political context, organizational mission and the quality ......political context, organizational...
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PoliticalContext,OrganizationalMissionandtheQualityofSocialServices:InsightsfromtheHealthSectorinLebanon
MelaniCammett(HarvardUniversity)
and
AytuğŞaşmaz(HarvardUniversity)
Abstract
Inmanydevelopingcountries,non-stateactorsareimportantprovidersofsocialwelfare.In
partsoftheMiddleEast,SouthAsiaandotherregions,religiouscharitiesandpartiesand
NGOshavetakenonthisrole,withsomeprecedingindependentstatehoodandothers
buildingparalleloralternativewelfareinfrastructurealongsidethemodernstate.Howwell
dothesegroupsprovidewelfaregoods?Dosomeexhibita“welfareadvantage,”ora
demonstratedsuperiorityinthequalityandefficiencyofprovidingsocialservices?Inthis
paper,weexplorewhetherdistinctorganizationaltypesareassociatedwithdifferentlevelsof
thequalityofcare.BasedonastudyinGreaterBeirut,Lebanon,wherediversetypesof
providersoperatehealthcenters,weproposeandtestsomehypothesesaboutwhycertain
organizationsmightdeliverbetterservices.Wefindlittleempiricalsupportforafaith-based
welfareadvantage,assomeresearchcontends.Instead,thedataindicatethatsecularNGOs
exhibitsuperiormeasuresofhealthcarequality,aseeminglycounterintuitivefindingin
Lebanonwherereligiousandsectarianactorsdominatepoliticsandthewelfareregimeand
commandthemostextensiveresources.Ourpreliminaryexplanationforthisfinding
emphasizesthewaysinwhichthesociopoliticalcontextshapesthechoicesofqualified
providerstoselectintosecularorganizationsandwhycitizensmightperceivetheseproviders
tobebetter,irrespectiveoftheactualqualityofservicesdelivered.
1
Introduction
Inmanydevelopingcountries,non-stateactorsareimportantprovidersofsocialwelfare,with
someprecedingindependentstatehoodandothersbuildingparalleloralternativewelfare
infrastructurealongsidethemodernstate.Awidearrayofactors,includingNGOs,religious
charitiesandevenpoliticalparties,areinthebusinessofprovidinghealthservices,schooling,
vocationaltrainingandotherimportantservices,andthusgreatlyaffectthestandardsof
livingandwell-beingoflowandmiddleincomepeople(CammettandMacLean,2014).Yet
littleresearchexploresthequalityofwelfaregoodssuppliedbyNSPs.Docertaintypesexhibit
a“welfareadvantage,”orademonstratedsuperiorityinthequalityofsocialservice
provision?
Inthisarticle,weproposeandassessavarietyofhypothesesrelatedtoorganizational
typeandthequalityofservicesanddevelopsomepropositionsabouttheeffectsof
organizationalmissiononservicedelivery.Basedonevidencefromanoriginalsetofsurveys
inprimaryhealthcentersaffiliatedwithdiversepublicandnon-stateactorsinGreaterBeirut,
Lebanon,weshowthatsecularNGOsdemonstrateanapparentwelfareadvantageoverother
providertypesinbothobjectiveandsubjectivemeasuresofhealthquality.1Further,patient
evaluationsofhealthcentersrunbydistinctorganizationsaredrivenlargelybyperceptions
ofdoctors,anddoctorswhoworkinsecularorganizationsreporthigherlevelsofsatisfaction
withtheorganizationswheretheywork.Thisapparentsecularwelfareadvantagecontradicts
manytheoreticalandempiricalexpectations,aswedetailbelow.Ourproposedexplanation
forthisresultcentersonthewaysinwhichthepoliticalcontextaffectsboththeobjectiveand
subjectivequalityofcarebysecular,religiousandpoliticalgroupsthroughbothsupplyand
1Whilewerecognizethattheterm“secular”iscontestedandhasmultiplemeanings(Asad,2003),hereweuse
thetermtorefertoorganizationsthatarenotconnectedtoanyreligiousgrouporcommunityandarenotlinked
topoliticalparties,religiousorotherwise.IntheLebanesecontext,secularorganizationsoftenexplicitly
distinguishthemselvesfromreligiousandsectariangroupsandideologies.
2
demandprocesses.Inapolitystructuredexplicitlyalongreligiouslines,beinganavowed
secularistgoesagainstdominantsocialandpoliticaltrendsandoffersfewifanymaterial
rewards.Asaresult,secularNGOsthatprovidehealthservicesmayattractdoctorswhoare
notincorporatedinpatronagenetworksassociatedwithmorepoliticallyconnectedreligious
andsectarianorganizationsand,therefore,maybemoremotivatedbycharitable
considerationsoracommitmenttoprofessionalism.Second,widespreadcitizen
dissatisfactionwithreligiousandsectarianorganizations,2whichareoftenviewedascorrupt
andself-serving,mayresultininferiorevaluationsofwelfareprogramsrunbysuchgroups
and,conversely,expressmorefavorableassessmentsofservicesprovidedbyorganizations
thatexplicitlydissociatethemselvesfrompoliticalsectarianism.
Inthenextsection,wejustifyourfocusonthehealthsector,presenta
multidimensionaldefinitionof“quality”inprimaryhealthcare,andreviewargumentsabout
whysometypesofprovidersmaybeespeciallyadeptatprovidinghealthcareandothertypes
ofsocialservices.Thethirdsectionofthepaperprovidesessentialbackgroundinformation
onLebanonandonthetypesoforganizationsinquestionanddescribesthedataandkey
variablesusedintheanalyses.Sectionfourpresentsdescriptiveandstatisticalanalyses
followedbyadiscussionoftheimplicationsofthefindingsfortherelationshipsbetween
organizationalmission,politicalcontextandthequalityofservicedelivery.Intheconclusion,
wesummarizethefindingsandsuggestabroaderresearchagendaonpoliticalcontext,
organizationalmissionandthequalityofservicedelivery.
2Werefertoorganizationsas“religious”whentheyhavenoformallinkagetopoliticalpartiesormovementsand
“sectarian”whentheyareexplicitlylinkedtoapoliticalpartywithlinkstoaparticularreligiouscommunity.
3
Politics,healthanddimensionsofhealthcarequality
Thehealthsectorisanappropriatearenaforexaminingwhetherdifferenttypesof
organizationsexhibitawelfareadvantagebecausemanyNSPsareinvolvedinthedeliveryof
medicalservicesandaccesstohealthcareisimportanttowell-being(Cammett, 2014; Thachil,
2014).Furthermore,foravarietyofreasons,socialscientists–andnotjustpublichealthand
medicalspecialists–shouldbeconcernedwiththepoliticsofhealth.First,accesstohealth
careisimportanttowell-being.Asaresult,peoplemayfeelindebtedtoinstitutionsthat
provideormediateaccesstomedicalservicesand,cognizantofthesepotentialpayoffs,
politicalorganizationsfaceincentivestodeliverorclaimcreditfortheprovisionofhealth
care.Thehealthsystemisalsoacriticallocusofcitizeninteractionswithgovernments,which
playanimportantroleinthefinancingandprovisionofhealthcareinmiddle-income
countries(Rockers,KrukandLaugesen,2012)andwithnon-stateproviders,whichareeither
wellestablishedorincreasinglyimportantinwelfareregimesindevelopingcountries
(CammettandMacLean,2014;GoughandWood,2006).Insocietieswithpoliticized
ethnoreligiousidentities,asinLebanon,theprovisionofbasicservicesalsohelpstoconstitute
asenseofgroupmembershipbyestablishingboundariesofinclusionandexclusionin
politicalcommunities(Cammett 2014, 2, 13-14).Thus,theprovisionofhealthcarecan
intersectwithpoliticsinbothdirectandindirectways.
Measuringhealthcarequality
Intheliteratureonhealthpolicyandmanagement,itiswidelyacceptedthatquality
encompassesmultipledimensions,includingobjectiveandsubjectivemeasuresaswellas
technicalandnon-technicalfactors.Inbroadterms,healthcarequalityincludesthree
componentsrelatedtothestructure,processandoutcomeofthedeliveryofhealthservices,
respectively(Donabedian,1988;Klassenetal.,2010).Thestructuraldimensionofquality
referstotheenvironmentinwhichhealthcareisprovided,orthematerialandhuman
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resourcesandcharacteristicsofthefacilitywhereservicesaredeliveredaswellasthe
organizationofthedeliveryofmedicalservices.Thisincludestheavailabilityandconditionof
medicalequipmentandtrainedmedicalstaff,medicationsandrelevantinfrastructureaswell
asthewaysinwhichphysicalandhumanresourcesaremanagedupanddownthesupply
chaininthedeliveryofcare.Theprocess-orientedcomponentofqualityaddressesthe
methodbywhich healthcareisprovided,focusinginparticularonthewaysinwhich
providersinteractwithpatientsaswellasprovidercapabilitiesandeffort.Processmeasures
assessdoctorknowledgeandtrainingaswellasthedegreetowhichtheyapplythis
knowledgetodeliverappropriatecaretopatientsinatimelyandrespectfulmanner.Finally,
outcomesdenotetheresultsofhealthcare,notablythehealthstatusofpatientsandpatient
satisfaction,amongotherfactors(StelfoxandStraus,2013;Tuanetal.,2005).
Twopointsrelatedtotheconceptualizationandmeasurementofhealthcarequality
shouldbeemphasizedandguideourchoiceofindicators.First,healthoutcomesresultfroma
varietyoffactorsaboveandbeyondthedeliveryofservices(MarmotandWilkinson,2004),
complicatingeffortstolinkthemdefinitivelytotheprovisionofmedicalcare.Asaresult,our
analysesdonotaimtoexplainhealthoutcomes.Second,publichealthresearchshowsthatthe
processdimensionsoutweighthestructuralaspectsofqualityinaffectinghealthoutcomes
(DasandHammer,2014).Adoctorwhoiswell-trained,regularlyshowsuptowork,and
practicesmedicineattheir“knowledgefrontier”hasagreaterimpactonpatienthealththan
themereavailabilityofmedicalsuppliesandnewmachines.Withoutcapableandcommitted
professionalstaff,state-of-the-artmedicalequipmenthaslittleeffectonpatienthealth.
Likewise,patientsaremorelikelytoreportmorefavorableviewsoftheirserviceproviders
whentheyseemcompetent,engagedandattentive,evenwhenthefacilityinwhichthecareis
providedislessattractiveandlesswellappointed.Thus,whileweaccountforthestructural
dimensionsofqualityinouranalyses,wefocusmostcentrallyonprocessquality.
Furthermore,mostofstatisticalanalysesaimtoexplainsubjectivemeasuresofquality,
5
notablypatientsatisfaction,becauseperceptionsofperformanceratherthanobjective
measuresofqualityaremoregermanetocitizenevaluationsofprovidersand,therefore,are
likelytohaveamoredirectimpactonpoliticalattitudesandpreferences(Cammett,Lynch
andBilev,2015;ChristensenandLægreid,2005).Indeed,ourhypotheses,whichhighlightthe
reasonswhycompetentdoctorsselectintosomeproviderorganizationandwhysome
patientsreportmorefavorableviewsofsomeprovidertypes,aremoredirectlyrelevantto
theprocess-orienteddimensionsofmedicalcare
OrganizationalMissionandtheQualityofServiceDelivery
Distinctsocialscienceapproaches,whichwereviewbrieflybelow,eitherdirectlyorindirectly
suggestthatdifferenttypesoforganizationsarelikelytoexhibitawelfareadvantage(or
disadvantage).
Faith-BasedOrganizationsandCharitableMotivations
Asubstantialliteratureonfaith-basedorganizations(FBOs)holdsthatthecharitable
dimensionsofreligionmotivatethepioustovolunteerorworkforminimalcompensationto
dosocialgood(ClarkeandJennings,2008;Cnaan,2002;DeHavenetal.,2004;Unruhand
Sider,2005;Wuthnow,2004).Theseapproachesholdthatreligiousorganizationstendto
attractpersonnelwhoarecommittedtotheirmissionsonspiritualgrounds,makingthem
willingtoputinlonghours,oftenforrelativelyminimalcompensation.Inaddition,staff
membersandvolunteersinreligiouscharitiesmaychoosetoserveothersasawaytoensure
thesurvivalofthecongregationthroughincome-generatingactivitiesorinordertofoster
acceptanceofthereligiousgroupinthecommunitywhereitisbased.Socialserviceprovision
mayalsoaidinproselytism,apotentiallypowerfulincentivefortheleadershipandstaffof
religiousorganizationstoofferhighqualityservicesandonethatisrelativelyuniqueto
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religiousgroups.ArecentspecialissueoftheLancetonreligionandhealthcareechoessome
oftheseclaims(Karametal.,2015;SummerkillandHorton2015).3
TheEconomicsofReligionand“Strict”Churches
Theliteratureontheeconomicsofreligionpointstoarelatedyetdistinctreasonwhyatleast
someFBOsmaydeliversuperiorwelfareservices.“Strictchurches”(Iannaccone1994)or
religiousgroupsthatrequiremajorsacrificesfromtheirmembersandcallonadherentsto
visiblydistinguishanddistancethemselvesfromtherestofsociety,exhibithigherratesof
volunteerismandattractmoredevotedpersonnelthanothers.4Thehighlevelsof
commitmentoftheirmembersenablessuchgroupstoweedoutlesscommittedindividuals,
therebyovercomingthefreeriderproblemsthatplaguemostorganizations,includingless
stringentFBOs.Theselectioneffectsatthecoreofthisapproachinturnmayaffectthequality
ofservicesbyincentivizingstafftodevotemoreefforttotheirworkforlittleorno
compensation.
Organizationalstrictnessmaybeassociatedwithhigherlevelsofsubjectiveand
objectivequality.Ontheonehand,organizationsthatexpectbigsacrificesonthepartoftheir
membersmayattractespeciallycommittedprofessionals,whoarelikelytoworktotheir
“knowledgefrontier”(Das,HammerandLeonard,2008),leadingtohigherlevelsof
objectivelymeasuredqualityofservicedelivery.Ontheotherhand,beneficiariesand
communitymembersmayperceivethatstaffmembersatfacilitiesrunbystrictgroupsare
morelikelytobeself-sacrificing,toworkespeciallyhard,andtoremaincommittedtotheir
cause,leadingtohighersubjectivemeasuresofservicequality.
3ReinnikaandSvensson(2010)provideevidenceofafaith-basedwelfareadvantageintheirstudyofreligious
non-profitorganizationsinUganda.Astheynote,“Thesefindingsareconsistentwiththeviewthatreligious
nonprofitprovidersareintrinsicallymotivatedtoserve(poor)people—workingforGodseemstomatter!”4AprimeexampleinIannaccone’swork(1994)istheChurchoftheLatterDaySaints.
7
EthnoreligiousPartiesandPoliticalIncentives
Whenadaptedtothepoliticalarena,similarlogicsmayapplytoethnicorsectarianparties,
whichcombinecommunalandpoliticalmessages.Attheindividuallevel,identity-based
partieswithaffiliatedsocialservicewings,suchasHezbollahinLebanon,HamasinPalestine,
theBharatiyaJanataPartyinIndiaandotherethnicandreligiousparties,mayattract
volunteersandstaffmemberswhoarewillingtoputinlonghoursatparty-linkedinstitutions,
whetherbecauseofgenuinecommitmenttothecause,integrationinpartypatronage
networksorboth.Attheorganizationallevel,thedrivetowinvotesortogalvanizenon-
electoralmobilizationconstitutesastrongincentiveforpoliticalgroupstoofferhigh-quality
services(Cammett,2014;Thachil,2014).Ethnicandsectarianpartiesmaythereforefacehigh
incentivestoofferattractiveandwell-runsocialprograms.
However,ifsectarianpartiesoperateaccordingtoaclientelistlogicratherthanan
ideologicalvision,thenstaffmembersatparty-linkedinstitutionsmaybelessinclinedto
makepersonalsacrificesonbehalfofparty.Incomparisonwithmoreintrinsicmotivations,
suchextrinsicincentivespotentiallyreducethedrivetoprovidehighqualityservices.
Similarly,communitymembersmayviewthewelfareagencieslinkedtocorrupt,patronage-
basedpartieswithcynicism,reducingsubjectiveevaluationsofthequalityofservicesoffered
bysuchinstitutions.
ThesedistinctapproachessuggestthatFBOsmaydeliversuperiorsocialservicesthan
othertypesofproviders,whetherbecausetheirreligiousmissionsincentivizestaffmembers
toprovidehighqualitycharitableservicesorbecausetheyattractespeciallycommitted
personneland,therefore,moreeffectivelyovercomefreeriderproblemsplaguingother
organizations.Someevidencealsosuggeststhatsectarianparties–particularlythosethat
emphasizeastrongideologicalmission–mayproviderelativelyhighqualityservicesunder
someconditions.Furthermore,thesacrificesthatstaffmembersmakebyworkingat
8
charitableorganizationsratherthanfor-profitinstitutionsmayalsogarnerhighersubjective
measuresofquality.
Apublicsectorwelfaredisadvantage?
Muchdevelopmentresearchfocusesontheroleofthepublicsectorinservicedelivery,
particularlyinthecontextofthegovernmentfiscalcrisesindevelopingcountriesandthe
emphasisontheprivatesectorandpublic-privatepartnershipsindevelopmentpolicysince
the1980s(CITES).Indeed,somestudiesoftheprovisionofservicesbyFBOsandidentity-
basedpartiesbenchmarkservicedeliverybytheseorganizationsagainstthatofstateagencies
(CITES;LANCET2015,ETC.).Otherworkcomparestheextentandqualityofservices
providedbygovernmentinstitutionswiththoseofthefor-profitprivatesector,whichisthe
fastestgrowingproviderofbasicservicesinmanydevelopingcountries(CITES).Whilealarge
bodyofworkexaminestheconditionsunderwhichstateagenciesprovidebetterservices
(WorldBank,2004;CITES),anoverarchingthemeisthatthepublicsectorfacesconstraintsin
effectiveservicedelivery.Theextenttowhichthisistrueisanempiricalquestionthatis
contingentonspecificsociopoliticalandeconomicconditionsandmayvarydependingonthe
typeofserviceinquestionanddimensionofquality,asourresultssuggest.
Inthenextsection,wedescribethesampleanddatausedtoassesswhethercertain
providertypesinLebanonexhibitawelfareadvantage,whethermeasuredinobjectiveor
subjectiveterms.
SampleDesignandDataCollection
Lebanonisanappropriatesiteforthisresearchbecauseabroadrangeofprimaryhealthcare
providersandnon-stateactorsoperateinthewelfareregimeandmostarewellestablished.
TheLebanesegovernmentisbasedonapower-sharingarrangement,whichenshrines
religioninthepoliticalsystemandstipulatesthatgovernmentpostsareallocatedbysect
9
accordingtoapre-establishedformula,effectivelyleadingtothedistributionofpublic
resourcesalongsectarianlines(SaltiandChaaban,2010).
Thesectarianpower-sharingsysteminLebanonhasshapedthepost-independence
welfareregime,whichinvolvesminimalstateinterventionandreliesheavilyonprivate,non-
stateactors,includingreligiouscharities,sectarianpartiesandNGOs.Asaresult,the
Lebanesecaseismostdirectlycomparabletocontextswithpoliticizedethnicorreligious
cleavages,aphenomenonthatisincreasinglycommonintheMiddleEastandSouthAsia,
amongotherplaces.However,theLebaneseexperienceofferspertinentlessonsforMiddle
Easternandotherdevelopingcountriesinthecontemporaryperiod,whenpublicwelfare
infrastructureisdeclining,non-stateprovisionisontheriseandsystemsbasedonhybrid
governancemodelsarepromotedbydevelopmentpolicies(CITES).
Inthehealthsector,thestateplaysaminimalroleintheactualdeliveryofhealth
servicesbutprovidesextensivefinancingfornon-stateproviders.Themajorsectarianparties
andmovementsholdgreatswayinpublicinstitutionsthroughthesectarianpower-sharing
system,perpetuatingweakstatecapacityandeffectivelyinhibitingreform.Asaresult,state
effortstobuildamorerobustpublicwelfareinfrastructureandtoexertmoreregulatory
controloverprivateandnon-stateactorsinthewelfareregimehasmetstiffresistance,
althoughtheMinistryofPublicHealthhasincreaseditsstewardshipofthehealthsectorin
recentyears.Inthissystem,stateagenciesandsocialprogramsarelucrativesourcesof
patronageforparties,politicalmovements,andlocalpoliticians,creatingentrenchedinterests
inthestatusquo(Cammett2014,ch.2).
AlthoughthemajorityofhealthcareprovidersinLebanonworkinthefor-profit
privatesector,thecharitablesector,whichcaterstopoorandlowermiddleclasspeople,isa
vitalandgrowingcomponentofthehealthsystemandisanimportantpartnerinthe
LebaneseMinistryofPublicHealth’s(MOPH)plantoofferuniversalcoveragetothe
population.TheMOPHnetworkofhealthcenters,whichisthefocusofthispaper,features
10
bothpublicsectorandnon-stateproviders.Inexchangeforprovidingheavilysubsidized
medicalservices,theMOPHprovidesnon-financialresourcesandaccesstofreeorheavily
subsidizedmedicationstocentersthatmeetminimumstandards.Religiouscharitiesand
sectarianpoliticalpartiesrunabouttwo-thirdsofprimaryhealthfacilitiesinthenetwork.Of
theremainingone-thirdofcharitablecenters,about60percentarerunbyseculargroups
(Cammett 2014, 53-54).5Invirtuallyallcharitablehealthcenters,doctorsworkonapart-time
basis,earningastandard,minimalfeecalculatedonaperpatientbasis,whiledevotingmost
oftheirtimetotheirownorotherprivate,for-profitpractices.Asaresult,thereislimited
variationintherateandstructureofcompensationfordoctorsworkinginfacilitiesrunby
differenttypesofproviders.
Sample
Thesampledesignforthepilotstudyfollowedthefollowingprocedures.First,allcentersin
thesamplearepartoftheMOPHcharitablenetwork.Second,allfacilitiesinthesample
operateonanot-for-profitbasisandprimarilyservepoorandlow-incomefamilies.Third,the
sampledfacilitiesaredrawnfromtheuniverseofcenterslocatedinGreaterBeirut,which
containsthehighestpopulationconcentrationinthecountryandfeatureshealthcentersrun
byallprovidertypes.ItisalsoimportanttonotethatmostcentersintheMOPHnetworkare
runbyaparentorganizationsuchasareligiouscharity,politicalpartyorNGO,whichhas
multiplefacilitiesacrossthecountry.GiventhatallsampledcenterswereintheMOPH
networkandarelocatedinthecapital,weexpectthesampletobesomewhatbiasedtowards
higherqualityservices.
Thedatacollectionteamwasabletocollectrelativelycompletedataon27ofthe36
centerslocatedinGreaterBeirutintheMOPHprimaryhealthcarenetwork.Table1
summarizesthedistributionofPHCsinthesampleacrossdifferenttypesofprovider
5Thesedataarefrom2008.
11
organizations,thekeyvariableofinterestinthispaper,andsamplesizesforeachdata
collectioninstrument.
12
Table1:Institutionaltypesofprimaryhealthcentersinthesample
Typeoffacility Numberoffacilitiesinthestudy
Samplesizeofchiefmedicalofficersurvey
Samplesizeofdirectobservations
Samplesizeofpatientexitinterviews
Samplesizeofmedicalvignettes/doctorsurveys
Publicinstitutions 4 4 15 16 5SecularNGOs 5 5 15 15 5Religiouscharities 11 11 63 64 20Politicalcharities 7 7 42 42 13Total 27 27 135 137 43
DataCollectionProcedures
Thedatacollectionforthisstudyentailedthedesignandimplementationofmultipleoriginal
surveys.6Cammetttrainedateamofenumeratorswhothencarriedoutthefollowingsurveys
intheselectedhealthcarefacilities:(1)surveyinterviewswiththechiefmedicalofficerand
medicalstafftoobtaininformationontheservicesandinfrastructureavailableatthefacility
andonmanagementandtrainingprocedures,amongotherissues;(2)directobservationof
clinicalexaminations;(3)exitinterviewswithpatientsattheselectedfacilities;and(4)
medicalvignettesadministeredtogeneralpractitionersateachfacilitytoassesstheirmedical
knowledgeandadvice.Severalmonthsafterdatacollectionwascomplete,Cammettthen
conductedin-depthinterviewswiththedirectorsofthehealthnetworksrepresentedinthe
sample.
Thechiefmedicalofficersurveyprovidescrucialbaselineinformationoneachhealth
center.Thequestionnairegathersdataonthenumber,educationalbackground,experience
andcompensationstructureofeachemployeeaswellastheoperatingbudgetofthefacility;7
theaveragepatientloadduringthepastyearandepidemiologicalprofilesofthepatients;
6SeveraloftheinstrumentswereadaptedfromtheworkofJishnuDasandhiscollaborators(Das,2011;Das,
HammerandLeonard,2008).7Mostintervieweesdeclinedtoprovideinformationonthefinancesandbudgetsoftheirrespectivecentersin
thesurvey,however,follow-upinterviewswiththeheadsofhealthnetworkssuccessfullygathereddataonstaff
compensationratesformanycentersinthesample.
13
availableinfrastructureatthefacilityrelatedtotheworkenvironmentandtomedical
proceduresandexaminations;andinternalproceduresformonitoringtheperformanceof
doctorsandnursesatthefacilityand,moregenerally,forhumanresourcemanagement.The
chiefmedicalofficersurveythereforeprovidesdataoninfrastructuralqualityandonsome
dimensionsofprocessqualityatthefacilitylevel.
Asecondmethodofdatacollectionprovidesinformationonthenatureofinteractions
betweendoctorsandpatientsbasedondirectobservationbythetrainedenumeratorsof
clinicalexaminations.Thedatacollectedincludeinformationaboutthepatient,suchasher
symptoms,age,gender;informationaboutthedoctor’sinteractionswiththepatient,notably
thenumberofquestionsaskedbythedoctorandthetypesofexaminationsandtreatments
given;andthepriceschargedfortheservicesrendered.Thesedataproviderelatively
objectiveinformationonthenatureofdoctorattentivenesstothepatient.Althoughthe
findingsaresubjecttoHawthorneeffects,8thissourceofbiasmaydeclinewiththetimespent
observing(LeonardandMasatu,2006).Furthermore,thebiasduetoHawthorneeffects
shouldbeconsistentacrossallcenters,enablingcomparativeanalysesofthedatacollected.
Third,patientexitsurveyswerecarriedoutatthehealthcenterstoassesspatient
perceptionsofthecaretheyhavereceived.Thesurveycollectsbasicinformationonpatient
characteristicssuchaseducation,wealthandage;self-reportedhealthstatus;aspectsofthe
doctor-patientinteraction;andpatientsatisfaction.Theseresponsesprovideasubjective
measureofthequalityofcarebydiversetypesofproviders.
Afinalsurveyentailedtheadministrationofmedicalvignettestodoctorsatthehealth
centersinordertoassesstheirmedicalknowledge.Twotrainedresearchersconductedthe
interviewwiththedoctor,withoneservingasa“patient”andtheotherasthe“recorder.”
8Hawthorneeffectsrefertothetendencyofintervieweesorthesubjectsofastudytoimprovetheirbehavioror
productivitywhentheyareconsciousofbeingobserved.
14
Theypresentedfourcasesofhealthconditionsorillnesses,whichwereadaptedtothe
Lebaneseepidemiologicalprofile,experiencedbydistincthypotheticalpatientswhovaryby
ageandgender.9Eachvignettebeganwiththepatientpresentinghersymptomsandthe
recorderinvitingthedoctortoproceedexactlyasshewouldforanormalpatient.Inresponse
toeveryhistoryquestion,thepatientprovidedastandardizedresponsethatwascarefully
rehearsedinadvance.Similarly,anyphysicalexaminationrequestedbythedoctorwas
followedbyastandardizedanswerofferedbytherecorder.Afterthedoctorgavethe
diagnosisandtreatmentplan,thepairofenumeratorsadministeredthenexthypothetical
case.Theinformationgatheredfromclinicianresponsesisusedtoconstructanindexof
medicalknowledgeandadviceofthemedicalstafffromdifferenttypesofproviders,
generatingarelativelyobjectivemeasureofprocessqualityand,morespecifically,ofdoctor
competence.
Finally,Cammettcarriedoutin-depthinterviewswithMOPHofficialsandthedirectors
ofthehealthcentersandnetworksincludedinthesample.Theseinterviewsgathered
informationonthehistoryofthehealthprogramsrunbydifferentinstitutions;the
organizationalmissionsoftheparentnetworks;staffselection,trainingandmanagement
procedures;thefinancesandbudgetsofthehealthnetworksandindividualfacilities;and
otherrelevantinformation.Thedatafromtheseinterviewsfillinsomegapsinthesurvey
data,particularlyrelatedtofinancesanddoctorcompensationschemesandtotheroleof
organizationalmissioninshapingthehealthprogramsofdiversenon-stateinstitutional
networks.
9BecausesectissopoliticizedinLebanon,thenamesofthehypotheticalpatientsweredeliberatelychosentobe
neutralwithrespecttoreligiousidentity.Forexample,namesthattendtobeusedintheShi’acommunity,such
asHussein,orintheChristiancommunity,suchasTony,werepurposefullyavoided.
15
DescriptiveAnalyses:IndicatorsofHealthCareQualityandVariationacrossProviderTypesAsexplainedabove,healthcarequalityincludesthreecomponentsrelatedtothestructure,
processandoutcomeofthedeliveryofhealthservices.Table2providessummarystatistics
fortheselectedmeasuresofquality,andmeansandstandarddeviationsforeachprovider
type.
14
Table2:Summarystatisticsofselectedqualityindicators
Qualityindicator Source N Mean St.Dev.
Min Max Publicmean(St.Dev.)
SecularNGOmean
(St.Dev.)
Religiouscharities
mean(St.Dev.)
Politicalcharities
mean(St.Dev.)
Workplaceequipment Chiefmedicalofficersurvey 27 0.943 0.091 0.636 1 0.89(0.17)
0.95(0.05)
0.94(0.08)
0.97(0.07)
Healthequipment Chiefmedicalofficersurvey 27 0.772 0.159 0.286 0.929 0.79(0.13)
0.81(0.1)
0.78(0.16)
0.72(0.22)
Organizationalmonitoring Chiefmedicalofficersurvey 27 1.667 1.177 0 3 1.75(1.5)
1.6(1.14)
1.82(1.17)
1.43(1.27)
Goodgovernance Chiefmedicalofficersurvey 27 0.578 0.279 0.056 1 0.51(0.4)
0.5(0.21)
0.64(0.29)
0.58(0.28)
Numberofphysicalexaminationsbydoctor
Directobservation 135 2.733 1.565 0 6 2.8(1.42)
2.87(1.41)
2.62(1.66)
2.83(1.56)
Doctormedicalknowledge Medicalvignettes 45 1.211 0.727 0 4 1(0)
2.3(1.1)
1.18(0.47)
1.12(0.65)
PatientsatisfactionwiththePHC
Patientexitsurvey 134 3.761 0.685 3 5 3.67(0.62)
4.27(0.7)
3.68(0.59)
3.73(0.78)
Patientsatisfactionwiththedoctor
Patientexitsurvey 134 3.791 0.684 3 5 3.67(0.49)
4.4(0.74)
3.7(0.61)
3.76(0.73)
15
Thefirstmeasure,“workplaceequipment”,whichrelatestoinfrastructuralquality,
capturestheavailabilityofmaterialsandequipmentessentialtorunacleanandfunctional
workingenvironmentforthedeliveryofprimaryhealthservices.Thisvariableisacomposite
indexbasedonachecklistofitemsavailableintheclinic.Thesecondvariable,“health
equipment,”isalsoacompositeindexmeasuringtheavailabilityofmaterialandequipment
usedinmedicaldiagnosesandtreatment.10
ThemeansinTable2indicatethattheavailabilityofinfrastructure,whetherrelatedto
theadministrativefunctioningofthecentersortomedicalequipment,isroughlysimilar
acrossalltypesofnon-profitproviders.Theaveragescoresfortheavailabilityofmedical
equipmentaresomewhatlowerbutalsorelativelyhigh,andthevaluesdonotvarywidely
acrossthedifferenttypesofhealthnetworks.T-testscomparingthemeanlevelsofthese
variablesindicatethatmeasuresofinfrastructuralqualitydonotdiffersignificantlyacrossall
providertypes.ThisisnotsurprisingthatmembershipintheMOPHprimarycarenetwork
requiresthatfacilitiesmeetbaselinestandardsfortheavailabilityandmaintenanceof
equipmentandsupplies.
Twocompositeindicatorsmeasuregovernanceatthelevelofthefacilitybasedon
questionsinthechiefmedicalofficersurvey.Thefirst,“organizationalmonitoring,”isan
indextogaugeoversightpoliciesandpracticeswithinthenetworkandfacilityitself.The
variableisanadditiveindextoassesswhethertheadministrationemploysoneormore
methodsofmonitoringthehealthcenter,includingvisitsbyrepresentativesfromtheparent
organization,theimplementationofpersonnelsurveystoobtainfeedbackonstaffconcerns,
andthefieldingofpatientsatisfactionsurveys.Asecondindicator,“goodgovernance,”isa
morecomprehensiveindexoffacility-levelsupervisionandmanagementandincludes
variablesrelatedtoexternalmonitoringbytheMOPHandinternaloversightbythe
10SeetheSupplementalOnlineAppendixPartA1foritemsincludedintheconstructionofthesetwoindicators.
16
administrationofthefacility.Theindexisbasedonanaverageofsixindicators,eachofwhich
rangesfrom0to1,includingregularvisitsbygovernmenthealthinspectorstothefacility,
regularvisitsbytheparentorganizationtoinspectthefacility,theadministrationofpatient
satisfactionsurveys,thecollectionofstaffsurveys,regularstaffmeetings,and
institutionalizedchannelsofcommunicationbetweenstaffmembersandthemanagementof
thecenter.
AsseeninTable2,acrossthefourtypesofproviders,nomajordifferencesareevident
intheextenttowhichorganizationsmonitortheirfacilitiesorpromotefeedbackanddialogue
withstaffandpatients.T-testscomparingthemeanlevelsofthesevariablesconfirmthat
levelsofinternalmonitoringandgovernancedonotdiffersignificantlyacrossallprovider
types.Again,thislackofvariationmayreflecttheneedtocomplywithasetofbasic
managementpracticesinordertomeettheconditionsformembershipintheMOPHprimary
healthcarenetwork.Giventherealandperceiveddeficiencyofpublicserviceprovisionin
academicresearch(CITES)andintheLebanesecontext[ARABBAROMETER/WVSSURVEY
DATA],thelackofvariationincertaindimensionsofhealthcarequalityacrossprovidertypes
–includingthepublicsector-isanimportantandcounterintuitivefindingworthyoffurther
research.
Anothermeasureofprocess-relatedquality,doctoreffort,isderivedfromdirect
observationsofclinicalexaminations.Onemeasureofdoctoreffortrecordsthenumberof
physicalexaminationsofthepatientbythedoctor(Das,HammerandLeonard,2008).11As
seeninTable2,thisvariablealsodoesnotsuggestmeaningfulvariationacrossprovider
types,afindingconfirmedbytheresultsofat-test.Infact,themeansandstandarddeviations
foreachprovidertypearequiteclosetoeachother.Thisfindingismoresurprisingvis-à-vis
11Thespecificphysicalexaminationsinthisstudyincludetheuseofastethoscope,bloodpressuremeasurement,gaugingbodytemperature,palpitation,checkingthepulse,andotherphysicalexaminationsrecordedbytheobserver.
17
sometheoriespresentedabove,whichimplythatstaffmembersatreligiousfacilities–and
especiallyatfacilitiesrunbyreligiousordersthatmakegreatdemandsontheiradherents–
wouldexertmoreefforttotheirworkininstitutionsrunbythereligiousorder.
Themedicalvignettesprovideawealthofinformationrelatedtoprocessquality,
focusinginparticularondoctors’medicalknowledge.Basedonfourvignettesofdifferent
healthconditionscommonlyfoundinLebanon,weconstructanindicatorof“doctorobjective
knowledge,”whichgaugesthenumberofvignettesdiagnosedcorrectlybythedoctorand
rangesfrom0to4.ThismeasurepointstoapotentialwelfareadvantagebysecularNGOs.As
seeninTable2,doctorsinNGOsearnthehighestaveragescorewith2.3conditionscorrectly
diagnosed,whereastheaveragescoresforotherorganizationaltypesareallapproximately
onecorrectdiagnosisoutoffour.At-testcomparingtheaveragenumberofcorrectdiagnoses
ofdoctorsintheNGOtypewiththemeanofallotherprovidertypesalsosuggeststhatthe
differenceisstatisticallysignificantatthe10percentlevel(t=-2.3527,df=4.224,p-value=
0.07483).ThisfindingprovidessuggestiveevidencethatNGOssomehowrecruitmore
competentdoctors.
Finally,theindicatorsweuseforoutcome-relatedqualityaresubjectivemeasuresof
satisfactionreportedbypatientsforthereasonswenoteearlierinthepaper.Intwodifferent
questions,patientsreporttheirlevelsofsatisfactionwiththehealthcenterandwiththeir
doctor,respectively.Patientsatisfactionalsoexhibitsmeaningfulvariationacrossprovider
types,againwithsecularNGOsdisplayingthehighestoverallvaluesonrelatedmeasures.The
averagescoreofpatientsatisfactionwiththecenterisalmost4.3forsecularNGOs,whereasit
isaround3.7forothertypes.Similarly,theaveragescoreofpatientsatisfactionwiththe
doctoris4.4forsecularNGOs,whereasitisaround3.7forotherorganizationaltypes.At-test
comparingthemeanvaluesofpatientsatisfactionwiththedoctorinsecularNGOsandin
othertypesofprovidersalsoindicatesthatthedifferenceisstatisticallysignificantatthe1
percentlevel(t=-3.4446,df=16.769,p-value=0.003146).Thisresultindicatesthatpatients
18
havemorefavorableperceptionsofdoctorsatNGOsthanatothertypesoffacilities,
regardlessofwhetherornotthequalityofcarewassuperiorbymoreobjectivemeasures.
Insum,descriptiveanalysesindicatethatmeasuresofqualityinprimaryhealthcare
aresimilaracrossprovidertypesforstructuralindicators,suchastheavailabilityof
administrativeandmedicalinfrastructure,andsomedimensionsofprocess-related
indicators,notablygovernanceproceduresandprovidereffortatthefacilitylevel.Measures
ofdoctorknowledgeandpatientsatisfaction,however,varyacrossprovidertypes,with
secularNGOsexhibitingadistinctadvantageinbothareas.Inthenextsection,weexplore
thesedescriptivefindingsinmoredetailtoseeiftheapparentsecularwelfareadvantagestill
holdsaftercontrollingforpotentialconfounders,andifso,whichcharacteristicsofNGO-run
healthcentersandofdoctorsatthesefacilitiesmightcontributetoexplainingthisvariation.
StatisticalAnalysesofSubjectiveHealthCareQuality
Controllingforpotentialconfounders
Thedescriptiveanalysissuggeststhatpatientsatisfactionlevelsarehigherathealthfacilities
runbysecularNGOs.Alinearregressionmodelthatusesdummiesforeachprovidertype
withpublicinstitutionsasthebenchmarkcategoryshowsthatthisassociationisalso
statisticallysignificantatthe5percentlevel(Table3Column1).Column2addstothemodel
anumberofpatientcharacteristicsthatcouldaffectboththechoiceofproviderandpatient
satisfaction.Thesepotentialconfoundersincludepersonalcharacteristics,generalhealth
conditions,anddistancetraveledtothefacility.12ThecoefficientonthetypeNGOvariable
remainspositiveandstatisticallysignificant.InColumn3,wethenshowthatpatient
satisfactionwiththefacilityisalmostperfectlypredictedbypatientsatisfactionwiththe
doctor.
12Formoreinformationonanddescriptivestatisticsofthesecontrolvariables,seetheSupplementalOnlineAppendixPartA2.
19
Takingsatisfactionwiththedoctorasthedependentvariable,Columns4and5suggest
thatpatientsaremoresatisfiedwithdoctorsinfacilitiesrunbysecularNGOs,evenafter
controllingforthesamebatteryofpotentialconfounders.Therelationshipisstatistically
significantattheconventional5percentlevel.Forourkeyvariableofinterest–thevariable
indicatingNGOtype–wealsoreportblock-bootstrappedstandarderrorstoovercomethe
potentialproblemofclusteringatthePHClevel.13Eventhoughthelargerstandarderrors
showthattheuncertaintyaroundtheestimatedeffectofNGOtypeincreaseswithblock-
bootstrapping,theeffectsarestillarguablyrobust,especiallygiventhesmallsamplesize.
TheestimationsinTable3suggestthatpatientsatisfactionwithdoctorsinNGO-run
facilitiesisalmostonestandarddeviationhigherthanthatofpatientsinpublicinstitutions.In
otherwords,therelationshipissubstantivelyimportant,callingforfurtherexploration.14
Becausepatientsatisfactionwiththedoctoralmostperfectlypredictssatisfactionwiththe
facility,wefocusonsatisfactionwithdoctorsasthedependentvariableintheremainderof
theanalyses.
13Block-bootstrappingisatechniqueofestimatinguncertaintywhenthereisalegitimateconcernaboutcorrelatederrortermsinamodel(orwithin-groupdependence),butthenumberofclustersissmallforcalculatingcluster-robuststandarderrors(Cameron,GelbachandMiller,2008).Inourcase,weuseblock-bootstrappingasourdataisclusteredatthePHClevel.14HierarchicallinearmodelswithvaryinginterceptsatthedoctorlevelorthePHClevel,andanorderedprobitmodelgenerateverysimilarresultsintermsofsubstantialandstatisticalsignificancetotheresultsofthelinearregressionmodelwereportinthemainbodyoftext.SeeOnlineAppendixPartA3foralternativespecificationsoftheoutcomemodel.Furthermore,weprovidetheresultsofmatchinginOnlineAppendixPartA4,whichleadtoverysimilarresults.
20
Table3:Regressionresultsregardingprovidertypeandpatientsatisfactionwiththehealthcenterandwiththedoctor
========================================================================================================================================================= Dependent variable: ------------------------------------------------------------------------------------------------------------------ Patient's satisfaction with the PHC Patient's satisfaction with the doctor (1) (2) (3) (4) (5) --------------------------------------------------------------------------------------------------------------------------------------------------------- Provider: NGO 0.600 0.512 0.048 0.733 0.568 (0.244)** (0.270)* (0.165) (0.239)*** (0.265)** [0.373]+ [0.412] [0.179] [0.342]** [0.380]+ Provider: Religious 0.016 0.290 0.110 0.032 0.221 (0.192) (0.212) (0.128) (0.188) (0.208) Provider: Political 0.065 0.316 0.126 0.089 0.234 (0.201) (0.223) (0.135) (0.198) (0.219) Gender: Female 0.199 0.004 0.239* (0.130) (0.079) (0.127) Age -0.003 -0.001 -0.002 (0.005) (0.003) (0.005) Socioeconomic status -0.187*** -0.009 -0.218*** (0.070) (0.044) (0.068) Minutes of transport to center -0.007 -0.009 0.002 (0.014) (0.009) (0.014) Vehicle used in transport (dummy) 0.032 0.067 -0.043 (0.163) (0.098) (0.160) Days of sickness before visit 0.003 0.002 0.002 (0.005) (0.003) (0.005) Self-reported health status 0.097 -0.009 0.130* (0.071) (0.043) (0.070) Previous visit to center (dummy) 0.173 0.139* 0.042 (0.136) (0.082) (0.133) Patient satisfaction with doctor 0.817*** (0.059) Constant 3.667*** 3.591*** 0.645** 3.667*** 3.606*** (0.172) (0.411) (0.325) (0.169) (0.404) --------------------------------------------------------------------------------------------------------------------------------------------------------- Observations 134 121 121 134 121 R2 0.070 0.155 0.698 0.103 0.196 Adjusted R2 0.049 0.070 0.664 0.082 0.115 Residual Std. Error 0.668 (df = 130) 0.662 (df = 109) 0.398 (df = 108) 0.655 (df = 130) 0.650 (df = 109) F Statistic 3.283** (df = 3; 130) 1.815* (df = 11; 109) 20.789*** (df = 12; 108) 4.962*** (df = 3; 130) 2.412** (df = 11; 109) ========================================================================================================================================================= Note: Normal standard errors are in parantheses, and block-bootstrapped standard errors (10,000 resampling) are in brackets. *p<0.1; **p<0.05; ***p<0.01; +p<0.15.
21
Potentialmediators
Whatfactorsmightmediatebetweenprovidertype,i.e.theapparentNGOadvantage,and
patientsatisfaction?Wefocusondoctor-levelvariablesaspotentialmediators,sincepatient
satisfactionistoaveryhighdegreedeterminedbysatisfactionwiththedoctor.Potential
mediatorsatthelevelofthedoctor,whichcanbothbeaffectedbyprovidertypeandaffect
patientsatisfaction,include:15
• Medicalknowledge:Patientsmaybemoresatisfiedwithdoctorswhoaremorecompetent,
asmeasuredbytheirmedicalknowledge.
• Jobsatisfaction:Thevignettessurveyasksdoctorshowsatisfiedtheyarewith
organizationwheretheywork.IfdoctorsinNGO-runfacilitiesexpressgreatersatisfaction
withtheirjobs,thenpatientsmayratethemmorefavorably.
• Professionalexperience:Patientsmaybemoresatisfiedwithdoctorswithmore(orless)
experience,andlevelsofexperiencemightalsobecorrelatedwithprovidertype.
• Perceiveddoctorcredentials:SomeLebaneseregarddoctorswhoreceivedtheirmedical
degreesfromformercommunistcountriesaslessqualified,andthereforepatientsmaybe
lesssatisfiedwithdoctorswiththesecredentials,irrespectiveoftheircapabilities.
Toseeifanyoftheabovefactorsactaspotentialmediators,wefirstneedto
demonstratethatthereisastatisticallysignificantrelationshipbetweenagivenvariableand
providertype,especiallyNGOtype.Tothatend,weregressthesevariablesonprovidertypes
alongwithappropriatecontrols(seeTable4).Theresultssuggestthatthereisapositiveand
significantrelationshipbetweenNGOtypeanddoctormedicalknowledgeandwithdoctorjob
satisfaction.Inotherwords,doctorswhoworkinNGOsarebothmorecompetentinwhat
theydoandmoresatisfiedwiththeircurrentjob.Thus,thesetwofactorsmaymediatethe
positiveassociationbetweensecularNGOsastheprovidertypeandpatientsatisfaction.
15SeetheOnlineAppendixPartA2fordescriptivestatisticsonthedoctor-levelpotentialmediatorvariables.
22
Table4:Regressingpotentialmediatorsonprovidertype
============================================================================================================ Dependent variable: ------------------------------------------------------------------------------------ Dr. obj. knowledge Dr. job sat. Dr. experience Dr. degree: Communist (1) (2) (3) (4) ------------------------------------------------------------------------------------------------------------ Provider: NGO 1.185 0.933 -5.368 -0.200 (0.382)*** (0.439)** (6.599) (0.317) [0.444]** [0.501]* [5.539] [0.335] Provider: Religious 0.152 -0.027 -2.247 -0.447* (0.321) (0.370) (5.595) (0.255) Provider: Political 0.087 0.022 0.418 -0.217 (0.320) (0.370) (5.575) (0.267) Doctor experience -0.014 0.006 (0.010) (0.012) Doctor degree: Communist -0.297 0.547** -6.839* (0.217) (0.256) (3.588) Constant 1.540*** 3.035*** 27.072*** 0.800*** (0.413) (0.481) (5.455) (0.224) ------------------------------------------------------------------------------------------------------------ Observations 38 37 38 39 R2 0.376 0.316 0.128 0.097 Adjusted R2 0.279 0.206 0.023 0.020 Residual Std. Error 0.595 (df = 32) 0.682 (df = 31) 10.372 (df = 33) 0.501 (df = 35) F Statistic 3.462** (df = 5; 32) 2.864** (df = 5; 31) 1.214 (df = 4; 33) 1.252 (df = 3; 35) ============================================================================================================ Note: Normal standard errors are in parantheses, and block-bootstrapped standard errors (10,000 resampling) are in brackets. *p<0.1; **p<0.05; ***p<0.01; +p<0.15.
Estimatingthemediationeffect
Wenowtestthelinkbetweenthepotentialmediatorsandthedependentvariable,i.e.patient
satisfaction.Totestbothofthehypothesizedrelationships(betweentheexplanatoryvariable
andthepotentialmediator,andbetweenthepotentialmediatorandthedependentvariable)
simultaneously,weusethemediationanalysistechniqueandthemediationpackage(Imai,
KeeleandTingley,2010;Imai,Keele,TingleyandYamamoto,2011;ImaiandYamamoto,
2013).Unlikeothercausalmediationanalysistechniques,thismethodenablesnon-
parametricidentificationofthemediationeffect,eveniflinearrelationshipsareassumed
betweentheexplanatoryvariableandthemediatorandbetweentheexplanatoryvariableand
thedependentvariable.Itproducesestimationsoftheaveragecausalmediationeffect
(ACME),whichrepresentstheportionoftheestimatedeffectoftheexplanatoryvariableon
theoutcomevariablethatgoesthroughthetestedmediator.
ToestimatetheACMEforeachpotentialmediator,themediationpackagerequires
specificationofanoutcomemodelandamediatormodel,throughwhichitthengenerates
predictionsforthemediatorandtheoutcomeandnonparametricallycomputestheACME.We
specifythesameoutcomemodelasinColumn5ofTable3,whileaddingthepotential
mediatorsandcontrolsatthedoctorlevel,asrequiredbythistechnique.Potentialmediator
variablesareatthelevelofdoctor,thustheoutcomemodelturnsintoamulti-levelmodel.For
thepotentialmediators–doctormedicalknowledgeanddoctorjobsatisfaction–themodelis
specifiedasinColumn1andColumn2ofTable4,respectively.Thus,themodelspecifications
forthemediatorandtheoutcomecanbedepictedasfollows:
!" = % + '(" + )*" + +"
,-" = ." + /0-" + 1-"
." = . + 2(" + 3!" + 4*" + 5"
inwhichVjisthevectorfordoctor-levelcovariates,Xijisthevectorforpatient-level
covariates,and�j,�ijand�jareeachnormallydistributedstochasticerrorswithzero
24
mean. TheACMEsareidentifiedwith90percentquasi-Bayesianconfidenceintervalsbased
on1,000simulations.TheresultsarepresentedinTable5.16
Table5:EstimatingtheAverageCausalMediationEffect(ACME)
Potentialmediatorvariable
Averagecausalmediationeffect
90%CIlowerlimit 90%CIupperlimit Proportionofthetotaleffectthroughthismediator
Doctormedicalknowledge
0.135 -0.213[-0.261]
0.536[0.617]
17.65%
Doctorjobsatisfaction
0.244 0.007[-0.053]
0.621[0.704]
28.17%
Note:“mediate”commandinthemediationpackageinRisusedtocalculatetheestimationsreportedinthistable.ACMEestimateandquasi-Bayesianconfidenceintervalsforeachpotentialmediatorarecalculatedwith1000simulations.Block-bootstrappedconfidenceintervallimits(individualPHCsareusedasblocks)areinbrackets.Whenblock-bootstrapping,100simulationswereusedforeachofthe500resamplings.
Table5suggeststhatdoctorjobsatisfactionisamuchmorelikelymediatorbetween
providertype(NGO,specifically)andpatientsatisfactionthandoctormedicalknowledge.
EventhoughdoctorsinNGOsusuallyhavehigherlevelsofmedicalknowledge,patients
treatedbythesedoctorsarenotnecessarilymoresatisfiedwiththecaretheyreceive,alogical
findinggiventhatnon-medicalprofessionalsarenotoftenqualifiedtoevaluatetechnical
training.ThisisrepresentedinthefirstlineofTable5,inwhichtheACMEofmedical
knowledgeisestimatedtobenotstatisticallydifferentfromzero.
ThesecondlineofTable5suggeststhatthepositiveeffectofNGOsonpatient
satisfactionmightatleastpartiallybeduetothehigherjobsatisfactionofdoctorsworkingin
facilitiesrunbysecularorganizations.TheACMEfordoctorjobsatisfactionisestimatedtobe
morethan0.2,andthevalueswithinthe90percentconfidenceintervalarealsodifferent
16Toestimatethemediationeffect,bothinthemodelpredictingtheoutcomeandinthemodelpredictingthemediatorweusesmallerversionsofthepatient-levelanddoctor-leveldatasets,because“thecurrentversionofthemediationpackagerequiresthatthemodelframesofthemediatorandoutcomemodelscontaintheexactsamesetofgroups,whichbecomesimportantwheneachmodelcontainsdifferentcovariatesandsomegroupsdropoutofthemodelframesduetomissingness.”(SeeTingley,Yamamoto,Hirose,KeeleandImai,2014.)Thus,thesmallerversionofthepatient-leveldatasetdoesnotincludethepatientswhowereexaminedbydoctoreliminatedfromthemediatormodelduetodatamissingness.Theestimationsoftheoutcomemodelbasedonthelargerdataset(n=135)andthesmallerdataset(n=97)arequalitativelythesame.
25
fromzero.ThegreaterjobsatisfactionofdoctorsinsecularNGOsexplainsonaverage28
percentoftheNGOadvantageingarneringhigherlevelsofpatientsatisfaction.
Asinthepreviousmodels,weemploytheblock-bootstrappingtechniqueinthe
mediationanalysistoovercomepotentialcorrelationinerrortermsduetotheunmeasured
effectsofindividualhealthcenters.Evenwithwiderconfidenceintervals,doctorjob
satisfactionremainsamuchmorelikelymediatorbetweenprovidertypeandpatient
satisfaction.17
Checkingthesensitivitytotheassumptionsofcausalmediation
Themediationanalysistechniqueweusedinthispaperinherentlyarguescausalityand,to
thatend,makesanimportantassumptioncalled“sequentialignorability.”Inadditiontothe
regularignorabilityofthetreatmentassumption,sequentialignorabilityassumesno
pretreatmentandposttreatmentconfoundingbetweenthemediatorandtheoutcome
variable.Totestforpretreatmentconfoundingbetweenthemediatorandtheoutcome,Imai,
KeeleandTingley(2010)offerasensitivityanalysisinwhichthesensitivityoftheACME
estimationscanbetested.Thisanalysisisbasedonthecorrelation,denotedwithρ, between
theerrortermofthemodelpredictingthemediatorandtheerrortermofthemodel
predictingtheoutcome.Ifsequentialignorabilityholds,allrelevantpretreatment
confoundershavebeenconditionedon,andthusρequalszero.Throughsimulation,itis
possibletocalculatethevaluesofρforwhichtheACMEiszerooritsconfidenceintervalis
zero.IftheestimatesoftheACMEcontainzeroatlowervaluesofρ,thisindicatesahigher
possibilitythattheremightbeunmeasuredpretreatmentconfoundersthatbothcauseboth
themediatorandtheoutcome,andthereforethesuggestedcausalpathmightbespurious.
17ThemarkedincreaseintheconfidenceintervalindicatesthatsomePHCsrunbysecularNGOsgarnerhigherlevelsofpatientsatisfactionthroughhigherlevelsofdoctorjobsatisfactionthanothers.Thisdeservesfurtherexplorationinfutureanalysesandinextensionsofthestudy.
26
Figure1reportsthesensitivityanalysis,i.e.ACMEestimatefordoctor’sjobsatisfaction
asafunctionofρ,forthecausalpathbeingarguedinthispaper.18Accordingly,ACMEturnsto
zerowhenρis0.2.Inotherwords,ifthereisapretreatmentconfounderthatleadstoa0.2
correlationbetweentheerrorterms,theACMEestimateturnsto0.Moreover,thelower
boundoftheconfidenceintervalforACMEturnszeroinverysmallamountsofcorrelation.
ThissuggestsamoderatedegreeofrobustnessoftheACMEestimatetopretreatment
confounders.Yet,theformulationofthequestionfordoctor’sjobsatisfaction19givessome
levelofconfidencefortheunconfoundedandpost-treatmentcharacteristicofthisvariable.
Furthermore,alargersamplesizewouldlikelyestablishtherobustnessofthesefindings.
Figure1:SensitivityAnalysisforDoctor’sJobSatisfactionasMediator
Sequentialignorabilityalsoassumesthatthereisnoposttreatmentconfoundingbetweenthe
mediatorandoutcomevariables.Themostimportantreasonforposttreatmentconfounding
mightbeacausalrelationshipbetweenpotentialmediators.FollowingImaiandYamamoto
18Thecurrentversionofthemediationpackagedoesnotallowforsensitivityanalyseswhenmultilevelmodelsareusedtopredicttheoutcomeandthemediator.Therefore,forthesakeofthesensitivityanalysis,weusedalinearregressionintheoutcomemodel.Thecriticalquantityofinterest,i.e.thelevelofsensitivityparameterρ,atwhichtheACMEestimateturnstozero,wouldnotdifferbetweenmodelsusingmultilevelregressionandmodelsusinglinearregression.19“Howwouldyourateyoursatisfactionwithyourjobinthishealthcenter?”(emphasisadded).
27
(2013),weregressthemediatorofinterest(inthiscase,doctorjobsatisfaction)ontheother
potentialmediator(doctormedicalknowledge)usingthetreatmentandappropriatecontrol
variables.BoththeregressionandanF-testsuggestthatthereisnosignificantrelationship
betweenthetwopotentialmediatingfactors.(See Online Appendix Part A5.) Itisimportantto
recallthatthisisabaselinecheck:Eventhoughwefailtorejectthenullhypothesisofno
conditionalassociation,wecannotfullyruleoutthepossibilityofacausalrelationship
betweenpotentialmediators.Nevertheless,thisresultgivesusmoreconfidencethatatleast
someofthepositiveeffectofNGOprovidertypeonpatientsatisfactionismediatedthrough
doctorsatisfactionwithherpositioninthehealthcenter.
Explainingthesecularwelfareadvantage?
AnalysesofdiverseindicatorsofthequalityofprimaryhealthcareinLebanonsuggestthat
doctorsatfacilitiesrunbysecularNGOsaremoresatisfiedwithandcommittedtothehealth
centerswheretheyworkandthatpatientshavemorefavorableviewsofprovidersatthese
facilities.Conversely,patientsexpressmorenegativeperceptionsofprovidersatfacilitiesrun
byreligiouscharitiesand,insomerespects,bypoliticalgroupsthanthoserunbyothertypes
ofinstitutions,whilemeasuresofinfrastructureandgovernanceproceduresshowno
meaningfulvariationacrossinstitutionaltype.Furthermore,doctorsatsecularNGOsappear
tobemorecompetentattheirprofession.
Thesefindingscontradictsometheoreticalandempiricalexpectations.First,several
strandsofliteraturesuggestthatreligiouscharitiesdeliversuperiorservices,whether
becausetheircharitablemissionsservetomotivatestaffmembersorbecauseexigent
religiousorganizationalcharacteristicsattractespeciallycommittedpersonnel.Second,the
resultsmaybesurprisinginthecontextoftheLebanesewelfareregime,wherepublicand
secularprovidersarewidelyperceivedaseitherinferiorormoreunder-resourcedthan
28
religiousandpoliticalgroupswhileFBOsofvariousstripesandsectarianpartiesdominate
thepoliticalsystemandcontrolsubstantialpublicandprivateresources.
Whatmightaccountfortheostensiblesecularadvantageinservicedeliveryin
Lebanon?Paradoxically,therelativemarginalizationofsecularorganizationsinpoliticsand
thewelfareregimemayworkintheirfavor.Onthesupplyside,giventhattheylackinfluence
inthesectariansystem,secularprovidersmayattractdoctorswhoareespeciallycommitted
toasenseofprofessionalismandhavelittletogainbeyondthesatisfactionofadvancingnon-
sectarian,humanitarianprinciples,acoremissionofthesecularNGOsinthesample.20These
ideologicalcommitmentsmayserveassourcesof“intrinsicmotivation”(RyanandDeci,
2000).forstaffmembers.Furthermore,seculargroupsinLebanondonothavewell-
developedpatronageandclientelistnetworks(Cammett,2014)and,therefore,their
professionalstaffcannotfulfillreciprocalobligationsthroughserviceinthesefacilitiesnor
cantheyderivematerialbenefitsbeyondgainingprofessionalexperienceandbuildingtheir
professionalreputations,amotivationsharedbydoctorsworkinginalltypesofhealth
networks.Asaresult,onaveragedoctorswhoworkatsecularNGOsmaybemorelikelyto
selectintotheseorganizationsinordertofulfillprofessionalgoals.
Ourfindingsaboutasecularwelfareadvantageareparticularlystrongwithrespectto
subjectivemeasuresofquality.Onthedemandside,beneficiariesmayperceivesecularNGOs
tobelesscorruptsincethesegroupsareeffectivelyshutoutofnationalpoliticsandderiveno
benefitfromthesectarianpower-sharingsystem,whichiswidelydisparagedbyLebanese
(Atallah,2012).Asaresult,secularNGOs,whicharenottaintedbyassociationwiththe
corruptandineffectivepoliticalsystem,maybenefitfromthesamekindofreputational
advantagethatsomereligiousactorsenjoyinpolitieswithcorruptsecularrulers(Brooke,
2014;CammettandJonesLuong,2014;Masoud,2014;Pepinsky,LiddleandMujani,2012).
20InterviewbyCammettwithChiefMedicalOfficer,LebaneseNGO,Beirut,January19,2015;InterviewbyCammettwithDirector,LebaneseNGO,Beirut,January15,2015.
29
Furthermore,lowexpectationsofsecularNGOscouldleadtoinflatedsatisfactionratings
whenpatientsdiscoverthattheservicesrenderedarebetterthananticipated,an
interpretationthatshouldbetestedmoresystematicallywithpublicopiniondatainfuture
research.
Inshort,inLebanon,whereseculargroupsareexcludedfrompatronagenetworksand
operateonthefringesofpower,servinginaffiliatedorganizationscallsuponpersonnelto
makepersonalsacrificesbyforegoingopportunitiestobenefitfromestablishedpatronage
networksandbydevotingthemselvestogroupsthataremarginalizedinpoliticalandsocial
life.Inturn,thehighcommitmentofstaffmemberstotheprogramsandactivitiesofsecular
groups,includingintherealmofwelfare,mayresultinmorefavorableperceptionsoftheir
services.Ourtentativeexplanationthereforepointstothewaysinwhichsociopolitical
contextmediatestherealandperceivedactivitiesofserviceproviderswithdistinct
organizationalmissions.
Conclusion
BasedonfindingsfromLebanon,whichfeaturesdiversepublicandnon-stateservice
providers,thispaperexploreswhetherdifferenttypesoforganizationsexhibitawelfare
advantageinthedeliveryofbasichealthcare.InsightsfromtheliteraturesonFBOsandthe
economicsofreligionaswellasspecificcharacteristicsoftheLebanesewelfareregime
suggestthatreligiouscharitiesand,especially,sectarianpartiesshouldofferhigherquality
servicesthanothertypesofproviders,notablythepublicsectorandsecularNGOs.Wefind
insteadthatsecularNGOsexhibitanapparentwelfareadvantageonsomeobjectivemeasures
(i.e.,doctorknowledge)and,morestrongly,onsubjectivemeasures.Toexplaintheapparent
secularwelfareadvantage,wehypothesizethatseculargroupsenjoyareputationaladvantage
inLebanon,wherereligionisassociatedwiththecorruptsectarianpower-sharingsystem.
SecularNGOs,whichofferfewmaterialrewardstotheirstaff,mayalsoattractqualifiedand
30
committedpersonnel.Inshort,sociopoliticalcontextmaymediatepopularperceptionsof
distinctwelfareinstitutionsandmayevenshapeselectioneffectssothatmorequalified
professionalsopttoworkforsometypesoforganizationsoverothers.
TheseinsightsfromLebanonaremostclearlygeneralizabletootherpolitieswith
politicallysalientidentity-basedcleavagesandwherediversenon-stateprovidersplay
importantrolesinthewelfaremix.YettheLebanesemaycaseofferrelevantinsightsintothe
politicsofservicedeliveryinotherplaces,too,especiallyinlightofthegrowingimportanceof
non-stateprovision,includingincountrieswithmorestatisteconomiclegacies.Furthermore,
thefindingscallforabroaderinvestigationoftheinterplaybetweenpoliticalcontext,
organizationalmissionandthequalityofsocialserviceprovision.Inparticular,future
researchshouldexplorethewaysinwhichformalandinformalfeaturesofthepolitical
systemshapethetypesofproviderorganizationsthatattractthemostcompetentpersonnel,
whichaffectsservicequalityintangibleways,andcitizenperceptionsoftherelative
proficiencyofdistinctproviders,whichcanaffectsubjectiveevaluationsofprovidersaswell
aspatientcompliancewithmedicaladvice,amongotheroutcomes.
31
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