Measuring the Quality of Education and Health Services

INUI Tomohiko
Faculty Fellow, RIETI

Spending on health and education represents an important investment in human capital, significantly affecting our quality and standard of living. In the Measurement of the Qualities of Health and Education Services, and Analysis of their Determinants research project which I lead, we aim at measuring the quality of health and education services, and analyzing the determinants for measured quality. In health and education services, supported with public funding and social insurance, it is an urgent task to (1) verify whether resources are appropriately distributed and (2) adopt a policy to rectify any distortion in resource distribution. In the case of health services, for example, we must accurately examine (1) whether resources are appropriately distributed, and whether essential health services are provided to the general public in the necessary quantity and quality. The key to this analysis is how to measure the quality of services provided. Merely having advanced medical equipment and facilities does not necessarily mean that high-quality health services are offered. Quality must be measured from various perspectives, e.g., whether the site is located in a place easily accessible by patients, whether patients can utilize its facilities when necessary, and whether the facilities deliver an expected treatment effect at certain probability. Evidence for the evaluation of service quality must be accumulated before we can move on to the next stage of discussing (2) a policy to rectify any distortion in resource distribution.

Recently, measuring the health and education sectors in the gross domestic product (GDP) by taking into account of the quality has been considered. There is a growing call for estimating output (value added) separately (Schreyer, 2010), rather than estimating conventionally as the total cost of inputs (labor, capital cost, and intermediate inputs). If output in these sectors can be estimated directly, it will be possible to evaluate productivity and show policy evidence necessary to discuss production efficiency, how to promote innovation, and improve resource distribution, similarly to that in other sectors. Yet, to this end, it is necessary to clearly define "output" and give economic consideration to how its quality can be estimated. Merely defining the number of patients or students as output ignoring the quality of medical or education services could result in a misleading productivity index.

Quality of childcare services and their effect on children's development

As an example of our project outcome, let me introduce a paper (Fujisawa and Nakamuro, 2017) which measured the quality of childcare services—the area which needs to be developed on a preferential basis for addressing the low fertility rate and expanding women's employment opportunities—and examined whether the measured quality actually has a positive effect on children's development.

The quality of childcare services can be gauged based on their educational value as well as to what extent the services meet the expectations and demands of service recipients/users (level of convenience in using childcare services, e.g., availability of extended care, as seen by parents, who are the direct users of childcare services). Internationally, the quality of childcare services is measured by the former approach, using the Infant and Toddler Environment Rating Scale—Revised (ITERS-R). This scale quantitatively evaluates childcare environment in seven aspects, i.e., "space and furnishings," "personal care routines," "listening and talking," "activities," "interaction," "program structure," and "parents and staff." It should be noted, however, that this scale was developed in the United States and is therefore based on childcare perceptions and systems different from those of Japan. Hence, we should be aware that there is a problem with applying this approach to Japan unmodified.

Fujisawa and Nakamuro (2017) examined the correlation between the quality of Japan's childcare environment/childcare staff (their qualification, educational standard, number of years served in the occupation) measured with ITERS-R, and the developmental status of infants and toddlers measured with the Kinder Infant Development Scale (KIDS). KIDS evaluates infants' development status based on nine criteria, i.e., "physical motor," "manipulation," "receptive language," "expressive language," "language concepts," "social relationships with children," "social relationships with adults," "discipline," and "feeding."

Quality of childcare environment and career duration of childcare staff affecting children's development

The study examined the quality of childcare services for 20 smaller childcare centers and seven medium-sized childcare centers in Japan. Results indicate that smaller establishments offer a better childcare environment than the medium-sized sites. Smaller childcare centers are often considered to be disadvantageous in terms of childcare environment due to the fact that they offer smaller space for play and exercise, and sometimes do not have individual classrooms for different age groups. However, ITERS-R evaluation shows that, on a scale of up to 7, smaller centers score higher at 4.47 on average as opposed to the average of 3.97 for medium-sized centers.

The study also indicates that the quality of childcare environment and career duration of childcare staff have a positive correlation with the developmental status of 1-year-old infants at the end of an academic year. At the same time, little correlation is shown between children's development and the scale of childcare centers, their child-staff ratio, and childcare staff's academic background before attaining qualification as childcare worker. This report is based entirely on a one-year study involving a small sample size, and should not be used for a hasty policy judgment. Yet, it is necessary to refer to such evidence and make continuous efforts to maintain discussion on achieving appropriate resource distribution in education and health services.

March 2, 2017

March 15, 2017