Can we improve quality of care in private health sectors? Evidence from a randomized field experiment in Kenya

At least half the world's 7.5 billion people lack access to essential health services, and many of the world's poor who seek care are at risk of catastrophic and impoverishing out-of-pocket spending. In low- and middle-income countries, well-established private sectors and low levels of quality, even in places with high access, contribute to the challenges of improving health care for the disadvantaged. To address these issues across Kenya, the 2012-2019 African Health Markets for Equity (AHME) program delivered a comprehensive package of interventions at private clinics to improve clinical decision making and to expand high quality health care access for the poor. By taking advantage of a randomized field experiment, we examine AHME's effects on quality of care and answer the question, “Can we improve quality of care in private health sectors?” We collected and analyzed unique data (including data from standardized patients, the state-of-the-art method to assess provider practice) to examine the program's effects on three quality of care dimensions: structures, processes, and health care outcomes. We find some significantly positive effects on structural quality, and surprisingly, AHME reduced correct care by 12% (p-value = 0.021). This relative reduction was consistent but not significant for rates of unnecessary testing and medicines, which dropped by 12.3% and 8.5% respectively, suggesting reduced waste. Since average knowledge of correct care was remarkably high (90% for diarrhea; 98% for malaria), effects may be because lowering quality is in the financial interest of these for-profit clinics, especially since patients and households did not recognize reductions in quality. We examine this hypothesis with a modified dictator game and find that the least altruistic providers at AHME clinics were the ones to reduce correct care, while charging 121% more than the least altruistic at non-AHME clinics. Across all clinics, we further uncover alarming deficits in laboratory quality and in the care given to poor clients compared to the non-poor. Since highly competent private providers give lower quality care to patients due to patient characteristics and provider preferences, the success of quality improvement in the private sector requires (1) stronger accountability with careful monitoring and (2) nuanced policies to account for patient and provider heterogeneity