Discrimination in health care: an experimental audit study

Last registered on May 17, 2023

View Trial History

Pre-Trial

Trial Information

General Information

Title

Discrimination in health care: an experimental audit study

RCT ID

AEARCTR-0011405

Initial registration date

May 11, 2023

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published

May 17, 2023, 2:36 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

Country

South Africa

Region

Primary Investigator

Name

Mylene Lagarde

Affiliation

LSE

Contact Primary Investigator

Other Primary Investigator(s)

PI Name

Nicholas Stacey

PI Affiliation

LSE

Contact Investigator

Additional Trial Information

Status

In development

Start date

2023-05-12

End date

2023-06-20

Keywords

Health

Additional Keywords

discrimination, health care, foreigner

JEL code(s)

Secondary IDs

Prior work

This trial does not extend or rely on any prior RCTs.

Abstract

Discriminatory attitudes and practices towards foreigners within healthcare facilities have been increasingly reported in South Africa, including in instances where foreigners have the same legal rights to access free health care services as South African citizens. While the existence and consequences of discrimination against foreigners has been documented in the media and through qualitative studies, this problem has not been studied empirically in a systematic way. We employ an audit study to answer the following questions:

1) Do foreign patients face more administrative constraints than South African citizens to access healthcare services?
2) Do foreign patients face more derogatory or rude behaviours than South African in the healthcare sector?
3) Do foreign patients receive the same quality of care as South African citizens?
4) Are there differences between the public and private sectors in the discrimination faced by foreign patients?

To answer these questions, we will use the random allocation of foreign enumerators to play the role of incognito standardised patients in a large audit study of the quality of healthcare services provided in a large urban metropole in South Africa. This design also allows for a between-subject analysis comparing differential behavior of healthcare professionals towards South African and foreign patients. The audit study will be followed by a short survey designed to record the providers’ demographic and socio-economic characteristics, as well as beliefs about xenophobic discrimination and implicit bias against foreigners.

External Link(s)

Registration Citation

Citation

Lagarde, Mylene and Nicholas Stacey. 2023. "Discrimination in health care: an experimental audit study." AEA RCT Registry. May 17. https://doi.org/10.1257/rct.11405-1.0

Sponsors & Partners

Experimental Details

Interventions

Intervention(s)

Intervention Start Date

2023-05-12

Intervention End Date

2023-06-20

Primary Outcomes

Primary Outcomes (end points)

The study will measure the following outcomes for patients:
- probability of being denied care (whether a standardised patient was told they could not receive care in the facility)
- effort exerted by the provider
- probability of being correctly managed
- cost (or value) of recommended treatment

We will compare these outcomes between the two groups: foreign and South African standardised patients. We also compare the outcomes in the public sector and in the private sector.

Primary Outcomes (explanation)

Data will be obtained from a debriefing questionnaire filled in by standardised patients immediately after their consultation.

Secondary Outcomes

Secondary Outcomes (end points)

- index of administrative barriers faced
- waiting time
- index of derogatory behavior faced (negative and rude attitudes by staff)

Secondary Outcomes (explanation)

Experimental Design

The study will leverage the presence of foreign and South African enumerators taking part in an audit study of the quality of care provided at 130 public and private located in a large urban area in South Africa. Specifically, we leverage the fact that each provider included in the audit study is to be visited by several enumerators trained to portray incognito standardised patients, each portraying one of five different clinical cases. To portray each case, we recruited and trained a team of four enumerators that included three South African and one foreign individuals. Given that individual enumerators are allocated to providers at random, we will be able to compare the experience and treatment received by foreign and South African individuals portraying the same clinical case.

Experimental Design Details

Randomization Method

Randomization of enumerator to provider is done by a computer.

Randomization Unit

Given that enumerator are randomly assigned to providers, providers will be randomly assigned to receiving a foreign or South African patient.

Was the treatment clustered?

Experiment Characteristics

Sample size: planned number of clusters

N/A

Sample size: planned number of observations

In total there will be 890 patient-provider interactions.

Sample size (or number of clusters) by treatment arms

In the public sector, there will be a total of 39 facilities, each receiving two different providers for each case. Hence a total of 39 facilities x 5 cases x 2 visits = 390 patient visits
In the private sector, each provider receives the 5 cases exactly once. Hence there will be a total of 100 providers x 5 cases = 500 patient visits
Given that we have a 1:3 allocation ratio of foreign to South African enumerators, we aim for a total of 223 consultations by foreigners (125 foreign private consultations and 97 public consultations) and 667 consultations by South African citizens.

Minimum detectable effect size for main outcomes (accounting for sample design and clustering)

Supporting Documents and Materials

IRB