Quality for sustainable healthcare
An assurance-based approach is the best insurance to achieve universal healthcare
The government of India's determined plan to achieve Health for all through Ayushman Bharat (AB) Programme is a path-breaking move towards achieving universal healthcare in India. AB caters to the substantial need for public healthcare by providing accessibility and affordability to large sections of the population. It aims at providing financial support through insurance/trust-based models to over 50 crore families in India and plans to set up 1.5 lakh health and wellness centres to strengthen primary healthcare. It is a revolutionary step, essential for bringing about substantial improvement in the healthcare indicators. However, such efforts need to be accompanied with quality assurance in health service to ensure robust health outcomes.
India's health sector suffers gravely on account of inadequacies in terms of infrastructure, poor quality of services, and human resource constraints. There is a dire need for the sector to lay greater emphasis on the quality of services. Quality refers to healthcare services which have the following features: effectiveness, efficiency, equity, safety, timeliness, and patient-centric. Quality also includes the use of scientific evidence, technologies, and equipment required to ensure accurate diagnosis as well as timely treatment. Inadequacy or the use of outdated technologies are likely to lead to a high incidence of delays and even erroneous diagnosis and treatment. According to a Lancet study, India ranks 145th among 195 countries when it comes to quality and accessibility of healthcare, lagging behind countries like Bhutan, Bangladesh, and Sri Lanka. The human resource element plays a large part in negatively impacting the quality of healthcare. The sector has been crippled largely by problems such as medical staff shortages, staff absenteeism, inadequate training, and the infamous brain drain from the medical sector. As per the National Health Profile 2018, India's doctor-patient ratio is around 1: 11,082, approximately ten times more than the recommended ratio of 1:1000 as stipulated by the WHO. In fact, the specialist surgical workforce for every 1,00,000 people stands at a mere low of 6.82 for India, compared to the world average of 30.147 as per the World Bank (2014). Fixed and abysmally low salary structures, lack of incentives to serve in backward districts, and poor infrastructure and logistics facilities are primarily responsible for the human resource constraints in the sector. Such discrepancies lead to the existence of wide disparities in terms of quality between private and public health sectors as well as across the different States of India. For instance, the health index score for overall performance ranges widely from a high of 76.55 for Kerala and a low of 33.69 for Uttar Pradesh, among larger states.
In fact, the Constitution of India has given utmost importance to health by putting it in the ambit of Fundamental Rights: Article 21, Right to life and Liberty. Honourable Supreme Court of India in Maneka Gandhi versus Union of India, 1978, included the right to timely medical treatment under Article 21 of the Constitution. Furthermore, it held as a Directive Principles of State Policy (Part IV of the Constitution) that every citizen has the right to live with dignity in line with Article 47. In State of Punjab v. Mohinder Singh Chawla (1997), it was held that right to health is essential to ensure Right to life and accordingly, the government is obligated to provide healthcare. Poor quality healthcare would thus be a direct infringement of this fundamental right. However, there is no Constitutional provision for addressing citizens' expectations with respect to non-provision of quality healthcare services by the State.
An integral part of guaranteeing the Right to Life and Personal Liberty is ensuring the Right to health to its citizens. Adequate public infrastructure, as well as social and financial support schemes, are a prerequisite for healthcare in India, but there exists an equally strong rationale for ensuring and maintaining the quality of healthcare facilities. A quality assurance healthcare model is an integrated and sustainable system which provides assurance to the patients regarding the healthcare. Assurance constitutes both the quality and adequacy of healthcare delivery in terms of infrastructure, personnel, and services. This means that when a patient visits a health service provider, he or she has confidence in the system that the diagnosis or treatment that the person is receiving is accurate, correct, and assured of quality. Thus, this model is based on the adoption of a patient-oriented approach. Such quality assurance needs to be provided across various levels of healthcare i.e. primary, secondary, and tertiary levels.
The adoption of assurance-based approach has the potential to bring long-term improvement in health indicators and health outcomes through accurate and timely diagnosis. This system would enable the people to use public health facilities and have more faith in the public healthcare system while reducing the time and costs through the reduction of patient transfers. Furthermore, quality improvements in public health would leverage the sector to attract quality medical professionals.
Therefore, it is imperative to recognise that one of the core pillars of sustainable healthcare in India is quality assurance. This calls for a major revamping of the sector through improved governance, management information systems, and regulatory frameworks.
First, there is a need to lay down a quality assurance framework with guidelines and protocols for timely diagnosis and treatment. There should be a mandatory system of ranking for healthcare centres and hospitals on quality parameters. Accordingly, stringent penalties against non-compliance built into the system would strengthen implementation. Second, there needs to be a higher budget allocation for investments in state-of-the-art healthcare devices and equipment, management information systems and data maintenance. Third, developing and adopting Telemedicine applications that would enable substantial quality improvement in both diagnosis and cure by overcoming information asymmetries. Telemedicine is likely to play a pivotal role in Indian healthcare, especially in providing healthcare access to rural areas. Fourth, there needs to be a framework of well-designed incentive structures for medical staff and professionals. The focus needs to be laid on the addressing vacancies in key positions as well. This step could be strengthened through the institutionalisation of a human resource management information system.
(The author is Young Professional, Economic Advisory Council to Prime Minister. The views expressed are strictly personal)