Measuring the quality of clinical veterinary services for Cattle: an application of a role play experiment in rural Uganda
© Ilukor and Birner; licensee BioMed Central Ltd. 2014
Received: 4 September 2013
Accepted: 13 November 2014
Published: 10 December 2014
The dominance of veterinary paraprofessionals in the animal health markets has been linked to the decline in quality of veterinary services. This study uses a role play experiment to analyze how the interaction of farmers and service providers influences the quality and the demand for clinical services for cattle. The quality of clinical services was measured by scoring the accuracy of the service provider prescribing the appropriate drug for selected cattle diseases.
The game was played in four rounds. Farmers were given “animal medical card” with the name of the disease written on it both in English and the local language in each round. Service providers were asked to write the clinical signs, and prescribe the drugs.
The results show that the ability to identify the signs of different diseases and the accuracy of prescriptions by veterinarians is not significantly different from that of paraprofessionals trained in veterinary science. However, the ability of service providers who are not trained in veterinary medicine to perform these tasks is significantly lower than that of service providers trained in veterinary science. The continued interaction between paraprofessionals and veterinarians gradually leads to an improvement in the ability of paraprofessionals trained in general agriculture and social sciences to perform these tasks. This was not the case for paraprofessionals with no formal training or education. Farmers do not easily change their beliefs about paraprofessionals, even if they receive information on their inability to diagnose diseases correctly and prescribe the correct drugs. Belief updating depends not only on the outcome of the previous round, but also on the gender of the farmer and the livestock production system.
This paper argues that the slow pace in which farmers update their beliefs about paraprofessionals limits paraprofessionals’ willingness to learn or consult with veterinarians. However, the use of “animal health cards” (records of diagnoses and treatments) could induce paraprofessionals to provide services of better quality clinical services for cattle and enable farmers to measure the quality of these services.
KeywordsBelief updating Lemon market Role play game
This paper is concerned with measuring and assessing the quality of clinical veterinary services in developing countries, using Uganda as an example. The existence of veterinarians and paraprofessionals of varying skills and training can be a major problem in animal health markets . Veterinarians have to compete with less qualified or unqualified service providers and professionals trained in general agriculture that may be providing less quality services compared with services of veterinarians . Livestock farmers who have no skills or training in veterinary science are not able to measure the quality of services being offered by these service providers. The failure of a farmer to assess and measure the quality of the service creates motivation problems such that a farmer is not willing to pay a premium fee for the service because he cannot judge the quality of the service he or she receives. As a result, service providers that deliver high quality services are forced to accept low payment since they cannot convince the farmer that their services are of high quality . Since service providers interact repeatedly with farmers, farmers’ failure to differentiate the quality of the service leads to high quality service providers being displaced or nudged off the market. Akerlof  describes this interface between quality heterogeneity and asymmetric information resulting to the disappearance of a market with quality goods and services as a market for “lemons”. As argued by Ly , a market for “lemon” has occurred in animal health markets in most developing countries, and the veterinary paraprofessionals have dominated the animal health market.
The dominance of the veterinary paraprofessionals in the provision of veterinary services, although useful in reducing costs and increasing access, has been linked to the decline in the quality of veterinary services [5, 6]. Improving relationship between veterinarians and paraprofessionals is seen as an important approach towards improving the quality of clinical veterinary services [7–9]. In addition, the economic literature on the provision of animal health services emphasizes that if farmers had information about the quality of service offered, they would be able to update their beliefs and more readily seek services of veterinarians who offer quality services. Belief updating (belief change) is the act of changing a previously held belief to take into account new information . By seeking quality services, paraprofessionals or low quality service providers would strive to consult with veterinarians in order to maintain and build their reputation.
In this study, a role play game experiment was used to assess the influence of information on farmers’ beliefs about service providers and the quality of clinical services. In particular, the study aimed at answering the following questions: (1) Does the quality of services provided by paraprofessionals differ with that provided by veterinarians? (2) Does quality improve as paraprofessionals and veterinarians interact? (3) Do farmers update their beliefs about service providers? And (4) what factors influence farmer belief updating? The paper proceeds as follows: Section 2 covers materials and methods; Section 3 presents the results, and Section 4 discusses the findings and provides a conclusion.
This study is part of the project aimed at analysing institutional arrangements for providing veterinary services in Uganda and Kenya. Ethical approval of prospective enrolment of humans to the study was obtained from the committees at directorates of the veterinary services at Ministry of Agriculture, Animal Industry and Fisheries in Uganda and the Ministry of Livestock in Kenya. The reference number for Kenya is RES/GEN/VOL.X11/63. The reference number for Uganda was not obtained, but verbal permission form directorate of animal resources was obtained. Consideration was also given to welfare of the subjects, and we are confident that the study did not pose any risk to the subjects since clinical trials were not involved. We also received permission from local governments and one staff in the veterinary department was assigned to work with us in each district. Consent of the subjects was also obtained.
Design of the game
The experimental data used in this paper were collected from two different districts in Uganda (referred to here as A and B to ensure the anonymity of the participants). District A is located in the pastoral production system while District B is located in the intensive livestock production system. Subjects were recruited from each district. The subjects included the farmers, paraprofessionals and veterinarians. They were asked whether they agreed to participate in a role play game. Farmers were told they would be paid, and their pay-off would depend on the outcome of the transaction (treatment of a sick animal in the role play) and their ability to negotiate with service providers for a fee the providers would charge. The farmers were provided with an initial endowment of 6,000 Uganda Shillings (US$2), which was approximately three times the daily wage for unskilled labour in the study regions. If the outcome was positive, a farmer would be paid a reward covering the difference between the fee of the service provider and the initial endowment. A positive outcome was one where the animal was cured, which happened if the service providers identified the right drug for the disease of the animal under consideration. If the outcome was negative, the farmer received nothing. A negative outcome means that the animal died because the service provider was not able to identify the appropriate treatment. Service providers were informed that their earning would depend on their reputation with farmers, which determined the number of farmers who demanded their service, and the professional fee they charged. Service providers were allowed to refer and consult other service providers. The cost of transport and drugs was considered as dead weight costs and hence not included in the game.
A total of 51 farmers were recruited to participate in the experiment, 26 in the pastoral livestock production system (10 female and 16 male) and 25 in the intensive livestock production system (12 female and 13 male). In each production system, it was planned to recruit two veterinarians and five paraprofessionals to participate in the game. In District A (pastoral area), however, veterinarians are usually absent from their duty stations because there are few trained veterinarians from these areas, and professionals from non-pastoral ethnic groups are often reluctant to work in pastoral areas because of the harsh climate and poor infrastructure . Therefore, two government animal health assistants with a two year diploma training in veterinary medicine were asked to act as veterinarians in the role play. Their performance in terms of disease diagnosis and drug prescription was later compared with that of veterinarians in District B, and it was found that there was no statistically significant difference in their scores. Therefore, it can be assumed that this replacement does not affect the results. The training level of the paraprofessionals differed between the districts. In the pastoral system, two of the paraprofessionals had diplomas in social science with three months of training in animal health, and the other three had either primary or no education, and they also had received three months of training in animal health. Three paraprofessionals in the intensive production system had certificates in general agriculture, and two had diplomas in general agriculture. In District B, there were no female service providers and in District A, two of paraprofessionals were women and the rest of the service providers were male. In the intensive system, three endemic livestock diseases that were identified and they are; East Coast Fever, Anaplasmosis, and Tryponamiasis. In the pastoral systems, extra two diseases were added, namely, Heart Water and Red Water.
Clinical signs and drugs for specific animal diseases
East Coast Fever
High temperature of about 40°C, swollen lymph nodes, increased breathing loss of appetite, nasal discharge, cough, white discharge in the eyes
Butarex, Parvexion, Clexion and Aflexion
multivitamins and oxy-tetracycline
High temperature (41°C), severe constipation, loss of appetite, loss of body weight, increased breathing and dry mouth
salts, multivitamins and oxy-tetracycline
High temperature, stunning hair, loss of body weight, lacrimation (crying), blood discharge from the ears or skin, mucus discharge and brown urine.
Suriname, Diminazene and Ethidium
Turning in circles, grinding of the teeth, sensitivity to touch, nasal discharge and high temperature
Reddish urine, high temperature, loss of appetite, laboured breathing and weight loss
Imisol, Diminazene and Berenil
The game was played in four rounds, and at the beginning of each round, the farmers received a new medical card. At the end of each round, both farmers and service providers received information about the outcomes, and their pay-offs were awarded. After the game, the participants were invited to share their reflections, and finally, the meal was served.
Analysis of data
To measure the quality of clinical cattle services and the effect of farmers’ decisions on the demand and quality of clinical veterinary services, the degree of accuracy in identifying the signs of the disease listed on the animal medical card and prescribing the appropriate treatment were used as indicators of quality of service provision. After every round, the participants were able to consult and share their results with others. The scores for every round were awarded as presented in Table 1. Each cardinal sign identified was awarded a score of one and the total score was transformed into percentage. In the case of drug prescription, scores were awarded based on the drugs prescribed by the service providers. As shown in Table 1 below, if a service provider prescribed one of the main drugs, he was given a score of 8 or 9. He also received 1 or 2 points for all supplementary drugs, depending on the disease. These scores were transformed into percentages and since eight points was the lowest score for prescribing the main drug, the pass mark could be set at 80%.
The data from the role play were entered into a database and analysed as follows: Scatter diagrams were used to analyse the quality of clinical diagnosis and drug prescription for each disease. Learning curves were constructed to examine whether the quality improved with experience or after paraprofessionals interacted with veterinarians. Learning curves are used in clinical medicine to measure quality of service, and they are derived by graphically plotting performance against experience gained from the acquisition of new information or knowledge from prior experience . Hopper et al.  argue that a steep learning curve implies that skills are acquired rapidly because the procedure is simple. In this particular case, a steep slope would mean service providers are consulting or learning from each other to build and maintain their reputation. Farmers’ belief updating curves were also constructed to examine whether farmers update their beliefs or change their beliefs about types of service providers. The slope of the curve measures the level of belief change or updating [10, 14]. Service providers were categorized into veterinarians and paraprofessionals. The latter were further differentiated by field and level of training. The mean scores in drug prescription for each category in each round were computed and plotted on a Cartesian axis in order to construct the learning curves. In addition, the total number of farmers seeking services from the different categories of service providers in each round was computed, and the results were used to construct farmers’ belief updating curves.
Non-parametric statistics were used to perform statistical tests because the Shapiro-Wilk test for normality and the Doornik-Hansen test for multivariate normality showed that the data violated the normality assumption. Since the normality assumption was violated, parametric tests were considered to be less powerful than the non-parametric tests because they do not assume normality . A panel probit model with random-coefficient that allows for unobserved heterogeneity in farmers’ belief updating in each round was estimated to determine factors that influence farmers belief updating. In the model, belief updating is measured as a farmer’s decision to change to a different service provider from the previous service provider. A random effects model was chosen because (1) the observations are many, but the number of rounds are few (R = 4); thus a fixed effect model would give inconsistent estimates, and (2) a random effects model allows one to make inferences about the whole population, something that cannot be done with a fixed effects model . Maddala  further notes that the probit model is well suited for estimating random effects because it produces correlations among errors yet logistic distribution is very restrictive for this purpose. Gibbons & Hedeker  used it to predict the probability of some doctors experiencing malpractice claims and in this paper it is used to determine factors that influence livestock farmers’ decision to change service provider.
Three models were estimated because of collinearity in the variables. In model one, sex of farmer, pay-offs of farmers, fees charged by service provider and livestock production systems were included in the model. Farmers’ education level and previous outcome were excluded because they were correlated with production system and pay-offs, respectively. In the model two, variable or production system was dropped, and farmers’ education was included. In model three, the pay-off variable was dropped, and the outcome variable was included and standardized beta values of the independent variables were reported because they show which of the independent variables have a greater effect on the probability to change service providers.
Analysis of service quality by disease
For Anaplasmoisis, there were thirteen cases with a score of below 80% in drug prescription; six cases were from the intensive system and seven from the pastoral system. In the intensive system, these service providers prescribed mainly multivitamins, Oxytetracycline, Butarex, Suriname, and Diminazene. In the pastoral areas, the prescriptions were mainly Oxytetracycline, multivitamins, and the following treatment: mixing either one litre or one-half litre of the cooking oil with one sachet OMO washing detergent. This sounds strange, but both service providers and farmers argued that using cooking oil and washing detergent yields positive results for Anaplasmosis.
In the case of Tryponamiasis, there were five cases where the score was below 80% in drug prescription, and all of these cases were from pastoral system. Two of the cases were from one service provider trained in social science, and three from service providers with no formal education. The drugs prescribed were Berenil and Oxytetracycline. Red Water and Heart Water had three cases each that recorded a score below 80% in drug prescription. All the cases were attributed to paraprofessionals without formal education, and the prescription for all the diseases in six cases was pen-strep.
Learning curves and quality of veterinary services
Demand for clinical services
Random-effects panel probit model results for farmer’s decision to change a service provider
Farmers’ pay-off from previous transaction
Fees charged in previous transaction
Intensive livestock production systems
Farmers with education
The objective of this study was to determine whether quality of clinical services for cattle differ between veterinary paraprofessionals, examine farmer’s choices of veterinary advice and implications of these choices on the quality of clinical services. The results show that paraprofessionals trained in veterinary science are capable of handling endemic cattle diseases just like trained veterinary professionals. However, the ability of paraprofessionals who are not trained in veterinary science is significantly lower than those of the service providers trained in veterinary science. The main problem in drug prescription by paraprofessionals was in the treatment of ECF and Anaplasmoisis. The learning curve for crop trained service providers was slowly increasing while those of the social science trained service providers assumed an asymptotic curve. The learning curve for service providers with no formal education took a sigmoid shape. Hopper et al.  suggest that the slow rise learning is an indication of a difficult task, while the asymptotic curve can be associated with quick learning. However, in this particular case, the slow rise in the learning curve may be attributed to low propensity to consult, while asymptotic curve can be attributed to the high propensity to consult. The learning curves also reveal that paraprofessionals were not performing well from round one to three and the best performance was recorded in round four.
The poor performance in round one to three can be explained by the unwillingness of paraprofessionals to consult with veterinarians while improved performance in round four can be explained by the loss of farmers to other providers. As the feedback meeting held after the game revealed, there are trade-off in consulting with other veterinarians. On one hand, consulting with veterinarians may increase the likelihood of losing a client to a veterinarian because farmers would lose confidence in them and veterinarians would use that as an opportunity to discredit them in front of their clients. On the other hand, consulting with veterinarians helps paraprofessionals to save face in front of their clients by avoiding negative outcomes. Secondly, farmers take a long to change their beliefs about the paraprofessionals. Thus, paraprofessionals have limited incentives to consult with veterinarians to save face in front of the farmers. As revealed by farmers during the feedback meeting, they would go back to the same paraprofessionals even when the previous outcome was negative because they knew them and would always want to give them the benefit of the doubt. The third reason could be a language problem which limits non-educated paraprofessionals to interact with veterinarians since most of the veterinarians especially is pastoral areas are not from same ethnic background .
The results generally contradict the findings by IDL , Oakeley et al.  and Admassu et al.  which showed that informal trained paraprofessionals as capable of performing diagnosis and drug prescription. For example, Oakeley et al.  conducted a random survey of veterinary service providers, including Community Animal Health Workers (CAHWs), who were only trained on the job, to examine the level of accuracy in drug diagnoses among different types of service providers. Their results showed that 85% of the diagnoses made by CAHWs were accurate. However, Curran & MacLehose  dismissed this finding on grounds that they do not have proper research design to assess the level of drug prescription, and in any case no scores were presented. In addition, the three studies cited above do not consider the role of information, behaviour of farmers and service providers in making animal health management decisions in real life. Chilonda & Van Huylenbroeck  argue that the study of the behaviour and decision-making processes of farmers, service providers and their interactions in different livestock production systems is a key to development of sustainable policy options for successful delivery of quality veterinary services to small-scale farmers.
The role play game has been identified and tested in the literature as a tool that can serve as an accurate and consistent method of assessment and decision forecasting [23, 24]. The tool captures complexities about actors (farmers and service providers) decisions and behaviours without losing reality [25–27]. The results show that while paraprofessionals with no veterinary training were found to be of low quality compared with service providers with veterinary training, farmers changed their beliefs about non veterinary trained paraprofessionals rather slowly, thus providing few incentives for these paraprofessionals to provide quality services. The slow pace by which farmers were updating their beliefs about non veterinary trained service providers was because these paraprofessionals are known to farmers while veterinarians were not known to farmers. Improving relations between paraprofessionals and veterinarians, therefore, is a key to improving quality of veterinary services . However, this depends on farmers’ ability to “punish” service providers who provide poor quality services by shifting to quality service providers. Model results show this depends on their education level, outcomes of the service, and gender.
The fee charged for the previous transaction was found not to have a significant impact on farmers’ decision to change their service provider. These findings are consistent with findings by Ahuja, et al. . They found out that the price is not an important determinant of farmers’ decision to use services of an alternative service provider. In fact, Leonard  argues that the issue is not that farmers are poor and unable to afford veterinary services, but rather that farmers have failed to distinguish qualifications of different services providers and the quality of services they offer. The use of animal health cards or animal medical cards has a strong potential as a tool to enable farmers to distinguish and measure quality of clinical veterinary services. Farmers can use exercise books and service providers could be asked to write their diagnosis and prescription in these books.
The role play experiment used in this study assumes that farmers do not self-treat, yet in reality farmers do treat the animal themselves. Self-treatment as an option was excluded because to include it the game would mean promoting unethical behavior. Secondly, the game assumed that the risk of an animal dying even when treated correctly is zero, and yet an animal can actually die even with the right treatment because of delayed reporting and drug administration . Thirdly, the experiment assumed that veterinarians are always available which is not always the case especially in the pastoral system. Lastly, the limited number of participants could limit validity of the results, but since “real” participants (farmers and service providers) were involved in the game, the results are still meaningful and valid.
In summary, this paper presents a systematic study on how the interactions of farmers, veterinarians and paraprofessionals influence the quality of clinical veterinary services in rural Uganda. Results reveal the quality of veterinary services provided by paraprofessionals with veterinary training are not significantly different from those of veterinarians. However, the quality of services offered by paraprofessionals without veterinary training is significantly lower than that of veterinary trained service providers, but would improve as they interact with trained service providers. Even though services offered by paraprofessionals without veterinary training would increase in quality from continued interaction with veterinarians, there are challenges of sustaining paraprofessional interaction with veterinarians. As the results show increased risks of losing clients, limited number (availability) of veterinarians and the slow pace by which farmers update their beliefs impede paraprofessional and veterinary interaction. From a policy perspective, investment in two years of training for veterinary paraprofessionals is a promising strategy for improving the quality of veterinary services since farmers are willing to pay for the private clinical veterinary services.
aThe Merck Veterinary manual for veterinary professionals http://www.merckmanuals.com/merckmanualvet-book.htm.
bOIE technical disease cards http://www.oie.int/animal-health-in-the-world/technical-disease-cards/.
JI is a Doctoral Fellow at the Food Security Centre, University of Hohenheim and his research interest is focussed on application of New Institutional Economics to analyse food security and service delivery challenges in developing countries. RB is the Chair of “Social and Institutional Change in Agricultural Development” at the University of Hohenheim, Germany and one of her research interest is on the question of how rural services, including veterinary services, can be delivered more effectively to rural poor.
The authors wish to thank the farmers and service providers from Uganda for their participation in the experiment. The study was funded by the Fiat Panis Foundation under the Food Security Center “Exceed” PhD scholarship program of the University of Hohenheim. The program is supported by DAAD and the German Federal Ministry for Economic Cooperation and Development (BMZ).
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