A 2018 study on mortality due to low-quality health systems reveals that almost 122 Indians per lakh die due to poor quality of care each year. This means that India’s death rate due to poor care quality is worse than that of Brazil (74), Russia (91), China (46) and South Africa (93), and even its neighbours Pakistan (119), Nepal (93), Bangladesh (57) and Sri Lanka (51).
While many of the challenges are not unique to India, it is a shame that even after decades of Independence, we still are woefully underequipped when it comes to healthcare delivery.
Here are a few hard truths:
95 per cent of healthcare facilities in India function with less than five workers. Only 817 (from over approximately 60,000) hospitals in the country operate with quality certifications.
Essential diagnostics such as mammograms have a scant 1 per cent coverage across India. h
Healthcare professionals in rural areas with requisite formal medical training do not provide significantly higher-quality care when compared to informal providers or quacks.
Private sector care does not necessarily translate to better quality of care.
Lack of universal health coverage, access and affordability across the country remains a major challenge.
The National Accreditation Board for Hospitals and Healthcare Providers (NABH) was set up in 2005 to establish and operate accreditation programmes for healthcare providers in the country. The board has done some good work in this area. However, it is not mandatory for all hospitals to get certified, and the reach of the board is largely limited to hospital networks in bigger cities and towns. What about the tens of thousands of nursing homes that haven’t bothered with NABH and blatantly violate regulations? What about the NABH-certified hospitals, who do the same?
Again, the indices they put together are more related to infrastructure and are focused on the ability of the hospital to deliver care. There is no daily mechanism in place to monitor if the accredited hospitals and labs are adhering to defined protocols. A periodic inspection does little more than provide a snapshot of their infrastructure and staffing patterns, and is a far cry from being able to reliably measure care. The net result is that hospitals and labs now boast of NABH certification to tell clients that they adhere to quality standards, while all that the certification does is to assess if they could deliver quality care, not if they actually do.
The government has, over the years, introduced many interventions to promote quality promotions: the Indian Public Health Standards 2008, National Quality Assurance Standards (NQAS) 2013, Mera-Aspataal (My Hospital) 2016, Labour Room Quality Improvement Initiative (LaQshya) 2017, and National Patient Safety Implementation Framework (2018-25).
But what is missing is a national body for monitoring quality of healthcare delivery. Organiastions like the Agency for Healthcare Research and Quality (AHQR) in the US and the Care Quality Commission (CQC) in the UK monitor nationwide healthcare delivery and ensure that quality care is delivered to patients.
Shouldn’t the government set up a national monitoring agency that will regularly and impartially monitor clinical quality and make this data available to the public? If this is done, hospitals will be forced to establish, maintain and monitor good clinical practices. The carrot-and-stick approach of rewarding facilities that consistently deliver high standards of care and penalizing defaulters will also help build a quality-conscious system.
Take other countries, for example. In the US, the AHRQ not only monitors quality but also introduces measures to improve it. Using one such intervention, the Comprehensive Unit-based Safety Program (CUSP),6 Detroit-based Henry Ford Hospital reduced the percentage of central line-associated bloodstream infections (CLABSIs) in its haematology-oncology unit by 75 per cent. This reduction not only helped patients, but also saved an estimated $385,000.
Successive central and state governments have pumped crores of rupees into building infrastructure. But is that the only solution? Is the healthcare delivery system equitable? Do all Indians have equal access to quality healthcare? How long will we accept economic disparities, geographic inequities and social distinctions?
India is one among a large number of countries, mostly in the developing world, that focuses predominantly on quantitative healthcare. This means that governments believe deploying large numbers of doctors, nurses, medical equipment and hospitals will ensure quality healthcare delivery. Hence, the focus is on opening more medical and nursing colleges, building more hospitals and procuring more of the latest medical equipment. Coincidentally, the public also views the creation of these assets not just as quantitative delivery but as signs of quality as well.
A doctor missing a diagnosis or giving the wrong medication to a patient will hardly be noticed at a village healthcare centre as people will simply not know any better. But the absence of a doctor for a week could lead to a riot. The focus on getting a person in a white coat in front of the patient often subsumes everything else in healthcare delivery.
Doctor has seen patient = healthcare goals achieved.
We continue to mechanically measure indices like Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), etc., and set targets without even analysing if the improvement in those indices occurred because of our interventions or due to other factors. For example, reduction in IMR and MMR may largely be due to the arrival of better antibiotics or greater awareness among the community, rather than the larger number of hospital beds provided in villages.
Quality in healthcare is difficult to measure. Governments find it more problematic because it could reveal lacunae in their healthcare system. And since the average patient really does not know about the quality anyway (beyond general cleanliness of the hospital, etc.), many governments have neither the inclination nor the will to put in systems to measure the quality of the care delivered.
Make no mistake, quantitative healthcare is very important too. Without the expertise, equipment and infrastructure, it would be nearly impossible to deliver quality care. But what quantitative healthcare measures tell us is the capacity or ability to deliver quality care and a broad high-level view on outcomes, not whether quality care is actually being delivered at the individual level.
In the private sector, quality indices are often a hinderance, exposing dangerous shortcomings that need expensive solutions, and therefore need to be papered over as no hospital wants to spend a rupee more than absolutely necessary. Solutions may involve adding staff or equipment or even designating specific areas for certain activities, none of which add to the revenue of the hospital directly. Where then is the incentive to invest in such measures?
Why go through the headache of measuring the quality indicators and finding out that you are well short of providing quality healthcare when you are unwilling to fix it anyway? That is the attitude of most of the private sector in India
Excerpted with permission from Sick Business: The Truth Behind Healthcare in India, Sumanth Raman, HarperCollins India.