A wide range of quality of care
- India’s health care sector provides a wide range of quality of care
- One of the striking features of India’s health care sector is the range of quality in available services
(IIP) - India’s health care sector provides a wide range of quality of care, from globally acclaimed hospitals to facilities that deliver care of unacceptably low quality. Efforts to improve the quality of care are particularly challenged by the lack of reliable data on quality and by technical difficulties in measuring quality. Ongoing efforts in the public and private sectors aim to improve the quality of data, develop better measures and understanding of the quality of care, and develop innovative solutions to long-standing challenges. We summarize priorities and the challenges faced by efforts to improve the quality of care. We also highlight lessons learned from recent efforts to measure and improve that quality, based on the articles on quality of care in India that are published in this issue of Health Affairs. The rapidly changing profile of diseases in India and rising chronic disease burden make it urgent for state and central governments to collaborate with researchers and agencies that implement programs to improve health care to further the quality agenda.
One of the striking features of India’s health care sector is the range of quality in available services. India is home to global leaders in innovation in and quality of health care such as the Narayana Hospitals, known for providing high-quality cardiovascular surgery at low cost, and the Aravind Eye Care System, whose hospitals provide a high volume of cataract surgery, as well as globally renowned medical teaching institutions such as the All India Institute of Medical Sciences, in New Delhi.1,2 Simultaneously, many Indians—especially the poor—receive unacceptably low-quality primary and hospital care.3,4 The rapidly growing burden of chronic diseases in India makes the low quality of care highly salient for health policy.
The challenge of low quality in health care is not unique to India. Studies from a range of developed and developing countries have demonstrated widespread problems with providers who make little effort to ensure that patients receive high-quality care, geographic variations in the quality of health care services, and high levels of medical errors.5⇓⇓⇓–9
Efforts to improve the quality of health care services in low-resource settings, including India, have typically focused on structural constraints.10 Recent studies in low-income countries have documented low levels of provider knowledge, in both the public and the private sectors, and have found evidence of large gaps between providers’ knowledge and the care provided, sometimes called “know-do gaps.”11,12 In addition to providers’ lack of capacity or knowledge in such settings, low quality of care could also be due to the lack of incentives in the health system or information problems in the health care market, combined with a lack of accountability among providers and poorly functioning governance systems in the health system. It is important to understand the process of delivering health care services and the factors that can limit providers’ effectiveness.
A cluster of articles in this issue of Health Affairs focuses on challenges related to the quality of health care in India. The cluster includes articles that describe challenges in using data from household surveys and hospital administrative records to measure the quality of care, examine a delivery model for high-quality surgical care, and evaluate a state-run ambulance service program designed to improve access to and use of care, as well as a DataWatch article on trends in state-level maternal and child health indicators. In addition to reviewing the state of research and evidence on the quality of health care in India, this article discusses critical challenges related to scaling up promising innovations and governance issues related to the quality of care.
Measurement Of Quality
Efforts to improve the quality of health care in India and attempts to evaluate the impact of these efforts invariably face challenges because of the lack of reliable administrative data. Of the three categories of Avedis Donabedian’s measures of the quality of health care (structure, process, and outcomes),13,14 structural measures have traditionally received the most attention in the form of government surveys of health facilities and record keeping to track the availability of resources such as numbers of hospital beds and personnel and quantities of supplies. Whether these resources can be used productively in delivering high-quality care to patients depends on the process aspects of care, including the capacity of health-sector workers. Measuring the quality of the process of delivering health care and the resulting health outcomes is especially challenging, requiring methods and approaches that go beyond standard service statistics and facility surveys.
Strategies To Improve Quality
A unique aspect of India’s health care sector is the limited availability of formally trained health care providers—those with at least a bachelor of medicine and bachelor of surgery (MBBS) degree, the equivalent of an MD in the United States—in rural areas, which is partly due to the challenges of recruiting and retaining qualified staff in the public sector in such areas.26 As a result, most health care in rural areas of India, where 75 percent of the country’s population lives, is delivered by providers who do not have formal medical training.4 Perhaps even more concerning is the fact that empirical studies have found that providers in such rural areas in India with formal medical training do not provide significantly higher-quality care compared to informal providers—which suggests that increasing the supply of formally trained providers alone might not solve the problem.11,12,16,27
An alternative strategy for improving the quality of care, in the interim, might be to increase the capacity of the existing supply of informal providers in rural areas by providing them with tools and incentives to deliver better care. However, empirical evidence on the impact of strategies to engage with informal-sector providers to improve the quality of care remains scarce.
In an experimental intervention in 2013 in West Bengal, the Liver Foundation—in collaboration with researchers—offered more than seventy sessions of training (covering a range of critical topics in health and health care) to informal-sector providers over a period of nine months.28 Not only did the intervention significantly improve the quality of care in terms of providers’ correctly managing cases, but it also improved adherence to checklists for best practices.
In contrast, another large-scale effort to engage with informal private providers—this one in the state of Bihar—relied on the use of social franchising and telemedicine to create a large network of health care providers in rural areas. Despite training thousands of informal providers and incorporating them into this network, the program failed to improve the quality of care or to achieve any of the target health outcomes at the population level.18,29
These diverse experiences hold valuable lessons both for efforts to improve quality and for evidence-based policy. One key lesson is that improving the quality of care delivered by informal providers who are already providing health services requires intensive efforts over a sustained period of time to change providers’ practices. A second lesson is that the effectiveness of new approaches to improve the quality of care needs to be demonstrated empirically before they are scaled up. In a positive example of evidence-based policy, building on the success of the Liver Foundation’s training program, the government of the state of West Bengal has recently approved a statewide scaling-up of the training program, in which the government will conduct once-a-week training for seven thousand providers for a period of six months.