Abstract
Healthcare quality in low- and middle-income countries (LMICs) remains low and highly variable across providers, with little oversight from regulators. As healthcare is a credence good market, there are information asymmetries between patients and providers: many (good) bad quality providers are (un)able to signal high quality. In Uganda, where 40% of facilities are private for-profit and out-of-pocket spending reaches 35% of health expenditure, private providers have a large incentive to exploit this asymmetry and to respond to patient beliefs about signals of quality. The result is market failure in healthcare, where patients cannot identify quality providers and overpay for inadequate care.
There are two possible causes of the persistence of this information gap between patients and providers. First, patients have limited access to information, absent of objective signals of quality such as provider ratings. Unable to directly evaluate medical expertise or qualifications of a provider, patients infer from a subset of possible characteristics which they observe during their interactions. Second, patients' mental models about healthcare (or how observable signals are weighted in assessments of provider quality) are often incorrect. For example, patients believe overtreatment and extensive testing signal quality, even in self-limiting cases.
In this study, we seek to cross-evaluate two interventions that target these sources of information asymmetry: 1) providing objective quality signals to individuals and 2) addressing errors in conceptual frameworks of healthcare. Earlier this year, we conducted an independent audit of government, private, and non-profit health centres using standard patients, generating objective evidence on healthcare quality, including provider effort, medical appropriateness, patient experience and cost. In Gulu, the audit revealed private providers performing substantially worse on case management, with only 40% SPs managed correctly (allowing for overtreatment). By contrast, non-profit and government providers managed patients correctly 60% of the time – a 50% improvement on private clinics. This evidence will form the basis of both information treatments. Intervention 1 will be delivered to participants through a short video – a voiced over animated presentation comparing provider quality – and report cards with comparative ratings of types of providers (government, public, non-profit). Intervention 2 will include all the information components, but the video will include an additional section addressing misconceptions about healthcare providers, focusing on private clinics’ tendency to overtreatment, lower medical accuracy, and higher costs.
To evaluate the relative effectiveness of information with / without addressing the misconceptions about provider quality signals, we will conduct a randomised controlled trial in Gulu, the largest city in the Northern region of Uganda. Between November 2025 and January 2026, we will recruit 1,500 current users of private providers in central locations; administer a baseline survey and elicit beliefs about the relative quality of government, private, and non-profit providers; then randomise the participants to either receive intervention 1, intervention 2, or the control condition (no information given). Our primary outcomes of interest are: 1) beliefs about providers’ relative quality, captured in a post-intervention module at the time of the survey; and 2) choice of provider when the participant next seeks care. The choice will be captured for 3 months following the survey using WhatsApp – pictures of patient report cards will be used to verify the provider visited. Jointly, these findings will inform if simple information or more extensive public education campaigns can redirect patients away from low quality providers.