Dr Priya Balasubramaniam, Senior Public Health Specialist & Director, PHFI-RNE Universal Health Initiative, Public Health Foundation of India and Akshya Patil, Project Associate, Public Health Foundation of India deliberate on how technology can be mobilised to reduce the gaps in maternal and child health
“Quality means doing it right when no one is looking.”
– Henry Ford (Industrialist and pioneer)
India’s healthcare sector has evolved in a manner that presents a curious paradox. While an increasing proportion of the country’s mixed healthcare delivery is borne by a competitive, unregulated and expanding private sector, its complex yet comprehensive public health system struggles to keep pace with rapid demographic and epidemiological transitions. More than 80 per cent of healthcare expenditures in the country are out-of-pocket driving 4.2 per cent of India’s GDP towards private healthcare services.
As India grapples to achieve global maternal and child health goals such as the Millennium Development Goals (MDG) and bridge ever widening gaps of inequality faced by vulnerable populations, there has been increased emphasis on improving access to healthcare and in the process we seem to have lost out on delivering consistent good quality healthcare. Unfortunately, merely giving populations access to health services without equal stress on the quality of care they are getting defeats the very provision of equitable healthcare.
The uneasy relationship between the public and private health sectors is especially stark around quality of care issues. While the public sector considers increasingly dominant private health providers as profit-making entities focussing on higher levels of care, the private sector perceives the public health sector to be lacking in infrastructure and hampered by poor management, thereby affecting quality and creating the very market that makes people opt for privately run health services.
While the public sector plagued with poorly run primary health centres, overcrowded hospitals, outmoded health camps and lack of accountability of those entrusted with the responsibility of delivering services, is often seen as a major culprit in the erosion of and low quality maternal and child health services, the private sector is no less culpable. The general lack of healthcare regulation has fostered a slew of providers who have, in numerous instances, compromised on care quality in their attempt to cut costs, resulting in the hapless patient often paying the price with their lives or chronic injury.
Yet, why should we prioritise quality in healthcare in a country that is barely able to provide clean water and sanitation for its populations and the spectre of undernutrition still looms large. Well largely because providing water and sanitation are invariably measures of effective governance while assuring good healthcare quality for individual patients and populations is intrinsic to the wellbeing of a society at large- and is neither expensive nor difficult to achieve. At the end of the day, an individual citizen walking into any health facility needs to be assured that she or he will be looked after in a clean and hygienic environment, treated with dignity and respect and delivered basic healthcare services in a considerate and error free manner. Neglecting to pay attention to quality in healthcare delivery and wide variations in standards of care has forced our health systems to incur even higher costs related to unnecessary deaths and wasted resources. The World Health Organization states that for low and middle income countries which especially need to optimise limited resources and expand population coverage, the process of quality assurance and improvement needs to be based on sound local strategies to achieve the best possible results for investments in health.
Let us look at some of the data in Reproductive Maternal and Child Health (RMNCH) that is influenced by quality: every year more than half a million women die of causes related to pregnancy and childbirth, and almost four million new-borns die within 28 days of birth. In 2010, India accounted for 19 per cent of all global maternal deaths despite an annual decline of 5.7 per cent in maternal mortality between the years 2005 and 2010. India has the largest number. Neonatal sepsis is one of the common causes of neonatal mortality contributing to 23 per cent of all neonatal deaths.
Quality of care is an increasingly significant predictor of service utilisation in maternal health, even more than access. Despite the improvement in the quality of maternal health services over the last ten years, India still fairs poorly in comparison to most emerging economies. The National Health Rural Mission launched in 2005 has contributed immensely to strengthening rural primary healthcare and enhancing access to health services for poor women and children in rural India. Yet, quality continues to remain a concern, with innumerable stories of negligence, deaths and infections being highlighted in the media on a regular basis.
While schemes like the Janani Suraksha Yojana promote institutional deliveries (driven by compensation package for the delivering woman and ASHA worker) they have resulted in side-lining other important areas like immediate post-partum contraception that ensures sustained maternal health. In addition, the inadequate staff and lack of space in many facilities frequently lead to most women being discharged from the hospitals within four to six hours of delivery with little follow-up on infection rates. Emergency obstetric care (EmOC) thus continues to be a challenge in public and private facilities in rural India, especially at the field level. The government has recently amended policy to allow staff nurses and ANMs to initiate treatment of pregnancy-related complications, including intravenous fluids and injectable oxytocics, antibiotics, and magnesium sulphate—that were earlier restricted to administration by physicians.
Post-natal care is a critical component of maternal and new-born health that has huge implications for standardised quality of care. Immediately after birth, bleeding and infection pose grave risk to the mother’s life; preterm birth, asphyxia and severe infections threaten the life of a new-born contributing to two-thirds of the neonatal deaths. Appropriate postnatal care critical to reducing maternal and neonatal problems is unfortunately one of the most neglected components of maternal care in India. Data from NFHS-3 shows that only 42 per cent of women surveyed received postnatal care after their most recent delivery.
Another quality control red flag in the field of RMNCH is related to efficient implementation of family planning methods. While it is estimated that about 140,000 to 150,000 maternal deaths can be prevented worldwide through efficient family planning (FP) measures, current practices for family planning continue to remain outmoded. About eight per cent of maternal deaths are attributed to unsafe abortions in India and the practice of incentivising health workers to encourage mostly vulnerable women to accepting invasive sterilisation methods has led to the neglect of spacing, use of contraceptive pills and other contraception methods. Data reveals that spacing methods and use of contraceptive pills are provided mainly by the private sector. The public system, which is still the major provider of family planning services, especially for the poor, must be strengthened to improve the choice and methods for delivering safe good quality services. Standards in maternal health care cannot be raised unless the health system guarantees good quality care that follows a consistent and continuous uptake of maternal health services across the country.
As mentioned earlier, improving standards in quality has to be a driving force in restoring public faith in public health facilities which have a long been associated with poor quality services. Why is this? – A common rationale is that public sector services invariably serve the very poor, uneducated and those that simply have no recourse to pay for their healthcare. Yet, is poverty an excuse for poor quality? Looking at our current public system, it seems that way. Even the recent Planning Commission report acknowledges that fact the government run facilities are characterised by high levels of absenteeism, poor availability of skilled medical and para-medical professionals, callous attitudes, unavailable medicines and inadequate supervision and monitoring. Factors like privacy, waiting time and average time devoted to each patient which influence patients perception of the type of care provided should be considered to improve the quality of RMNCH and primary healthcare services in India.
To monitor the impact of primary healthcare and ensure quality of RMNCH services, comprehensive health information systems must be developed. The widespread availability of information technology should be well leveraged by the primary healthcare system in far more innovative ways. Quality measures that systematically evaluate and monitor quality of services provided at the primary healthcare level are fundamental for the success of any programme.
So, what are some of the solutions to address quality issues in primary health and RMNCH services in our health system? The first is of course at the policy level: designing interventions based on evidence supported by micro-level planning, consistent monitoring and calibrated evaluation. This of course involves drastically
improving bureaucratic inefficiencies and creating accountable management structures, all systems level changes that will invariably take time. The second option is to harness technology to assess quality with robust measurement of processes, outcomes and costs as part of a broader strategy that tracks the health of a population. Health quality outcome measures will allow state government policy makers to decide when additional resources need to be spent on direct healthcare (i.e. improving access) and when they need to be spent ensuring that the care is good (i.e. quality). Making quality-related data subsequently publicly available will reduce the risk of extra spending being wasted by corrupt systems.
- Structure
- Process and
- Outcomes
Structure refers to the infrastructure elements of a healthcare delivery system that promote or prevent access to and provision of services. Process refers to what occurs during the patient-provider interaction, and consists of both technical (the appropriateness of an intervention) and interpersonal excellence (the humane and responsive nature of the care provided to a healthcare seeker). Outcome, the third dimension of quality, refers to the effect of the care on the health status of both patients and populations; it includes efforts to prevent, diagnose, and treat health problems, and is often viewed as the ‘bottom-line’ of healthcare quality assessment.
Embedding technologies like telemedicine within existing primary health and RMNCH infrastructure can be applied to evaluate and standardise quality of care functions like patient safety, sterilisation and infection control, procedural checklists and provider accountability in especially in more remote rural areas that have fewer healthcare facilities. Telehealth tools are ideal to address quality of care issues associated with health facility condition and access, administration, health data storage and exchange as well as patient and provider training and education. The scope of decision support technologies should also be explored in assessing the impact of quality metrics on consumer choices in RMNCH. These technologies are being used to screen patient referrals, examine laboratory investigations and develop procedural guide-lists that
can be monitored across various levels of care, counselling or treatment based on the patient history and serve as triage and increasing patient-provider contact time.
The real strength of technology for quality assessment lies in its potential for use among the non-physician providers and allied health professionals who form a large part of RMNCH care in the country today. Mobile device technology can also part of low-cost solutions towards enhancing transparency in healthcare facilities and in improving reporting mechanisms where none exist. The Swasthya Slate developed at Public Health Foundation of India is a successful example of harnessing the potential of mobile devices to build capacities of front line health workers in provision of care and simultaneously addressing quality of care issues at the frontline, empowering policy makers who have access to real time data collected by health workers. The slate has applications that cover key aspects of RMNCH care that includes antenatal care, intra-natal care, post-natal care, immunisation and adolescent health.
Finally, technology is only one aspect of the solution to enhancing quality of care in the country. No technological innovation can be a standalone. What we need is a mix of sound health policy that emphasises on quality of care and programmes that ensure it is complemented by validated technological innovations. By not choosing to consciously invest resources to measure and ensure health care quality India is creating huge risk for the future of its health sector. If the country is to travel the road to achieving Universal Health Coverage and access without concurrently focusing on quality, it may likely waste an immense amount of resources and lives.
References:
- National Sample Survey Organization (NSSO). NSS 60th Round, NSSO, New Delhi: NSSO, Govt. of India; 2006. Available from: mospi.nic.in/nspb_m.htm.
- UNFPA.(1994): The State of World Population. UNFPA, New York.
- UNFPA.(1995): The State of World Population. UNFPA, New York.
- Nair H, & Panda R. Quality of maternal healthcare in India: Has the National Rural Health Mission made a difference? Journal of Global Health. 2011; 1(1), 79–86.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484741/#