Quality in Healthcare: Time to askthe right question?
The health of the people of India andHealthcare in the country are on a positivetrajectory despite many challenges.
Intensely debated, optimists quote private health care being on parwith global standards and cost amongst the lowest in the world assupportive evidence. Simultaneously, activists, public health professionals call out the inferior status of primary care, dominant outof pocket payment system, poor Insurance coverage, and inadequate regulation, as a bane. However, a persistent blind spot in the evolutionstory is “health outcome" as a quality measure to assess the quality of healthcare delivery. It answers the question, how good is the healthcare provided when measured by improvement in health status
“Health outcome” is what is valued most by patients and family members. We would all want our loved ones to be better, irrespective of where, how and why we seek care. In well-evolved health systems health outcome is an indicator under intense scrutiny by users,policy makers and payers. At a system level, it requires data definition,data aggregation, analysis, metrics, reporting, and dissemination.Health outcome of populations can be compared across regions,providers or trended over time. In the Indian health system, in abroader context, such a core objective of the health system remains inthe realm of unknown.
In India, the private healthcare has potential lessons to imbibe from the public health care system. For several decades, public Institutions,state, and central government have been systematically reporting health indicators of population, in globally accepted formats and frequency (to be read as health outcome indicators) like life expectancy, infant mortality rate, maternal mortality rate. It has helped the health system gauge performance of maternal and child care,understand barriers and improve inputs and processes. It is commendable that these indicators have improved significantly despite growth in the volume of services.
Health outcome analysis could be potentially combined with study ofthe cost incurred to achieve a defined outcome. Such an initiative would dissect "appropriate cost", which are essential to achieving quality versus "excessive or unnecessary cost" which could be wastage or what is often construed as profiteering. We are battling to justify the cost stretch” in care provision between the judgmental compulsions of medical fraternity often done with the right intentions, and the perception of “excessive and unnecessary diagnostics and interventions” by users of the system, in a dominant private provider model.
It may be unfair to say that quality is unmeasured in healthcare in India. Health care providers project "quality inputs" like technology, physical infrastructure, ambience, and healthcare workforce as quality indicators.
In recent times accreditation bodies like “National accreditation body for Hospitals and healthcare providers" or NABH has made significant progress in bringing this dialogue to centre stage. These efforts are dominantly process-centric and some indicators of outcome also being captured. The momentum is encouraging, with third-party payers valuing accreditation and promoting a higher fee for service for acknowledged quality providers.
It may not be a fair argument to project lack of capabilities, capacity,data capture, and analytics as limiting factors. There are potential opportunities to pursue this goal utilising a wealth of data source that lies in Insurance claims. An analysis will provide insight into the outcome, cost, and length of stay for a diverse set of medical conditions for which third-party payment payers have payment systems. There have been small academic initiatives of such analysis,but we may need to broaden scale and scope.
Similarly, accreditation bodies NABH mandate collection of data on Hospital-acquired infections, safety events which have a negative impact on the health of hospitalised patients. Here again, the collective and systematic analysis is not pursued. As a regulator, the government does not mandate the submission of critical specific patient outcome data to be an integral part of hospital licensing. Given the profound variance in access, type of care, proficiency, skillsof the healthcare team, technology, cost and quality across regions states and cities, such initiatives would provide a view of secondary ortertiary level curative care in Tier I and Tier II cities.
In a way, Indian healthcare has the potential to be a good system butremains far from an ideal one which the country needs. As we transition to become a better health care system regarding effectiveness, efficiency, and equity, it is apt to focus on quality, the rightway. Hence it is imperative that patients and their advocates aggressively demand from the other stake holders in health care that “outcome” matters the most, above all. We all owe it to ourselves.
- Copyright ©2019. Published by MOHAN Foundation
- Keywords: Quality in Health care, Health Outcome, Appropriate cost, Quality Inputs, Hospital Aquired Infections