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Background Should health systems invest more in access to care by expanding insurance coverage or in health care services including improving the quality of care? Comparing these options experimentally would shed light on the impact and cost-effectiveness of these strategies. Methods The Quality Improvement Demonstration Study (QIDS) was a randomized policy experiment conducted across 30 districts in the Philippines. The study had a control group and two policy intervention groups intended to improve the health of young children. The demand-side intervention in QIDS was universal health insurance coverage (UHC) for children aged 5 years or younger, and a supply-side intervention, a pay-for-performance (P4P) bonus for all providers who met pre-determined quality levels. In this paper, we compare the impacts of these policies from the QIDS experiment on childhood wasting by calculating DALYs averted per US$spent. Results The direct per capita costs to implement UHC and P4P are US$4.08 and US$1.98 higher, respectively, compared to control. DALYs due to wasting were reduced by 334,862 in UHC and 1,073,185 in P4P. When adjustments are made for the efficiency of higher quality, the DALYS averted per US$ spent is similar in the two arms, 1.56 and 1.58 for UHC and P4P, respectively. Since the P4P quality improvements touches all patients seen by qualifying providers (32% in UHC versus 100% in P4P), there is a larger reduction in DALYs. With similar programmatic costs for either intervention, in this study, each US$spent under P4P yielded 1.52 DALYs averted compared to the standard program, while UHC yielded only a 0.50 DALY reduction. Conclusion P4P had a greater impact and was more cost-effective compared to UHC as measured by DALYs averted. While expanded insurance benefit ceilings affected only those who are covered, P4P incentivizes practice quality improvement regardless of whether children are insured or uninsured.

Background : Misdiagnosis may be a significant and under-recognized quality of care problem. In birthing facilities located in anurban Philippine setting, we investigated the diagnostic accuracy for three obstetric conditions: cephalopelvic disproportion (CPD), post-partum hemorrhage (PPH), and pre-eclampsia. Design : Identical simulated cases were used to measure diagnostic accuracy for every provider ( n =103). We linked misdiagnosis – identified by the simulated cases – to obstetrical complications of the patients at the participating facilities. Patient-level data on health outcomes and costs were obtained from medical records and follow-home in-person interviews. Results : The prevalence of misdiagnosis among obstetric providers was 29.8% overall, 25% for CPD, 33% for PPH, and 31% for pre-eclampsia. Linking provider decision-making to patients, we found those who misdiagnosed the simulated cases were more likely to have patients with a complication (OR 2.96; 95% CI 1.39–3.77) compared with those who did not misdiagnose. Complicated patients were significantly less likely to be referred to a hospital immediately, were more likely to be readmitted to a hospital after delivery, had significantly higher medical costs, and lost more income than non-complicated patients. Conclusion : Diagnosis is arguably the most important task a clinician performs because it determines the subsequent course of evaluation and treatment, with the direct and indirect costs of diagnostic error, placing large financial burdens on the patient. Keywords: misdiagnosis; health outcomes; health costs; Philippines; quality of care; practice variability; obstetrics (Published: 15 December 2016) To access the supplementary material for this article, please see Supplementary files under ‘Article Tools’ Citation: Glob Health Action 2016, 9 : 32672 - http://dx.doi.org/10.3402/gha.v9.32672

Improving clinical performance using measurement and payment incentives, including pay for performance (or P4P), has, so far, shown modest to no benefit on patient outcomes. Our objective was to assess the impact of a P4P programme on paediatric health outcomes in the Philippines. We used data from the Quality Improvement Demonstration Study. In this study, the P4P intervention, introduced in 2004, was randomly assigned to 10 community district hospitals, which were matched to 10 control sites. At all sites, physician quality was measured using Clinical Performance Vignettes (CPVs) among randomly selected physicians every 6 months over a 36-month period. In the hospitals randomized to the P4P intervention, physicians received bonus payments if they met qualifying scores on the CPV. We measured health outcomes 4-10 weeks after hospital discharge among children 5 years of age and under who had been hospitalized for diarrhoea and pneumonia (the two most common illnesses affecting this age cohort) and had been under the care of physicians participating in the study. Health outcomes data collection was done at baseline/pre-intervention and 2 years post-intervention on the following post-discharge outcomes: (1) age-adjusted wasting, (2) C-reactive protein in blood, (3) haemoglobin level and (4) parental assessment of child's health using general self-reported health (GSRH) measure. To evaluate changes in health outcomes in the control vs intervention sites over time (baseline vs post-intervention), we used a difference-in-difference logistic regression analysis, controlling for potential confounders. We found an improvement of 7 and 9 percentage points in GSRH and wasting over time (post-intervention vs baseline) in the intervention sites relative to the control sites (P ≤ 0.001). The results from this randomized social experiment indicate that the introduction of a performance-based incentive programme, which included measurement and feedback, led to improvements in two important child health outcomes.

To assess the quality of medical treatment by disaggregating quality into components that distinguish between insufficient and unnecessary care.Randomly selected doctors were asked how they would treat a sick child. Their responses were disaggregated into how much of an evidence-based essential treatment plan was completed and the number of additional non-essential treatments that were given. Key variables included the expected cost, the health consequences of insufficient and unnecessary care and comparisons between public and private physicians. Responses to 160 clinical performance vignettes (CPVs) were analysed.Philippines.One hundred and forty-three public and private physicians in the Philippines, collected in November 2003-December 2004 and September 2006-June 2007.CPVs administered to physicians.Process quality measures (accounting for the possibility of both over-treatment and under-treatment).Based on CPVs, doctors gave both insufficient and unnecessary treatment to under-five children in 69% of cases. Doctors who provided the least sufficient care were also the most likely to give costly or harmful unnecessary care. Insufficient care typically had potentially worse health consequences for the patient than unnecessary care, though unnecessary care remains a concern because of overuse of antibiotics (47%) and unnecessary hospitalization (34%).Quality of care is complex, but over- and under-treatment coexist and, in our analysis physicians that were more likely to under-treat a sick child were also those more likely to over-treat.

In this paper, we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a randomized policy experiment known as the Quality Improvement Demonstration Study. Among study participants, using a difference-in-difference regression model, we estimated a 9–12 and 4–9 percentage point reduction in the likelihood of wasting and having an infection, respectively, as measured by a common biomarker C-reactive Protein. Interestingly, these benefits were not apparent at the time of discharge; the beneficial health effects were manifest several weeks after release from the hospital. Copyright © 2010 John Wiley & Sons, Ltd.

Even when health insurance coverage is available, health policies may not be effective at increasing coverage among vulnerable populations. New approaches are needed to improve access to care. We experimentally introduced a novel intervention that uses Policy Navigators to increase health insurance enrollment in a poor population.We used data from the Quality Improvement Demonstration Study (QIDS), a randomized experiment taking place at the district level in the Visayas region of the Philippines. In two arms of the study, we compared the effects of introducing Policy Navigators to controls. The Policy Navigators advocated for improved access to care by providing regular system-level expertise directly to the policy-makers, municipal mayors and governors responsible for paying for and enrolling poor households into the health insurance program. Using regression models, we compared levels of enrollment in our intervention versus control sites. We also assessed the cost-effectiveness of marginal increases in enrollment.We found that Policy Navigators improved enrollment in health insurance between 39% and 102% compared to the controls. Policy navigators were cost-effective at 0.86 USD per enrollee. However, supplementary national government campaigns, which were implemented to further increase coverage, attenuated normal enrollment efforts.Policy Navigators appear to be effective in improving access to care and their success underscores the importance of local-level strategies for improving enrollment.

Physicians' links with pharmacies may create perverse financial incentives to overprescribe, prescribe products with higher profit margins, and direct patients to their pharmacy. Interviews with pharmacy customers in the Philippines show that those who use pharmacies linked to public-sector physicians had 5.4 greater odds of having a prescription from such physicians and spent 49.3 percent more than customers using other pharmacies. For customers purchasing brand-name medicines, switching to generics would reduce drug spending by 58 percent. Controlling out-of-pocket spending on drugs requires policies to control financial links between doctors and pharmacies, as well as tighter regulation of nongeneric prescribing.

OBJECTIVE Generally, lead poisoning is not considered a significant environmental hazard for children in rural areas of developing countries. With a prospectively designed policy experiment, the research community and the government are conducting a broad-based investigation to introduce and evaluate the impact of health policy reforms on children in a rural area of the Philippines - the Quality Improvement Demonstration Study (QIDS). As part of this study, we researched lead exposure in children under the age of five. METHODS: We sampled a population of children from the Visayas region in the central Philippines, covering approximately one third of the country's geographical area. From December 2003 to September 2004, the survey collected blood lead levels (BLL) together with demographic, socioeconomic and child health data points. Supplemental field-testing among a sub-sample of the most exposed children assessed the sources of environmental lead exposure. FINDINGS: Among children in this study, 21% (601 of 2861 children) had BLL greater than10 µg/dl. BLL were associated independently with age, haemoglobin concentration, water source, roofing material, expenditures and history of breastfeeding. A follow-up assessment of possible environmental exposures among the sub-sample of children with elevated BLL revealed no single or predominant exposure source. Instead, there appear to be multiple potential sources, such as fossil-fuel combustion, lead paint (in or around 38% of homes) and household items. CONCLUSION: Elevated BLL are common among children in the Visayas, and may signify an under-recognized threat to children living in rural areas of other developing nations. This setting has varied environmental sources of lead. Observed correlates of BLL may be of clinical, environmental and public health utility to identify and mitigate the consequences of lead toxicity.

We tracked doctors who had previously participated in a randomized policy experiment in the Philippines. The original experiment involved 30 district hospitals divided equally into one control site and two intervention sites that increased insurance payments (full insurance support for children under 5 years old) or made bonus payments to hospital staff. During the 3 years of the intervention, quality-as measured by clinical performance and value vignettes-improved and was sustained in both intervention sites compared with controls. Five years after the interventions were discontinued, we remeasured the quality of care of the doctors. We found that the intervention sites continued to have significantly higher quality compared with the control sites. The previously documented quality improvement in intervention sites appears to be sustained; moreover, it was subject to a very low (less than 1% per year) rate of decay in quality scores.

In low- and middle-income countries, government budgets are rarely sufficient to cover a public hospital’s operating costs. Shortfalls are typically financed through a combination of health insurance contributions and user charges. The mixed nature of this financing arrangement potentially creates financial incentives to treat patients with equal health need unequally. Using data from the Philippines, the authors analyzed whether doctors respond to such incentives. After controlling for a patient’s condition, they found that patients using insurance, paying more for hospital accommodation, and being treated in externally monitored hospitals were likely to receive more care. This highlights the worrying possibility that public hospital patients with equal health needs are not always equally treated.

The merits of using financial incentives to improve clinical quality have much appeal, yet few studies have rigorously assessed the potential benefits. The uncertainty surrounding assessments of quality can lead to poor policy decisions, possibly resulting in increased cost with little or no quality improvement, or missed opportunities to improve care. We conducted an experiment involving physicians in thirty Philippine hospitals that overcomes many of the limitations of previous studies. We measured clinical performance and then examined whether modest bonuses equal to about 5 percent of a physician's salary, as well as system-level incentives that increased compensation to hospitals and across groups of physicians, led to improvements in the quality of care. We found that both the bonus and system-level incentives improved scores in a quality measurement system used in our study by ten percentage points. Our findings suggest that when careful measurement is combined with the types of incentives we studied, there may be a larger impact on quality than previously recognized.

Large health surveys use subjective (self-reported) and objective (biomarkers) measures to assess heath status. However, the linkage or disparity of these measures has not been systematically studied in developing countries. Method: Using data from the Philippine Quality Improvement Demonstration Study, QIDS, this study evaluated the associations between General Self-Reported Health Status (GSRH) and height, weight, hemoglobin, red blood cell folate, C-reactive protein, and blood lead levels. The authors modeled each biomarker as a function of GSRH controlling for socioeconomic status and selection effects. Changes in biomarkers and GSRH in children who had previously been hospitalized were also examined. Results: GSRH independently predicted hemoglobin, C-reactive protein, stunting, and wasting. GSRH did not vary significantly with folate deficiency and blood lead levels. Conclusions: In addition to being a measure of overall child health status, GSRH may be a useful and inexpensive screening tool for identifying children that need further health testing.

Background: Improving the quality of inpatient hospital care is increasingly attainable in a variety of settings. However, the relationship between rising quality and costs is unclear; similarly the relationship between varying levels of quality and a patient's satisfaction remains poorly defined. Methods: We use data from the Quality Improvement Demonstration Study (QIDS) based in 30 district hospitals in the Philippines. There were 974 children in the study; these children were cared for by 43 physicians. To measure quality of care, the physicians completed vignettes, a valid and inexpensive measure. Patient exit surveys were given to parents of children on the day of discharge, collecting information on services and hospital charges for the inpatient stay, payment sources for the hospitalization, and the Patient Satisfaction Survey (PSQ-18). Results: We found a nonlinear relationship between quality and hospital charges: at low levels of quality improvements are linked to lower hospital charges. However, as quality improves further, these changes lead to higher charges. Higher quality also demonstrated a similar nonlinear relationship with patient satisfaction. Conclusions: The U-shaped association between quality and hospital charges suggests that targeting the lowest quality providers may decrease costs. The similar relationship between patient-reported satisfaction and quality improvement suggests that investments in quality will raise satisfaction, perhaps even when charges are increased.

Background. Factors that increase likelihood of readmission or mortality postdischarge from diarrhea and pneumonia cases among children is less understood. Methods. This study investigated the deaths of 24 children from a cohort of 3275. Using logistic regression, the authors compared data from those who survived with those who died to estimate the determinants of mortality in the study population. The authors also analyzed the hospital charts and completed mortality interviews with families of the deceased children. Results. Poor quality of care significantly increased the likelihood of mortality. Sicker children, those born to less-educated mothers, and those who had longer lengths of stay also had a higher likelihood of mortality. Hospital charts corroborated findings from clinical vignettes. The mortality interviews revealed delays in seeking care from onset of symptoms. Conclusion. Quality of care contributes to postdischarge mortality and that clinical vignettes are an effective means to identify where quality can be improved.

Objectives Measuring and monitoring health system performance is important albeit controversial. Technical, logistic and financial challenges are formidable. We introduced a system of measurement, which we call Q*, to measure the quality of hospital clinical performance across a range of facilities. This paper describes how Q* was developed, implemented in hospitals in the Philippines and how it compares with typical measures. Methods Q* consists of measures of clinical performance, patient satisfaction and volume of physician services. We evaluate Q* using experimental data from the Quality Improvement Demonstration Study (QIDS), a randomized policy experiment. We determined its responsiveness over time and to changes in structural measures such as staffing and supplies. We also examined the operational costs of implementing Q*. Results Q* was sustainable, minimally disruptive and readily grafted into existing routines in 30 hospitals in 10 provinces semi-annually for a period of 2½ years. We found Q* to be more responsive to immediate impacts of policy change than standard structural measures. The operational costs totalled US$2133 or US$305 per assessment per site. Conclusion Q* appears to be an achievable assessment tool that is a comprehensive and responsive measure of system level quality at a limited cost in resource-poor settings.

It is unclear whether health provider accreditation ensures or promotes quality of care. Using baseline data from the Quality Improvement Demonstration Study (QIDS) in the Philippines we measured the quality of pediatric care provided by private and public doctors working at the district hospital level in the country’s central region. We found that national level accreditation by a national insurance programme influences quality of care. However, our data also show that insurance payments have a similar, strong impact on quality of care. These results suggest that accreditation alone may not be sufficient to promote high quality of care. Further improvements may be achieved with properly monitored and well-designed payment or incentive schemes.

Background Many developing countries promote social health insurance as a means to eliminate unmet health needs. However, this strategy may be ineffective if there are barriers to fully utilizing insurance. Methods We analyzed the utilization of social health insurance in 30 hospital districts in the central regions of the Philippines between 2003 and 2007. Data for the study came from the Quality Improvement Demonstration Study (QIDS) and included detailed patient information from exit interviews of children under 5 years of age conducted in seven waves among public hospital districts located in the four central regions of the Philippines. These data were used to estimate and identify predictors of underutilization of insurance benefits - defined as the likelihood of not filing claims despite having legitimate insurance coverage - using logistic regression. Results Multivariate analyses using QIDS data from 2004 to 2007 reveal that underutilization averaged about 15% throughout the study period. Underutilization, however, declined over time. Among insured hospitalized children, increasing length of stay in the hospital and mother's education, were associated with less underutilization. Being in a QIDS intervention site was also associated with less underutilization and partially accounts for the downward trend in underutilization over time. Discussion The surprisingly high level of insurance underutilization by insured patients in the QIDS sites undermines the potentially positive impact of social health insurance on the health of the marginalized. In the Philippines, where the largest burden of health care spending falls on households, underutilization suggests ineffective distribution of public funds, failing to reach a significant proportion of households which are by and large poor. Interventions that improve benefit awareness may combat the problem of underutilization and should be the focus of further research in this area.

Objective Because little is known about its effects on cognitive function among children in less-developed countries, we determined the impact of lead exposure from other nutritional determinants of cognitive ability. Study design Data were from a cross-sectional population-based stratified random sample of 877 children (age 6 months-5 years) participating in the Quality Improvement Demonstration Study we are conducting in the Philippines. With data from validated psychometric instruments, venous blood samples, and comprehensive survey instruments, we developed multi-stage models to account for endogenous determinants of blood lead levels (BLLs) and exogenous confounders of the association between BLLs and cognitive function. Results A 1 μg/dL increase in BLL was associated with a 3.32 point decline in cognitive functioning in children aged 6 months to 3 years and a 2.47 point decline in children aged 3 to 5 years olds. BLL was inversely associated with hemoglobin and folate levels. Higher folate levels mitigated the negative association between BLL and cognitive function. Conclusions These population-based data suggest greater lead toxicity on cognitive function than previously reported. Our findings also suggest that folate and iron deficient children are more susceptible to the negative cognitive effects of lead. Folate supplementation may offer some protective effects against lead exposure.