Price in Southern Africa (incl. VAT and postage): R 5.00 or it can be downloaded from our website

Patients in rural Africa choose between available health facilities in patterns that suggest they know the levels of various aspects of quality in those facilities, even when many of these aspects of quality are unobservable to patients. This paper investigates the hypothesis that learning about quality takes place through the observation of the outcomes of visits to health care providers by patients, their families and their neighbors and friends. Using two different data sets from Tanzania we show that patients know about the illness episodes of their neighbors at varying distances, that they invest additional effort in learning about illness episodes when the information generated should be most valuable, that during the period learning is taking place there are spatial patterns in the influence of learning and that when patients have learned quality, the spatial patterns disappear. We estimate that patients learn quality in the period between 1 and 5 years after a clinician has arrived with the steepest ascent in the learning curve at about 3 years. These patterns are supported by evidence from two separate data sets. The fact that patients are adaptive and rational has important policy implications for the delivery of health care and policies that facilitate the generation and spread of information about quality. ∗This work was funded by NSF grant number 00-95235 and an ISERP (Columbia University) seed grant. We are grateful to the careful and extensive input of David Bedoll as a reasearch assistant, and to Tim Conley for his advice on spatial analysis.