy Eddiah, Malaysia. 2 Dear All, We would like to bring in an economic perspective to the debate on utilisation of mid-level workers in low-income countries. In the specific, we would like to question whether having a mid-level cadre performing functions customarily typical of medical doctor could lead to the creation of a two-tier health system, with all the rural services offered through mid-level cadres (técnicos de medicina e de cirurgia), and

5 all the urban and hospital services offered by physicians. This not only would have a perverse effect on the quality and equity of the system, but also on its financing, as city-based physicians notoriously have a larger influence on state budget as well as ability to capture health funds. Looking forward to hear your experiences on this. Giuliano (on the behalf of the Health Research Unit of the Lisbon Institute of Hygiene and tropical Health) -- Giuliano Russo, DrPH Research fellow in health economics and policy Instituto de Higiene e Medicina Tropical Rua da Junqueira 100, Lisboa (PT) Tel (ext.359) 3 after some interesting exchanges from colleagues on access issues, I would like to move to today's topic, quality of care with MLP. 1. Should MLPs quality of health care be measured on their merit using the above criteria for quality in health care, or should their performance be compared to doctors (Medical Officers/Specialists)? I think evaluating care provided by MLP should be indeed done in relation to the quality of services rendered by doctors. Patients expect quality services from the person in the white coat who is visiting them, regardless whether he or she is a specialist, a basic doctor, a clinical officer or whatever else. So setting a lower bar for MLP in my view would reinforce the perceptions of two-tier systems and poorer quality of care with MLP. I think what should be the difference is the range of services provided, so obviously doctors should be trained to do more procedures (and obviously more difficult and technically challenging procedures) than MLP. But within the group of services that MLP are trained for and take responsibility for, there should be no differences in quality, otherwise people will rightly avoid MLP-provided services and go to doctors whenever they can.

6 I know that in some cases the alternative is no services at all, but it would be politically impossible - and maybe unethical - to plan for lower quality services provided by lower quality cadres. Also, evidence from Mozambique shows that surgical technicians perform as well as doctors in doing Cesarean sections. So if similar quality of care can be achieved for major surgery by countries, why should we settle for less in other clinical and surgical areas? In many respects Angola and Mozambique share a similar heritage and health system, including language, the effects of civil war, etc. so maybe this is an area where we should learn more from them. 2. Are there studies done or ongoing in your country measuring the quality of care by MLPs in the process of task shifting? Not to my knowledge, but I don't work in research so I am not sure. Dr Alfonso Tavares Angola 4 Dear Colleagues, Really pleased that I m taking part in this insightful discussion. It is allowing me to receive an in-depth scope on country perspective in mid-level provider. The centre for Health Policy and Innovation is currently reviewing its existing work plan on health policy, health care workers and maternal health, coupled with mid-level provider research, which this discussion is providing us with a grasp of critical issues which we will explore further and further research on country quality of care. Apologies for going on, but here are my responses to the 5 th day of the discussion on mid-level providers. 1. Should MLPs quality of health care be measured on their merit using the above criteria for quality in health care, or should their performance be compared to doctors (Medical Officers/Specialists)? MLP quality of care should be measured and comprise of three elements: Structure refers to stable, material characteristics (infrastructure, tools, technology) and the resources of the organizations that provide care and the financing of care (levels of funding, staffing, payment schemes, incentives). Process is the interaction between caregivers and patients during which structural inputs from the health care system are transformed into health outcomes. Outcomes can be measured in terms of health status, deaths, or disability-adjusted life years a measure that encompasses the morbidity and mortality of patients or groups of patients. Outcomes also include patient satisfaction or patient responsiveness to the health care system (WHO 2000).

7 Structural measures are the easiest to obtain and most commonly used in studies of quality in developing countries. Many evaluations have revealed shortages in medical staff, medications and other important supplies, and facilities, but material measures of structure, perhaps surprisingly, are not causally related to better health outcomes. Although higher technology or a more pleasant environment may be conducive to better-quality care, the evidence indicates only a weak link between such structural elements and better health outcome. The notable exceptions are cases in which physical improvements either increase access to primary care in very poor settings or increase the volume of a clinical procedure, such as cataract surgery, that is specifically linked to better health outcomes. At best, however, structure is a blunt approximation of process or outcomes; structural improvements by themselves rarely improve the health of a population. Despite the urgency of improving health in developing countries, quality of care has been largely ignored. Both providers and patients agree this must change, but how can this goal be reached? From the information marshaled for this chapter, we can draw five conclusions: Better quality leads to better health outcomes in developing countries. Process, the proximate determinant of health outcomes, can be measured in valid and reliable ways, such as clinical vignettes and electronic medical records. Measured in the above ways, the process of care in developing countries is poor. The process of care can be improved in the short term. Policies affecting structural conditions, including the actual process of care or the continual design and redesign of the health care system, have been shown to be effective in developing countries. 2. Are there studies done or ongoing in your country measuring the quality of care by MLPs in the process of task shifting? Best wishes, Yes, there are complete and ongoing studies in South Africa and various other countries in which the Centre is providing technical, analytical research measuring the quality of care b y MLP in the process of task shifting. One such study which is ending, is looking into Mid-level providers in emergency obstetric and newborn health care, factors affecting their performance and retention within the Malawian Health System. Marco Gomes --- Marco Gomes, PhD. Health and HIV Policy Adviser Center for Health Policy and Innovation Essential Drugs and Medicines Policy and Research Cluster Health Policy, Systems Research and Development African Branch 23 Wellington Road Parktown, Johannesburg 1120, South Africa