[Editor’s Note: Back in February, the Harvard Kennedy School’s Ash Center hosted an event titled “Stories and Statistics: Why we need mixed methods to understand international development.” The event featured principal investigators from the Transparency for Development project representing opposing sides of the methodological spectrum: quantitative versus qualitative analysis. Instead of a sparring match over which method reigns supreme, the discussion centered on why we need both quantitative and qualitative evaluation methods to understand the full picture of impact. Building on this event, the “Stories and Stats” blog series is a way for us to share some exciting quantitative trends we’re observing in the early stages of our analysis in Indonesia and Tanzania — and to dig into the stories behind the numbers. For more, read the first two posts of this series: “How qualitative methods help us read between the numbers” and “The surprising ways citizens demand accountability when it comes to health care.”]
What would you do if your doctor was offensive, disrespectful or rude to you? Depending on the severity, many of us would land somewhere between finding a new provider and a lucrative malpractice suit. But this freedom of health provider choice is quite rare outside of high-income countries and major urban centers. For most rural denizens in the developing world, having access to even one provider is a luxury, regardless of their bedside manner (if there is even a bed in the first place).
Our Transparency for Development (T4D) project, which empowers community representatives to voluntarily take action on local maternal and newborn health challenges, has unearthed deep discontent within communities regarding health provider behavior and attitudes. This isn’t surprising, but what IS surprising is how the communities have decided to address these challenges and what we’ve learned about the root causes of this disrespectful behavior. The bottom line? Sometimes, these perceived instances of rudeness result from providers trying to navigate larger problems entrenched in the health system.
Addressing patient dissatisfaction
Client dissatisfaction with provider attitudes is a well-known and often significant barrier to health service uptake in low- and middle-income countries. Unsurprisingly, then, data from the specific communities participating in the Transparency for Development project showed this to be a major problem there as well.
After the communities identified key issues and challenges related to improving maternal and child health, they developed action plans. Many (about 16 percent) of these action plans focused on improving provider knowledge or attitudes, disrespectful behavior or client dissatisfaction. In Indonesia, every village decided to take at least one action related to these barriers. And in Tanzania, 35 percent of the villages in Tanzania selected providers’ negative attitudes as one of their top challenges. (To learn more about how communities design social actions to address MNH barriers, read this post.)
From those numbers, the more penal among us might expect to see many communities taking actions to replace or punish providers or otherwise change their behavior through negative incentives. But surprisingly, confrontational social actions were the minority, especially among the subset of actions targeting service providers’ negative attitudes.
Of the 112 Indonesian actions targeting provider attitudes, only 28 percent were confrontational. In Tanzania, confrontation was even rarer — of the 156 actions, only 5 (3 percent) were confrontational. Overall, community representatives seemed to prefer collaborative or positive incentives, such as highlighting the “provider of the month” or installing suggestion boxes at health facilities in Tanzania. If confrontational approaches were used at all, they were often reserved as a second step, like a Tanzanian community who wrote a letter of complaint to the district medical officer only after community members met with health workers collaboratively and the latter refused to improve their attitudes.
Exploring root causes of perceived rudeness
Sometimes, a rude doctor is just a rude doctor. But sometimes there is more to story. This is where qualitative data can be particularly telling.
In analyzing the data from the Indonesian and Tanzanian communities, we found that many providers cited social or systemic issues beyond their control as the root causes of their negative attitudes. In many cases, as communities engaged health providers about their concerns, the two became allies, and health providers helped channel community requests for supplies or additional health staff to higher levels of the health system. The top four underlying issues health care providers cited as pain points:
1. Lack of patient knowledge and trust in providers
Several Tanzanian health care providers tried to excuse their reputations as being curt or rude as the only way to overcome patients’ lack of knowledge and failure to adhere to medical advice. In one case, providers expressed frustration over how late many mothers start seeking antenatal care services. In response to this new information, community representatives changed their planned action and, instead of telling the providers to improve their attitudes, suggested that providers increase their efforts to educate the community on the importance of early antenatal care. In another case, health workers at first refused to participate in community meetings, because “they believe that the community does not trust them” and “there are rumors they will be reported to high authorities due to their negative attitudes.” Eventually, working through the village government as a broker, the community representatives were able to convince the providers to try to improve their bedside manners, and coupled that action with a community education campaign to build trust and collaboration between the health care providers and the community. As a result, the community later reported increased rates of facility delivery and other maternal health service uptake.
2. Limited supplies, medicines and equipment
In two different Tanzanian villages, the community representatives collaboratively approached health care workers to improve their education and outreach services as well as their poor attitudes, only to find that a higher-level supply issue was to blame for low performance.
Some health workers were reported as defensive or did not participate in the community representatives’ efforts, but many agreed to improve their attitudes and also suggested actions to address the supply issues. One of the villages was successful in acquiring additional medical supplies from the district, and the other is confident they will soon receive the additional vaccines they requested as well.
3. Limited health staff
In one Tanzanian village, community representatives originally asked a health worker to increase efforts to provide education and services to the community outside of the facility. The health worker agreed, but explained that additional effort would be impossible without additional staff to share the burden. Community representatives then decided to deliver that request to the district medical officer.
In another Tanzanian village, health workers complained that it was the community’s attitudes toward male health workers that was the challenge. The community representatives then started a campaign to convince the community to trust the male health workers and to explain the shortage of female health facility staff.
4. Limited facility space
One Tanzanian healthcare worker blamed her clients’ dissatisfaction more on the tiny space in which she had to see them, rather than anything inherently wrong with her performance. In a similar Indonesian example, community representatives asked the health facility head to expand the facility and acquire a village ambulance. When the facility head explained that he did not have the authority to address the community representatives’ requests, the community representatives convened an interface meeting with the facility head and the village head. As a result of this collaborative meeting, the community achieved additional clinical space at the village government office, and the village head promised to consider the ambulance procurement in the next budgeting process.
Of course, providers should treat all patients respectfully and do their best with the tools at their disposal. Any excuses for doing otherwise should be viewed with healthy skepticism, but perhaps some of their exasperation at the limited health resources inhibiting their work is understandable and forgivable.
These observations should not be seen as trying to excuse rudeness, mistreatment or fatalistic apathy in low- and middle-income country health systems. Rather, they should be viewed as another voice in the growing chorus of warnings against the “seduction of contestation” in externally designed accountability projects, or with newly-amplified voices becoming frustrated with slow, zero, or negative progress.
In other words, all that glowers is not (necessarily) a golden opportunity for “rude accountability” responses.
Photo © Transparency for Development/Jessica Creighton