So welcome back.
Today, we are in Washington, DC, at the World Bank.
And I am particularly excited because we have, as our guest, Jishnu Das,
who is an economist at the World Bank.
And Jishnu has really been at the frontier of thinking about and measuring health care
quality in low and middle income countries.
Jishnu, thank you so much for being here.
Pleasure to be here, Ashish.
Look forward to it.
So, Jishnu, let's get right into it.
There is a lot of interest in thinking about health care
quality in high income countries.
There's been a lot of work that's been done in the US and England.
Most of us feel like we know less about the state of health care
quality in low income countries or middle income countries.
What is the state of health care quality in India?
I think it's fair to say that the state of health quality in India is not good,
and there are many, many ways you could look at that.
First of all, the country's bifurcated in two.
There's a better-performing south and a worse-performing north.
And I think you see that in every held statistic that we have.
The second part of it, which I think is less known,
is that that bifurcation carries over to health care quality.
And you can think about that in a couple of ways.
The one way I like to think about health care quality
is to just try and see what happens when you, as a patient, go to a doctor?
And then say, how, as researchers, can we mimic that experience?
How can I tell you a little bit about the average person who goes to a doctor
and what happens to them?
I think the simplest way to think about it is to say, pick a condition that's really,
really salient.
So, for instance, we've picked chest pain in a middle-aged man.
Which usually, in a place like the US, 98% of the time
will be diagnosed correctly.
And in the case we picked, for instance, if the doctor
had questioned appropriately, done the right exams,
he or she would have diagnosed it as unstable angina
or what's, in common parlance, called a heart attack.
So we train people to depict these symptoms very, very carefully
and send them to many, many doctors.
And I think the simplest way you could think about poor health quality
is you can ask, how many of these patients would receive the right treatment and nothing
else?
That answer is about 5%.
So things got slightly better when you say, how many of these guys
would have received the right treatment but would have also
received something else?
Maybe the doctor did the right thing, but he also
did a bunch of things that were not totally correct.
So that's about 40 to 45%.
But you're still left with a majority of doctors not being able to pick up, diagnose, or treat
a very textbook case of chest pain that, not appropriately diagnosed and
treated, would lead into a heart attack.
Just so I understand what you're describing, you take standardized patients, people who
have been trained, and you send them off.
And about 5% of the time, the physician gets it right
and doesn't do anything else and a majority of the time,
they don't even get it right at all.
So what's going on?
Where is the failure?
Are they not asking the right questions?
Are they not doing the right exam?
What do we know about why people have a hard time arriving
at the right diagnosis and treatment?
The first failure could be that the doctor just doesn't know.
I mean, the guy hasn't been trained, he doesn't have the medical knowledge,
perhaps.
And if he doesn't know that a chest pain could be a heart attack,
maybe that's the biggest problem.
And, in fact, if you read a lot of the literature on health care, a lot of it
is about the "massive shortage" of health care workers or a staffing
problem.
And they don't have sufficiently trained doctors.
The second part of it, which I think is less salient
in the kind of health policy world, but hits us, as patients,
every day is that the doctor may not put in enough effort.
So I don't know how many people have been to clinics in low income
countries, but unlike, say, clinics in the US
where you're cordoned off from the other patients, there's a door,
you're alone with the doctor, the doctor listens to you.
A typical clinic that we work in-- if you go in,
there are five people sitting in the clinic.
These could be patients, might be other people, might be friends,
might be people from the community.
The TV is blaring, the patient comes in, sits, the doctor's talking on his cell
phone.
He'll pick up every call.
So it's an extremely distracted environment.
There are various things going on, and you want to start worrying about, is the doctor
putting in enough effort to look after you.
The third issue is, sometimes-- and this has been a worry especially with India
and other countries-- people think, well, maybe the doctor
is getting paid to do something which they know is not right.
One way to think about it in India is, maybe they're getting paid to ask you to get a bunch
of tests done because they're getting kickbacks from the industry.