Evaluation of quality is skewed & unequitable

Sheenu Jhawar

Quality is the latest buzz word that has hit the Indian health care market. So the question arises, what is quality, and what does it mean to each of us? To my mind, ’quality’ in the health sector means a system of steps and procedures adopted by the provider organisation to ensure that patients receive the highest possible quality of care.

Therefore any interpretation of quality should ideally include:

• A patient centered approach
• An accountability for quality towards the patient
• An attempt to ensure high standard and safety of treatment during the patient’s stay/visit

In the current scenario, we find concentrated efforts in evaluating quality, focussed only within the hospital industry. These evaluations do not apply to the entire health care sector and are therefore skewed and highly inequitable. We find quality assessment done to evaluate tertiary care being provided to people who can identify their illness and access the hospital service, rather than that of care provided within the whole gamut of the health care structure.

Within this larger framework we find that our country lags behind the expected and optimum standards on even basic health care structure and facilities. Presently, Primary Health Centres (PHC) serve health care needs only for rural communities. Often, these centres are not able to deal with early detection of diseases, due to a lack of multi-disciplinary medical expertise and laboratory facilities. Patients usually do not visit PHCs in the early stages of their diseases, while health care providers (if at all present) are forced to focus on only seriously ill patients due to the volume of cases.

The WHO report specifically points out that to some extent, the deterioration in health status can be attributed to inadequacies in PHC implementation. It does take on board that wider factors have been responsible for this deterioration such as lack of political commitment, and inadequate allocation of financial resources to PHC. It’s a well-known fact that community participation and any intersectoral strategies have often not progressed beyond words.

The report further adds that increasing socio-economic disparities have resulted from globalisation and the unrestrained growth and penetration of markets. Commercialisation of health care has further aggravated health inequities.

When speaking in the Guildhall of London in March 1994, the then Prime Minister of India said that he knew of no great industrialist who would come and look after the PHCs of India. That, he said correctly, was for the governments to do. Nonetheless, left at their own, the real picture is there for everyone to behold.

In the Alma Ata meeting, or the first time, it was officially recognised that improving health in developing countries can only be achieved by an intersectoral, primary preventive approach, oriented towards basic needs and poverty alleviation.

In 1998 a meeting was held in Alma-Ata, which brought together a number of original participants to review PHC 20 years later. Also over the last few years WHO has been reviewing the experience of primary health care throughout the world. This year is the 25th anniversary of the Alma-Ata Declaration, making it appropriate to evaluate the experience since the past 25 years.

What has been the progress within this area in a bid for quality of care in the last years? Some of the reviews of primary care centers point out gross neglect, inadequacy of treatment, almost absence of medical staff and a complete joke of the promise hitherto considered the backbone of our national health policy framework.

As an example for one of our state’s health centre, a newspaper report pointed out that, more than 80 per cent of the staff, including the Senior Medical Officer, of the PHC (which caters to 191 villages) were found absent during a surprise check by the Vigilance Bureau. The bureau, also found expired medicines in the health centres during the raid. Many residents alleged that class IV employees, as the doctors were running some of the subsidiary health centres and para-medical staff rarely visited the remote areas, thereby alleging that the entire health system in the region stood collapsed.

The urban population, where the clout for any policy formulation usually lies anyway, probably sees this as a remote occurrence not affecting them. However, some of us see it in a different light. It does affect each of us.

Would it be so wrong to say that lack of quality within the primary and secondary care centres is also adding to the influx of patients to tertiary care?

With this I shall also add that the influx of patients in the hospital is anyway not indicative of the true requirement of medical care within the society. Firstly, there are thousands of people who cannot perceive their illness, then there are thousands who cannot afford, avail or access care services, and owing to the lack of health care quality there must be thousands who re-require medical care and are forced to go for tertiary care when the visit could well have been avoided. Well-equipped health centres are mostly located in towns or cities and are seldom accessible to the poor.

The medical care gap analysis reveal that India has 94 beds per 100,000 population as compared to WHO norm of 333 beds per 100,000. There are only 43 doctors for a population of 10,000. Bearing in mind that India adds 45000 people every day and 16 million people every year to its population, can the rate at which health care provision expands, keep up with this explosion?

The cost burden of this attitude is enormous and the increase falls on all of us, including the patients. Seen economically, if the resources of tertiary centres are spent on preventable and /or ‘curable if presented early’ cases, it is an improper resource utilisation.

In the light of new quality assessment tools, urban population is exercising right to choose. The rural population is still awakening to their right to basic medical care. The ‘quality of care’ revolution is laudable, but requires an infiltration into all tiers of the health care structure within the country.

With this viewpoint, I must also add that in a novel example of an inspired move, the India Population Project in a particular state sought ISO 9002 for its 25 primary health centres and six maternity homes attached to it in the city.

As the protocols of ISO certification state that this infact is only benchmarking against what is documented, therefore within the concept of quality it still remains to be seen whether patient care is indeed being positively affected at these centres. However, it is still the beginning and hopefully will gain momentum nationwide.

The author is clinical auditor, Mid Stafford General Hospital, UK. Email:sheenujhawar@yahoo.com