YJ: We are together this afternoon to discuss an issue that both of us are very interested in, which is the quality of health care services especially in public health services. We are limiting our discussion to the Indian scenario. So, if you permit, may I start shooting off questions that I would want you to answer as well as you know.
TS: Yes, we should focus on the problems and challenges that public providers and health care managers encounter when they work at improving quality of care as well as some of the policy challenges in this area.
YJ: Let me start with a very generic question. When we talk about quality of healthcare, what is it that you think of?
TS: In a broader sense, quality refers to specific attributes of a process that ensures that user-needs are met. In the context of health policy, we understand universal access to healthcare services as universal access to quality health services. In other words, the right to health care is a right to quality healthcare. In this context the specific attributes would be:
- That the care that was provided was effective– viz- it provided the cure or the optimum improvement or relief from suffering or other desired outcomes. . We have lots of instances where people going to a health facility will get a consultation, receive in-patient care, or medicines, their insurance card is swiped, or payment is made. This episode will be recorded as utilization of services. But was the utilization of services “effective” in terms of outcomes? We have lots of people put on ventilators during the COVID-19 pandemic. Was that effective? Neither the provider nor the patient can be sure of the outcomes in a single case, but evaluating outcomes at an aggregate level helps in assessing effectiveness, making it a key measure of quality.
- Another quality attribute is acceptability. Whether the care was provided with a certain sense of dignity and respecting the rights of the patient? Was it comfortable? Was it convenient? Considerations like privacy, confidentiality, adequate and sensitive communication about risks and costs, respectable care of a pregnant woman during labor time etc. which are, not necessarily linked to effectiveness of care, but very much important in the notion of acceptability. The poor may have no options and may have to accept any care available, but that’s not what we would mean by quality care.
- The third dimension relates to patient safety. While this could be considered part of effectiveness, there is advantage in considering it on its own merit. We are talking about just patient safety, but sometimes also of provider safety, and facility safety because we have a concern of infection prevention and control across all users of the facility.
There is also the question of affordability, but this is not necessarily linked to quality. In popular discourse expensive care could be confused with quality care- and though good quality care has higher costs, more costly care is not necessarily of better quality. This is one of the issues/myths that would need to be addressed. Related to this is the question of efficiency. If care is of better quality for every rupee spent we are getting a better outcome.