The effects of performance evaluations
and trust on popular strategies for
dealing with uncertainty about the
outcome of critical surgery
Dr Neil Munro
Lecturer in Chinese Politics
“Violence towards healthcare professionals: an assessment
of causes, frequency, prevention and solutions”
University of Chicago Center, Beijing
September 17-18, 2013
.
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Key Issue
• Why is there violence towards health care professionals?
• Understanding reasons for behaviour is often the key to stopping it.
• If widespread, it may point to a crisis in the relationship between the
medical profession and the general public.
• Outline
– Key concepts
– Data
– Survey item: strategies to improve outcome of critical surgery
– Independent variables: performance evaluations & trust
– Effects on choice of strategy
– Implications for understanding violence in health care settings
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Key concepts
• Agency dilemma: patients are principals, doctors are their agents.
How can patients ensure that the doctor offers as far as possible the
same treatment as they would administer to themselves if they were
the patient?
• Exit: a strategy for resolving the dilemma by changing the doctor or
health care provider for another one, presumed to be more loyal to
the patient’s interests
• Voice: a strategy for resolving the dilemma by speaking or acting to
influence the behaviour of the doctor or health care provider
• Particularism: a strategy for resolving the dilemma which helps a
particular patient but not others in a similar situation.
– VIOLENCE is a particularistic form of voice-in-action.
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Table 1. Three Dimensions of Strategy
Proactive
Passive
Universalistic
Voice
Exit
Make a
Change
formal
provider
complaint
Particularistic
Voice
Exit
Pay a bribe, Use
Ask the
connections
provider to to find
change
another
their
provider
decision
Accept the treatment without resolving the dilemma,
Don’t know,
Give up treatment
Source: adapted from Hirschman, A. O. (1970). Exit, Voice and Loyalty:
Responses to Decline in Firms, Organizations and States. Cambridge,
MA, Harvard University Press.
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Why use violence?
• Violence implies a step change in degree of conflict.
• Violence is qualitatively different from other forms of voice. It is a
transgression of universal norms of acceptable social behaviour.
• Two kinds of logic can be used to explain it (March & Olsen 1989):
– Logic of consequences (egocentric logic): violence will help me
get what I want, and consequences for me are acceptable;
therefore, I will use it.
– Logic of appropriateness (socio-tropic logic): there are rules of
conduct in my subculture under which violence is regarded as
an appropriate response in certain circumstances.
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Data
• Performance Evaluations, Trust and Utilization of Health Care in
China Survey, 2012-13. Funded by the UK Economic and Social
Research Council, Grant No. ES/J011487/1.
• nationwide survey in 31 provinces on mainland China
• fieldwork carried out 1 November 2012 to 17 January 2013
• target population: mainland citizens age 18 to 70 residing for more
than 30 days in family dwellings
• GPS Assisted Area Sampling Method
• Sample of 5,424 dwellings: 3,684 valid interviews
• Response rate of 67.9 per cent
• More information at http://www.gla.ac.uk/petu
Figure 1 Strategies to Improve Chances of Successful
Surgery
B22. If your friend needed a life-saving operation but the surgeon in a
public hospital told them that he could not guarantee that the operation
would be successful, what would you advise the patient to do? (One
answer).
(% replies)
Source: Performance Evaluations, Trust and Utilization of Health Care in
China Survey, fieldwork 1 November 2012-17 January 2013, N=3680.
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Figure 2a. Perceived Prevalence of Overprescribing
C21. Some people say medical ethics is a big problem in this
country, but others say such reports are just exaggerated. Judging
from your own personal experience, how likely do you think it is
that you would encounter the following types of situations in city or
county hospitals around here? a) Prescribing medicines not
covered by insurance even when effective alternatives covered by
insurance are available.
Source: Performance Evaluations, Trust and Utilization of Health Care in
China Survey, 2012-13.
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Figure 2b. Perceived Prevalence of Taking Hongbao
b). …Taking bribes (“red envelopes” or hongbao) for treatment
which has already formally been paid for.
Source: Performance Evaluations, Trust and Utilization of Health Care in
China Survey, 2012-13.
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Figure 2c. Perceived Prevalence of Unnecessary Testing
c). …Requiring comprehensive check-ups from patients even
when the diagnosis is perfectly clear.
Source: Performance Evaluations, Trust and Utilization of Health Care in
China Survey, 2012-13.
So how do people respond to uncertainty?
• Dependent variable: which strategy does respondent prefer?
• Key independent variables:
• Performance evaluations:
• health system as a whole
• skills & competence of doctors
• Trust in health care institutions (global trust)
• Perceived likelihood of unethical practices (fidelity)
• Comparisons between public & private
• Controlling for: demographics, education, urbanization,
hukou, self-assessed health, difficulty paying health bills,
local government spending per capita
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Figure 3a. Impacts of Odds of Using Voice
Impact*
Overall
satisfaction
with health
care system
Agricultural
hukou
Local gov’t
expenditure
per capita
* Impact on logged risk ratio relative to reference category, computed by multiplying
multinomial logistic regression coefficients by the mean of the independent variables.
Impacts not significant at .05 level are not shown.
Source: Generalized linear mixed model for data in Figure 1, N=3,506.
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Figure 3b. Impacts on Odds of Using Particularistic Strategies
Impact*
Struggles
to pay family
medical bills
Overall
satisfaction
with health
care system
Unethical
practices
likely
Education Agricultural
hukou
* Impact on logged risk ratio relative to reference category, computed by multiplying
multinomial logistic regression coefficients by the mean of the independent variables.
Impacts not significant at .05 level are not shown.
Source: Generalized linear mixed model for data in Figure 1, N=3,506
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Figure 3c. Impact on Odds of Using Exit Strategies
Impact*
Struggles to
pay family
medical bills
Age
in deciles
Unethical Private
practices treatlikely
ment
better
Education
Agricultural
hukou
Local gov’t
expenditure
per capita
* Impact on logged risk ratio relative to reference category, computed by multiplying
multinomial logistic regression coefficients by the mean of the independent variables.
Impacts not significant at .05 level are not shown.
Source: Generalized linear mixed model for data in Figure 1, N=3,506.
Key Findings
(System performance) People who are satisfied with performance of
the health care system as a whole, are more likely to:
• use voice (ask the doctor to change treatment & make
complaints)
• use connections to get a referral.
(Medical ethics) People who think unethical medical practices are
widespread are more likely to:
• pay hongbao
• go to a private hospital.
(Trust) People who trust hospitals are less likely to complain to the
hospital administration.
(Clinical performance) People who are satisfied with the skills &
competence of hospital doctors are more likely to complain.
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A theory about reasons for violence
• Unsuccessful surgery can cause people to lose those they love
and on whom they depend.
• Patients regard payment, especially informal payment, as
creating an obligation on doctors to resolve a health care
problem.
• Failure to fulfil that obligation is a violation of norms of
reciprocity.
• Reciprocity is a strong norm in Chinese culture.
Violence towards health care professionals is an extreme
expression of moral indignation about unfulfilled reciprocal
obligations.
Evidence is circumstantial: need detailed case studies
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