The healthcare ecosystem must not only provide affordable services to the people but has to be pivoted on quality and accountability standards, too. Better policies and not achieving the goals cheaply should be the aim
A 2018 Lancet study titled, ‘Mortality due to low-quality health systems in the universal health coverage era: A systematic analysis of amenable deaths in 137 countries’ claims that more Indians die due to poor quality of healthcare services rather than due to access to healthcare. The study analyses “amenable deaths” in 137 low and middle-income countries (LMICs) using data from the 2016 ‘Global Burden of Disease’ study. It estimates that in 2016, more than 2.4 million Indians died due to conditions that could have been treated by healthcare. Of this, nearly 1.6 million people or 66 per cent died due to poor quality of healthcare services while 838,000 people died due to non-utilisation of healthcare services, according to the study.
In low-income economies, evidence is emerging that expanding healthcare coverage does not necessarily result in better outcomes. The Lancet research was undertaken in the context of the Universal Health Coverage (UHC), which is aggressively being pushed by the Government through the Ayushman Bharat scheme. The idea behind UHC is to reduce the financial burden for better access to health services. However, despite improved coverage and reduced financial risk, mortality and morbidity will not reduce on its own. This because universal healthcare coverage by insurance will not guarantee “quality.”
According to the National Family Health Survey (NFHS) conducted in 2015-16, 55 per cent of Indian households reported not using Government health facilities when sick and 48.1 per cent households cited poor quality of care as the reason. Consequently, private healthcare facilities have had to shoulder a disproportionate burden of care, especially in metro cities. However, the paradox is that private sector healthcare delivery is fragmented and erratic due to the lack of standardisation of protocols and the inability of promoters to invest in “quality.”
Some of the pressing challenges for the Government include spending on health infrastructure, training and educating professionals, getting latest technology and expanding the network of hospitals, dispensaries and primary health centres to ensure quality and, thus, solve the larger crisis in the health sector.
India remains among the lowest spenders on health — it currently, spends 1.5 per cent of the GDP for health, which is the lowest in the world. The public health system, too, is in shambles and private services, while being unaffordable, are riddled with profiteering malpractices — from overcharging to unnecessary procedures imposed upon people to general apathy — that have cost lives. Almost 122 Indians per 100,000 die due to poor quality of care each year, as per the study.
There are numerous reports, which prove that the Government-run insurance schemes have not only ended up increasing people’s out-of-pocket expenditure but they also lead to private hospitals imposing unnecessary procedures to extract money. AB-PMJAY has come as a relief to the poor, but it can’t strengthen primary healthcare or improve curative care facilities or reduce the burden for hospitalisation. To address primary care, the scheme includes opening of wellness centres but results are yet to be seen.
The performance of private providers is quite varied. In the absence of categorisation of hospitals, all are seen through the same lens. There is no specified patient safety standard or a comprehensive monitoring mechanism that can enable patients to compare clinical outcomes. Clinical data is not accumulated at a central level nor are outcomes or even patient experience ever discussed. Quality gets compromised as decision-makers attempt to solve sectoral problems in isolation.
Efforts to improve the quality of healthcare and attempts to evaluate the impact of these efforts invariably face challenges because of the lack of reliable administrative data. Measuring the quality of the process of delivering healthcare and the resulting health outcomes is especially challenging, requiring methods and approaches that go beyond standard service statistics and facility surveys. Stringent laws, with the end target of improving clinical outcomes and patient experience, are a necessity but would need significant investment from States, financial and otherwise, to create competitive and world-class healthcare facilities.
Recently, the Government indicated a positive interest in making healthcare a national priority, along with accompanying budgetary allocations. With multiple stakeholders and varying degrees of capabilities, the crux of any programme should rest on the question of standard accountability from all formats and sizes of healthcare providers as much as affordability. The entire healthcare ecosystem needs to be pivoted on quality and accountability standards. Some structural issues are now being addressed with the Ayushman Bharat programme but there should be a National Quality Monitoring Agency embedded in the National Health Authority, that can monitor clinical quality, publish data on clinical outcomes, patient safety and infection rates in various hospitals across the country. Patients should have access to clinical data so as to make informed choices.
Moreover, a quality regulatory mechanism will encourage hospitals to constantly map their performance on diverse components of patient care, making the establishment of good clinical practices obligatory. A mechanism to reward and incentivise hospitals that consistently deliver great standards of care, while appropriately penalising defaulters, will encourage compliance and help build a robust healthcare delivery model. This will encourage understanding of the components that contribute to the cost of high-quality care and the pricing of healthcare services.
(The writer is founding member, Indian Alliance of Patient Groups)
