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Quality improvement and its impact on the use and equality of outpatient health services in India

Future Health Systems

Rao DK, Peters DH. Quality improvement and its impact on the use and equality of outpatient health services in India. Health Economics. 2007; 16: 799-813.



This paper examines the impact of quality improvements in conjunction with user fees on the utilization andequality of outpatient services at a range of public sector health facilities in India. Project impact on outpatientvisits was estimated via the difference-in-difference method using pooled time series visit data from project andcontrol facilities. The results indicate that the quality improvements significantly increased visits at all facility types.The project effect was largest at primary health center (PHC) and community health center (CHC), followed bydistrict hospital (DH) and female district hospital (FDH). Pro-rich inequalities in outpatient visits increased at DHsand FDHs while at CHCs and PHCs the distribution remained equitable. This suggests that quality improvementsat public sector health facilities can increase utilization of outpatient services in the presence of nominal user fees,but can also promote greater inequality favoring the better-off. At the referral hospital level, quality improvementsshould be made in conjuction with programs which encourage utilization by the poor. In contrast, the benefit ofquality improvements at PHCs and CHCs is equitably distributed.