Well-functioning health systems across countries, are constantly working towards achieving universal health coverage. Access to high quality healthcare is a critical component of UHC. In the Indian context, the launch of public health insurance under thePradhan Mantri Jan Arogya Yojana (PM-JAY) component of the Ayushman Bharat program and other existing state-level programs that began with theArogyashree Social Health Insurance program in the erstwhile state of Andhra Pradesh, have managed to give financial cover to nearly half of all Indians against catastrophic expenses for hospital-based care. Growing private and employee health insurance along withthe ongoing efforts to bring unprotected informal workers under risk protection, has brought the SDG goal of protecting 80 percent of the population by 2030 well within sight. And yet, major challengescontinuesto impede our ability to meet the other two dimensions of UHC. These are the proportion of total health needs and total health expenses covered.
While we address the above challenges, a greater challenge facing us is that of the unsurmountable quality chasm in the healthcare provider system. The core purpose of medicine – do no harm, relieve suffering, and prolong lifeis more relevant today than ever before. It is estimated that many more lives are lost or disabled by poor quality of healthcare services across the developing and underdeveloped world. Apathy from successive governments have led to poorly functioning public health services and unregulated private healthcare. Deep rooted systemic issues underlie the current malady. Unless we fix these, mothers will continue to die during childbirth, babies and children will continue to die and have poor health outcomes, communicable diseases will continue to claim lives, non-communicable diseases will continue to impede lives prematurely, and the elderly will have no means to face their sunset years with dignity.
There is, however, a way to bridge this quality chasm. Systems approach is the right way to overcome deep rooted systemic issues. Simply put, it uses the quality improvement framework of input-processes-output-outcomeswhile addressing these issues. Resources for health such asthe health workforce, infrastructure, drugs, devices, disposables, and diagnostics among others are the critical inputof healthcare services. Quality Assurance of input is the first step in bridging the chasm. Developing national quality standards, building capacities of quality accreditation institutions, and strengthening quality regulatory systems are some of the preliminary steps in laying the foundations for quality assurance.
The core processes include clinical services, revenue-cycle management, human resource management, and supply chain management. Clinical services include processes such as admission-transfer-discharge and consultation-diagnosis-treatment-follow-up for in-patient and out-patient departments. Optimizing the core processes, using proven methods in other service industries (business or clinical process reengineering, continuous quality improvement using standard management tools like Plan-Do-Study-Act cycles, check-list methods) improves safety, efficiency, outcomes, and patient experience. Information technology not only plays a major role in gathering, storing, and sharing the data, but can also be designed to drive standard processes.
With the growing burden of rising healthcare costs, the narrative has shifted from ‘quality’ to ‘value’ (Quality/ Cost). This incorporates cost-effectiveness of a service. Hence, along with using evidence-based risk-benefit analyses in developing quality standards and clinical practice guidelines, scientific costing-based cost-effectiveness analyses are also being taken in account. The amount of resources needed to save one life or prevent one disability is taken into consideration while framing guidelines. When a system has finite amounts to support health needs, a trade-off is needed in prioritizing the services, especially when they are funded by public or pooled money as in public or private health insurance programs.
While there are enough tools and knowledge to deliver quality services, the means to achieve these are different. One is to arrive at a reasonable estimate of per capita health expenditure needed to ensure essential quality of healthcare and make efforts in financing these needs. High spending does not always means high quality. Second is to use the financial lever of a large payer (government in case of publicly funded programs) to demand quality services from the provider, called as strategic purchasing. Third is to use theregulatory lever to force quality assurance from providers of healthcare goods and services. Fourth is to leverage digital health to drive efficiencies, to monitor and improve quality and to enforce regulation. Healthcare services will be a lot more effective if quality, equity, and dignity are taught as part of medical ethics in the formative years of health professionals. It is also equally important to create public awareness on their right to quality of care.
While the above discourse is relevant to formal medicine, it becomes ineffective in case of the informal healthcare provider system, that has deep rooted presence in rural India. The only solution is to ensure access to essential formal healthcare services for the rural and marginalized urban population. Apart from the context of healthcare services, quality plays an important role in the food we eat, the water we drink, the air we breathe, and the roads we travel. Our people deserve better care.
Dr. Krishna Reddy Nallamalla
Country Director, ACCESS Health International