Quality healthcare in India – What is needed?

For quality healthcare, the care has to be safe, effective or appropriate, timely, efficient, equitable and people-centric. An insight by Dr Krishna Reddy and Siddhartha Bhattacharya

For a developing country like India Universal Health Coverage (UHC) cannot or rather should not be a political choice. UHC calls for vision, courage, long-term thinking and actions on mission mode at the ground level. As India initiates a journey towards universal health coverage with Ayushman Bharat PMJAY, it is clear that improving quality of care will require system level action. PMJAY, a major social insurance programme that covers catastrophic medical expenses for nearly 50 per cent of India’s population, particularly the most vulnerable and economically weaker sections of population, primarily focuses on quality and affordability care.

A recent Lancet Study on “Health systems in the Sustainable Development Goals era: time for a revolution” reveals that Universal Health Coverage for SDG conditions could avert 8.6 million deaths per year but only if expansion of service coverage is accompanied by investments into high quality health systems. The care that people receive is often inadequate, and poor-quality care is common across conditions and countries, with the most vulnerable populations faring the worst. In low- and moderate-income countries, the evidence of poor-quality healthcare challenges the assumption that increasing utilisation through improved access and financial protection will lead to better outcomes. In fact, nearly 2/3rd of avoidable deaths were on account of poor quality.

What should be the design of quality systems that will deliver better outcome at lower costs? As demand for healthcare picks up through demand side financing and expansion of delivery capacity, this will be a key question on the journey ahead. There are many industries in the world who have moved into six sigma standards of quality with proven quality improvement methodologies for business process improvement like Kaizen and Lean. India’s healthcare delivery has pockets of excellence, but quality remains patchy outside a few select institutions of eminence. The cost of unpredictable quality in India will be a significant issue that will have to be overcome to instill confidence and trust in healthcare. Therefore, what can be done about it?

Methods and tools for quality

For healthcare in India, a common belief is quality improvement can be achieved solely based on input criteria like quality of physical infrastructure, qualification of staff and availability of medical infrastructure. This is known as quality assurance (QA) which essentially are a set of basic ingredients required for quality. But none of these approaches can be linked to value optimisation without a framework of quality improvement (QI) that drives improved quality from a patient perspective at reduced costs. Quality assurance mechanisms covers only the hardware component of the quality framework. The software that makes continuous quality improvement possible is harder to achieve as this requires process standardisation, delivery integration, a different approach of care delivery through task shifting and a robust information technology system that allows data driven decision making.  The methods and tools that have been well tested for multiple non-health sectors can be easily adopted for healthcare delivery, albeit at a higher level of complexity.

For quality healthcare, we believe that the care has to be safe, effective or appropriate, timely, efficient, equitable and people-centric. This requires a careful convergence of healthcare delivery design, process standardisation, integrated information system, financing, task shifting, team-based skilling and process standardisation.

Paradigm shift

To achieve these six paradigms of quality improvement, it is clear that we will have to raise profile and understanding of healthcare quality in public and policy dialogues. It will be important to recognise and support front-line quality measurement and improvement. At the heart of this movement, there needs to be an enlightened leadership and management culture that supports the journey of quality improvement through data driven experimentation and decision making. Accreditations should be linked to value and wherever possible we should link payments to accreditation levels, submission of quality related data and eventually quality improvement through strategic purchasing.

The way forward

Quality improvement in India will require a dedicated authority to develop policy framework to support quality measurement and improvement strategies. The states will require to develop protocols, guidelines and conduct data collection/analysis with standardisation of quality reporting to support strategic purchasing under Ayushman Bharat. As India moves towards Universal Health Coverage (UHC), there has to be collaboration between payers and providers to ensure quality and accountability on one side and to ensure sustainability of provider enterprises through realistic pricing mechanism through scientific costing on other side. It will be a good idea to create a separate fund to reward quality initiatives and create a movement of quality champions who come up with breakthrough process innovations that deliver the value in the hexagon. While institutional accreditation is important, recognising individuals who excel in creating breakthrough accomplishments in improving quality should be a priority. Equally important will be to create an institutional structure to support multiple quality collaborative across public and private sector in India through hub and spoke models and diffuse quality improvement experience. This can be set up as a Public Private Partnership where the benefits reach the people of India.

As India drives towards making healthcare more accessible, affordable and inclusive, quality should be front and centre in policy discourse. A low-quality healthcare system, if scaled, can set the clock back. We should evangelize a “fit for purpose” unique healthcare model that is made in India for all Indians and make it a model of affordable excellence.

Reference: Lancet Report https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30386-3/fulltext