‘Bengal doctor beaten up’, ‘Hospital ransacked by angry relatives’, ‘AIIMS doctor assaulted by patient’s relative, FIR filed’… over the last many years such events continue to make frequent headlines. The quality of care in health remains among the promises yet to be achieved.
The overwhelming focus on quantity of health care in India has long ignored a massive problem with the quality of health care that is delivered both through public as well as private institutions. However, it is in the last three years that there has been a lot of interest in the quality of health services in the country. This is an interesting development and long due, however the reasons behind this have not been well understood. Why has quality suddenly started occupying centre stage in the delivery of health-care services today? One reason is that private health care has suddenly exploded in the country in many forms, including the entry of corporate entities. The other reasons could be heightened expectations from new governments and easy access to health information.
More regulation no solution If quality was such a simple thing to measure and account for, why has it not become an important element driving health-care services in the country? What measures have been taken to ensure quality in public as well as private health care? By and large, most policymakers feel that more stringent regulations can help ensure quality. This is countered by organisations like the Indian Medical Association which feels that overzealous regulation such as the Clinical Establishments (Registration and Regulation) Act will only complicate matters, increase cost and can be detrimental to affordable health care in a country such as India. It is without doubt that weak enforcement of regulation is a major impediment in ensuring quality of care. However, it is to be noted that the experience of developed countries in the West has proven that regulation, while a prerequisite, does not always ensure high-quality health care. The other important question to address is: are doctors and health-care workers always to blame for the lack of quality or is it a systemic problem that requires more resources?
These deficiencies in quality of care represent neither the failure of professional compassion nor necessarily a lack of resources. In fact, they result from gaps in knowledge, inappropriate applications of available technology or the inability of organisations to change. Health-care systems, public or private, have failed to align practitioner incentives and objectives to measure clinical practice, or to link quality improvement to better health outcomes. The Prime Minister’s ambitious Skill India Mission is a great initiative which needs to be applied with rigour to the health sector. Without improving skills, expanding access through insurance mechanisms will not yield results.
Investing in quality The Institute of Medicine, U.S., defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. Given the proliferation of private medical colleges in India and poor quality of professional education, it isn’t difficult to understand why such violent episodes recur frequently. Outcomes also include patient satisfaction or patient responsiveness to the health-care system. Interestingly it is this angle which has been highlighted in recent times by the media. Although good outcomes are the objective of all health actions, outcomes alone are not an efficient way to measure quality for two reasons.
The first is the quality conundrum. A patient may receive poor-quality care but may recover fully, or a patient may receive high-quality care for a complicated illness (such as cerebral malaria or tuberculosis) and still not recover. Second, adverse health outcomes are relatively rare and obviously do not occur with every encounter. Efficiency is also another buzzword confused with quality — measuring and comparing hospital efficiencies require skill sets which are not easy to find and replicate all over the country.
Measuring quality has to move from away from a simple “public versus private” debate and a blame-game mentality so as to be an inclusive strategy that takes into account many of these themes. Measuring quality and not just outcomes in health care and making those data widely available to the public will help make better judgments. It will also hold policymakers accountable to the bottom line: improving the health and well-being of the population.
When countries invest in quality, an investment can be beneficial but can come at a cost. This is important to note. India has the potential to be a game changer in quality with use of low-cost technology to measure and improve quality of care in the health sector.
The Prime Minister’s clarion call for “zero defect” in “Make in India” shouldn’t be restricted to manufacturing alone; the quality of health-care services which affect citizens on a day-to-day basis is equally important as quality of products manufactured, and will help in branding India.
Rajmohan Panda is a senior public health specialist at the Public Health Foundation of India. His current interest lies in improving primary care and governance mechanisms in health systems for better health outcomes.