How can intervention measures strengthen the relationship between patient and healthcare professional?

Responsible researcher: Viviane Pires Ribeiro

Paper Title: Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak

Authors: Darin Christensen, Oeindrila Dube, Johannes Haushofer, Bilal Siddiqi and Maarten Voors

Intervention Location: Sierra Leone

Sample Size: 5,080 households

Big topic: Health

Variable of Main Interest: Health System

Type of Intervention : Community monitoring and non-financial awards

Methodology: Randomization

Can improving the perceived quality of healthcare promote community health and ultimately help contain epidemics? Seeking to answer this question, Christensen et al. (2021) use a field experiment, in the context of the 2014 Ebola crisis in West Africa, to evaluate two programs designed to improve the use of government-run clinics and the quality of care provided at these facilities. One program focused on community monitoring and the other program providing non-financial awards to clinic staff. The results, in general, indicate that promoting accountability not only has the power to improve health systems in normal times, but can also make them more resilient to emerging crises.

Assessment Context

Developing countries are characterized by high mortality and morbidity rates. A potential contributing factor is the low utilization of healthcare systems, resulting from the perceived low quality of care provided by personnel in this area. This factor not only frustrates the treatment of endemic diseases, but can also hamper the containment of emerging epidemics. Containing epidemics requires compliance with public health guidelines related to, for example, testing and quarantine. As evidenced by the outbreaks of Covid-19, Zika and Ebola, epidemics and pandemics recur with devastating local and global effects.

In September 2014, when the World Health Organization (WHO) described the Ebola epidemic in West Africa as the most serious acute public health emergency seen in modern times, Sierra Leone, officially the Republic of Sierra Leone, was one of the countries who had chronic health problems worsened by this crisis. 

At the end of the crisis, early 2016, when the Centers for Disease Control and Prevention (CDC) estimated more than 28,000 confirmed, suspected or probable cases, Sierra Leone accounted for about half of those cases and just under 4,000 deaths.

Intervention Details

Before the Ebola outbreak in Sierra Leone, Christensen et al. (2021) designed a large-scale field experiment to evaluate two programs designed to improve the utilization of government-run clinics and the quality of care provided at these facilities. The research period allowed us to examine the effects of the programs both under “normal conditions” and during the ensuing Ebola crisis (final research was completed in June 2013 and the first case of Ebola was reported in May 2014). The authors later evaluated the effects of these programs during the ensuing Ebola epidemic. Thus, it was possible to observe whether the interventions contributed to the resilience of the health system.

The research was carried out including 318 primary health clinics. Among these, 254 clinics were analyzed, so that all clinics in the sample were separated by at least 3 kilometers to minimize spillovers. At the beginning of the study, the clinics had, on average, just over two employees present and were open six days a week, serving around 450 patients per month.

More than 80% of clinics had walls and ceilings in good condition, access to piped or protected water, and stocks of basic medicines (e.g., oral rehydration salts and antibiotics). However, only 10% of them had functional electrical lighting.

Methodology Details

Christensen et al. (2021) randomly assigned 254 clinics to one of two interventions or control, in partnership with the Government of Sierra Leone and three international Non-Governmental Organizations (NGOs). The first intervention, Community Monitoring (CM), provided information to patients and a public forum to monitor frontline healthcare workers. The intervention distributed cards to rate local health services and convened interface meetings between community members and health professionals to discuss these ratings and develop “joint action plans” to improve service delivery.

The second intervention provided non-financial awards (NFA) to improve clinics. Clinical staff were encouraged to develop action plans, and winning clinics received wall plaques and letters of recommendation from the district government. Neither program provided resources for clinics; rather, they were intended to motivate healthcare professionals to provide higher quality care under existing resource constraints.

Aiming to test whether interventions contribute to the resilience of the health system, it questioned whether they affect the reporting of Ebola cases. To do so, the authors used a de-identified database maintained by the Government of Sierra Leone and Centers for Disease Control and Prevention to construct weekly counts of tested and confirmed patients in small administrative units called sections. The research focused on the 160 sections that contained a single clinic from the experimental sample, which allowed for unambiguous coding of treatment status for each section.

The 254 clinics in the sample were grouped into matched trios using Greevy and Beck's (2016) non-bipartite matching algorithm. Clinics in a trio fell within the same district and exhibited similar levels of utilization and performance at baseline. Blocking matched trios, 84 clinics were randomized to control, 85 to Community Monitoring (CM), and 85 to Non-Financial Awards (NFA).

Results

Two years before the 2014 Ebola outbreak in West Africa, Christensen et al. (2021) randomly assigned two interventions to health clinics run by the government of Sierra Leone, one focused on community monitoring and the other providing non-financial rewards to clinic staff. Before the Ebola crisis, both interventions increased clinic utilization and patient satisfaction. Community monitoring has also improved child health, resulting in 38% fewer deaths among children under five. Later during the crisis, interventions also increased Ebola case reporting by 62%, and community monitoring significantly reduced Ebola-related deaths.

Evidence on mechanisms indicates that both interventions improved the perceived quality of health care by encouraging patients to report Ebola symptoms and receive medical care. Improvements in health outcomes under community monitoring suggest that these changes reflect, in part, an increase in the underlying quality of care administered.

Therefore, the study points out that improvements in the perception of quality of care in intervention clinics led to an increase in reports during the crisis, and improvements in care administered in community monitoring clinics also persisted during the crisis period. Thus, community monitoring has qualitatively stronger effects than non-financial awards to clinic staff before the crisis and during the Ebola outbreak. This suggests that involving the community in promoting accountability may be especially effective in improving the quality of health services.

Public Policy Lessons

The results observed not only indicate improvements when interventions were implemented in the health system in the short term, as well as resilience in relation to crises that occur in the long term. According to Christensen et al. (2021), the increase in patients using health services in the pre-Ebola period, although not high, has significant effects during the Ebola pandemic.

This suggests that incentives contributed to moderate changes in perceived quality of care. Therefore, they can strengthen health systems during crises and pay substantial dividends during these critical periods. If these interventions are also effective in other contexts, they could constitute a promising approach to preparing for future health crises.

Improvements in health outcomes under community monitoring indicate that these changes reflect, in part, an increase in the underlying quality of care administered. Overall, the results suggest that promoting accountability not only has the power to improve health systems in normal times, but can also make them more resilient to emerging crises.

References

CHRISTENSEN, Darin et al. Building resilient health systems: Experimental evidence from Sierra Leone and the 2014 Ebola outbreak. The Quarterly Journal of Economics , vol. 136, no. 2, p. 1145-1198, 2021.