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The influence of health technology on principal-agent relationship: a study of virtual doctor consultations in Rwanda
Abstract
Use of technology in health care delivery is considered as one solution to speed up the health care delivery in underserved areas. Because of this, a number of health technologies have been brought into play, such as providing virtual doctor consultations. The idea of Principal-Agent relationship has turned out to be generally acknowledged in health economics. The health insurance market appears to fit into the standard Principal-Agent relationship that is described by a principal (poorly educated individual) and an agent (educated person), who endeavour to boost their utility capacities. In Rwanda, the health services are openly regulated while yet third part, payer, health insurance, for example, Rwanda Social Security Board (RSSB) and other private insurance providers dominate the buying of human services. Therefore, this study focused on assessing the influence of health technology on principal-agent relationship focusing on the virtual doctor consultation. This exploratory study utilised a qualitative approach to gather primary data. The qualitative data was collected using Key Informant Interview (KII) guide and Focus Group Discussions (FGD) guide. Collected data from both the FGDs and KIIs were analysed using Atlas.ti version 8.4 software after a proper transcription of the recorded data. The study findings suggested some challenges and numerous opportunities brought by health technology particularly virtual doctor consultations in Rwanda. Challenges include lack of interoperability of software leading to data concerns like data ownership, data access and data security, lack of stable infrastructure and a high cost of infrastructure development, differences in health care packages at different levels of treatment, scepticism especially with old people, literacy levels, smartphone penetration and cost of internet. Opportunities include cost saving, time saving, convenience, confidentiality, accessibility and proper utilization and distribution of the scarce healthcare workforce especially general practitioners (GPs). Moreover, induced demand due to encouragement and due to convenience of the service was identified by the study. However, as it would be anticipated that induced demand is a big concern for the insurance institutions, it was found not to be as major as anticipated patients are prompted to utilize health services at an early stage of illness, which makes the cost lower. Finally, the study identified that information asymmetry that exist between the agent and principal was found to be huge and of a great concern especially the regulators who have no information on where the information for patients is kept and what it is used for. The study recommends proper integration, incentives alignment, proper identification of the technology and cost effectiveness analysis for proper incorporation of health technologies in the health system.
Purpose
The recent pandemic of COVID-19 has posed challenges for delivering essential and desirable health-care services for the masses. Digital health-care services initiated by several hospitals and health practitioners promise efficient and safe health care in the new normal post-COVID era but need a supportive enabling ecosystem. Therefore, this study aims toward identifying and modeling the key enabling factors for digital health-care services.
Design/methodology/approach
A total of nine factors were identified from the literature review and verified by the domain experts which can enable the wider acceptance of digital health-care services. The identified factors were then modeled with the help of the total interpretive structural modeling (TISM) approach and fuzzy Matrices d’Impacts Croises Multiplication Appliquée à un Classement (MICMAC) and a meaningful contextual relationship were developed for the factors.
Findings
This study reflects that the trust of patients is required for the acceptance of digital health care. Quality of patient care and affordability cum accessibility of online services will define mass engagement. Hospital staff resilience, hospital care service capacity, strategic partnerships and collaborations supported by technology and regulatory structure are the major factors defining the enabling ecosystem.
Originality/value
This study has its uniqueness in the way the TISM approach and fuzzy MICMAC are used for modeling the enabling factors toward growth and acceptance of digital health-care services in the days to come in developing nations. The focus of this study can be considered as relevant for the study interested in investigating the role of cognitive dimensions in influencing actors’ behaviors and decisions.
Mobile health (mHealth) offers new opportunities to improve access to health services and health information. It also presents new challenges in evaluating its impact, particularly in linking the use of a technology intervention that aims to improve health behaviors with the health outcomes that are impacted by changed behaviors. The availability of data from a multitude of sources (paper-based and electronic) provides the conditions to facilitate making stronger connections between self-reported data and clinical outcomes. This commentary shares lessons and important considerations based on the experience of applying new research frameworks and incorporating maternal and child health records data into a pseudo-randomized controlled trial to evaluate the impact of mMitra, a stage-based voice messaging program to improve maternal, newborn, and child health outcomes in urban slums in India.
The potential of digital health tools such as smartphones and sensors to increase access to and enhance delivery of healthcare is well known. However, a lack of regulation and delineation between those technologies seeking to offer direct clinical diagnostics and treatments and those involving clinical care enhancements or direct-to-consumer resources has led to patient and clinician confusion about the appropriate use and role of digital health. Here, we propose that creating boundaries and better defining the scope of digital health technology will advance the field through matching the right use cases with the right tools. We further propose that ethical clinicians, as stewards of standard of care, are well suited to uphold these boundaries and to safeguard best practices in digital health.
Declaration of interest
H.H. is an employee of Verily Life Sciences and owns equity in this company. The views expressed here are those of the authors and are not official views of Verily Life Sciences.
Since the 1900s, there has been rapid generation, continuous innovation and incremental improvement of
medical technologies. However, not all innovation and development result in overall health gains, nor does their
implementation result in improved cost-efficient solutions. Health systems worldwide need to ensure efficiency
and demonstrate value for investment, and when coupled with cost pressures and constrained resources they
create a difficult decision-making environment for investing in health technology. To overcome these challenges
there is a need to evaluate all technologies and eliminate those that are ineffective and not cost-effective, and
that have been superseded. Evaluation should consider the availability of resources as well as the organisational, societal, legal and ethical issues pertaining to the country or the local setting. Starting in the 1950s, the concept of health-technology assessment (HTA) has been developed to generate evidence-based foundations to illustrate the relevant preconditions and consequences when using a health technology. It involves multidisciplinary teams applying a systematic approach that is grounded in the scientific method. The goal is to generate, or synthesise, the highest possible level of evidence to inform the decision-making process about health technologies. HTA offers a simple structure to unify the multiple dimensions (including clinical, patient-related, organisational, economic, ethical and legal aspects) in the consideration of complex problems/questions regarding technology deployment and reimbursement. However, its role has evolved to encompass technologies from inception to obsolescence as well as early awareness and alert systems, reassessment post introduction, evidence briefs and recommendation for disinvestment. HTA is increasingly seen as an innovative way to sustain and improve health systems. This process can contribute towards decision-making information at all levels of the healthcare system, including political administrative and clinical. It is regarded as a ‘way of thinking’ to improve decision-making related to the planning, administration and management of healthcare interventions.
It has been suggested in the literature that a source of incompleteness in the agency relationship between the doctor and the patient is that the provider may respond to an incomplete or biased perception of the patient's interests. However, this has not been shown empirically. This article is novel in presenting an empirical test of the fundamental assumption of the agency model that health-care professionals understand what their patients want. Discrete choice experiments (DCEs) are conducted simultaneously within samples of patients (women who gave birth) and care-givers (doctors and nurses), to elicit and contrast patients' authentic preferences (for five maternity ward attributes) with what care-givers believe them to be. Conclusion: agents have a biased perception of principals' preferences, and therefore a complete agency relationship does not exist. Our findings add a novel empirical contribution to the agency relationship literature. Moreover, parallel preference patterns of patients and care-givers are certainly of much interest to the field of health economics: Informing the unaware medical care-givers about the patients' preferences, will improve treatment and patients' satisfaction.
What is the nature of the agency relationships that arise in health care? To explore this issue Figure 1 presents a stylised model of a health care system which involves six economic actors:
(1)
the state, which encompasses politicians and administrators;
(2)
the general public in their roles as both citizens and patients;
(3)
providers of insurance, such as sickness funds or private insurance companies;
(4)
purchasing agencies, such as GP fundholders and District Health Authorities in the U.K.;
(5)
providers of health services, including organisations such as hospitals, along with doctors and other health care professionals.
Governance is increasingly recognized as an important factor in health system performance, yet conceptually and practically it remains poorly understood and subject to often vague and competing notions of both what its role is and how to address its weaknesses. This overview article for the symposium on health governance presents a model of health governance that focuses on the multiplicity of societal actors in health systems, the distribution of roles and responsibilities among them and their ability and willingness to fulfil these roles and responsibilities. This focus highlights the principal-agent linkages among actors and the resulting incentives for good governance and health system performance. The discussion identifies three disconnects that constitute challenges for health system strengthening interventions that target improving governance: (1) the gap between the good governance agenda and existing capacities, (2) the discrepancy between formal and informal governance and (3) the inattention to sociopolitical power dynamics. The article summarizes the three country cases in the symposium and highlights their governance findings: health sector reform in China, financial management of health resources in Brazilian municipalities and budget reform in hospitals in Lesotho. The concluding sections clarify how the three cases apply the model's principal-agent linkages and highlight the importance of filling the gaps remaining between problem diagnosis and the development of practical guidance that supports 'best fit' solutions and accommodates political realities in health systems strengthening.
The principal-agent problem in health care asserts that providers, being the imperfect agents of patients, will act to maximize their profits at the expense of the patients' interests. This problem applies especially where professional regulations are lacking and incentives exist to directly link providers' actions to their profits, such as a fee-for-service payment system. The current analysis tests for the existence of the principal-agent problem in the private health market in Vietnam by examining the prescribing patterns of private providers. I show that: (1) private providers were able to induce demand by prescribing more drugs than public providers for a similar illness and patient profile; (2) private providers were significantly more likely to prescribe injection drugs to gain trust among the patients; and (3) patients' education as a source of information and empowerment has enabled them to mitigate the demand inducement by the providers. The hypotheses are supported with evidence from the Vietnam National Health Survey 2001-02, the first and, so far, only comprehensive health survey in the country.
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