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Quality control a must to bolster healthcare

THE Global Burden of Disease study (2018) gives us a good indication of the current status of our health sector.

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Amarjit Singh
Former Secretary, Government of India

THE Global Burden of Disease study (2018) gives us a good indication of the current status of our health sector. India has improved its ranking on global healthcare access and quality (HAQ) index from 153 in 1990 to 145 in 2016. Nevertheless, India’s score of 41.2 points is well below the global average of 54.4. We rank lower than neighbouring Bangladesh and Sri Lanka, and even Bhutan with 47.3 points has done far better! Within India, best performers Goa and Kerala scored more than 60 points on the HAQ index, while Assam and Uttar Pradesh were among the laggards. Recent surveys by the Association for Democratic Reforms show that healthcare and drinking water matter the most to people after jobs.

The Global Hunger Index (2018) puts India at the 103rd rank out of 119 countries. Because of poorly fed mothers, lack of adequate food for children in the first two years of their lives, and causes such as malaria, 38.4 per cent of Indian children under 5 are stunted (height for age); 21 per cent are wasted (weight for height) and 35.8 per cent are under-weight. Timely treatment could save the lives of malnourished children. Those who remain untreated are at risk of dying from diarrhoea and acute respiratory infections, delayed growth and impaired brain development.

Seventy per cent of our water is contaminated; India is ranked 120th among 122 countries on the water quality index. The poor water quality, according to the NITI Aayog, causes around two lakh deaths every year. The prolonged exposure to poor-quality air, with an Air Quality Index between 300 and 500, causes respiratory illness, affects healthy individuals and seriously distresses those with existing diseases.

The social determinants are equally unfavourable. According to a recent ASER survey (2018), 13.5 per cent of the girls in the 15-16 age group were not enrolled in schools because of the perceived poor quality of education, concerns about their safety, and work demands at home. Such girls are likely to be married early and become vulnerable to complications during pregnancy and childbirth, the leading cause of death for 15 to 19-year-old girls globally.

These differences are further accentuated by large variations in physical access to health facilities, the state of health infrastructure, the level and scale-up of medical technologies, and the provision of effective services across the spectrum of care. 

The care that people receive is often inadequate, with the most vulnerable populations faring the worst. Less than half of the suspected cases of tuberculosis are correctly managed, and fewer than one in 10 persons diagnosed with major depressive disorder receive minimally adequate treatment. 

Existing indicators, however, do not capture many of the processes and outcomes that matter the most to people. There is a need for fewer but better measures of outcomes, people’s confidence in the system, system competence and user experience, along with measures of financial protection and equity. 

Effective registration of births and deaths, and dependable routine health information systems are prerequisites for good performance assessment. This has to be supplemented by regular rapid surveys to validate the data and understand the health status of the population. This would require huge investment in national institutions and capacity-building of health professionals in quantitative and qualitative skills to make sense of the available data. Simultaneously, new research would be required for measuring the quality of the health system as a whole, across the care continuum.

According to ‘The Lancet Global Health Commission, on High Quality Health Systems in the SDG Era’, more than 8 million people per year in low and middle income countries (LMICs) die from conditions that should be treatable by the health system. In 2015, these deaths resulted in $6 trillion in economic losses. About 60 per cent of the deaths from conditions amenable to healthcare are due to poor-quality care. The remaining deaths result from non-utilisation of the health system. High-quality health systems could prevent 2.5 million deaths from cardiovascular disease, 1 million newborn deaths, 9,00,000 deaths from tuberculosis, and half of all maternal deaths, in the LMICs each year. 

The health system leaders need to adopt a shared vision of quality care, a clear quality strategy, strong regulation, and continuous learning. There is a need for partnerships between the Health Ministry, the private sector, civil society, and sectors outside of healthcare, such as education, infrastructure, communication and transport. Countries should redesign service delivery to maximise health outcomes rather than geographical access to services alone. Countries should transform the health workforce by adopting competency-based clinical education, introducing training in ethics and respectful care, and better supporting and respecting all workers to deliver the best care possible. Governments and civil society should ignite demand for quality to empower people to hold systems accountable and actively seek high-quality care.

Additional targeted actions in areas such as healthcare financing, management and district-level learning can complement these efforts. India currently spends just 1.4 per cent of the GDP on health, as against the WHO recommendation of 4-5 per cent to achieve universal healthcare. The Pradhan Mantri’s Jan Arogya Yojana (PM-JAY) is a step towards achieving universal health coverage (UHC). It provides financial protection of Rs 5 lakh each to almost 10.7 crore poor households against hospitalisation costs. It also aims at strengthening healthcare infrastructure in tier 3 and 4 towns where most of the beneficiaries reside. The urgency of operationalisation should not, however, come in the way of doing things that are important. Progress on the UHC should be measured on the basis of effective (quality-corrected) coverage of the poor. Providing health services without guaranteeing a minimum level of quality would be ineffective, wasteful and unethical.

The onus is on the media to confront political leaders with probing questions that are crucial to people’s health and guide voters to make informed choices.

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