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MAQARI

In the last 5 years, the Government of India (GOI) has embarked upon a series of ambitious initiatives to improve the delivery of health care services, including the flagship National Rural Health Mission (NRHM). Unfortunately, little is known about access to medical services and especially about the actual quality of medical advice that households receive when they visit providers in rural India. Current literature is based almost entirely on the public health care system, while more than 80 percent of household visits are to medical providers in the private sector.

The Medical Advice Quality and Availability in Rural India (MAQARI) component of the Health and Education in India project is a multi-year study that seeks to close this information gap and better inform policy by measuring the quality of medical care and piloting interventions that could potentially improve the delivery of care. First, we mapped all medical providers who practice within a representative sample of 1520 villages across the 19 most populous states in India. This provides basic information on the total number of public and private medical providers practicing in a typical village, which until now was unknown. In Madhya Pradesh, we conducted a more in-depth mapping of all providers who are available to households in 100 villages across 5 districts (this includes all providers who practice within the village and in nearby villages or small towns). The availability component of the MAQARI project provides updates on previous work1 that measured the absence rates of providers in government clinics in rural India, which highlighted high levels of absenteeism with high inter-state variation. The quality component of the MAQARI project uses medical vignettes to assess provider knowledge in 19 states in India and uses a combination of medical vignettes, standardized simulated patients, provider observations, and patient exit interviews to assess both provider knowledge and effort in Madhya Pradesh.

There are two components within the MAQARI project:

MAQARI 1:  Between 2009 and 2010, detailed surveys were conducted in 1,520 villages across the 19 most populous states in India that measure the number of medical providers and the quality of medical advice available to an average Indian household in rural India. The key objectives are as follows:

To map the entire set of public and private medical providers practicing in sampled villages, in order to determine access to medical services for an average household in a rural area.

To provide first estimates of the quality of care measured through medical vignettes on Tuberculosis, Pre-Eclampsia, Diarrhea, and Dysentery.

To provide revised 2009-10 measures for absence rates in government clinics (Sub-centers, Primary Health Centers, and Community Health Centers). These are updates of the previous 2003 estimates and are key to understanding whether NRHM is making a difference.

MAQARI 2:  To better understand health care markets in rural areas, a detailed set of studies were conducted in Delhi and rural Madhya Pradesh. The key objectives are as follows:

The study in Delhi expands upon previous work2 on quality of care that showed low competence among both public and private providers and highlighted gaps between providers’ knowledge (i.e. what they know) and effort (i.e. what they do).

In Madhya Pradesh, 5 districts were chosen to provide the first estimates on the availability of care by different types of medical providers in a health market. This is different from the all-India work (MAQARI 1) since the health market of a village is arguably larger than the village itself and includes medical providers practicing in nearby villages or small towns. In the sampled 100 villages across these 5 districts in MP, all providers located in any cluster where term paper examples villagers go to seek care were covered.

For these 5 districts, the quality of care measured using medical vignettes and direct provider observation will also be provided, in order to estimate both provider knowledge and effort.

In 3 of these districts, standardized simulated patients (SSP) were introduced as a new measure of provider effort. Surveyors were extensively trained by a team of international experts to pose as patients and present Unstable Angina, Asthma, and proxy Dysentery cases.

In each of the 100 villages, a full household census asking members about their preferences for medical providers in the health market was conducted. Thus, demand for a particular provider can be correlated with at least 3 different metrics of provider quality.

1 "Missing in Action: Teacher and Health Worker Absence in Developing Countries" (with Nazmul Chaudhury, Jeffrey Hammer, Michael Kremer, Halsey Rogers), Journal of Economic Perspectives, Winter 2006, pp 91-116

2 Das, Jishnu & Hammer, Jeffrey, 2007 Money for nothing: The dire straits of medical practice in Delhi, India, Journal of Development Economics, Elsevier, vol. 83(1), pages 1-36, May