Locating ‘Quality’ in Health Care and Universal Health Care Mosaic

Introduction

Rising health inequalities, catastrophic health care costs pushing people below the poverty line along with glaring gaps between trends of economic growth rates and health status of people have raised many questions about post liberalisation health sector reforms in India. Having one of the lowest rates of public spending on health has become a source of discomfort for the country in the face of failure to achieve the targets set for Millennium Development Goals (MDGs). Other developing countries having similar health expenditure patterns of about 5 per cent of GDP (public + private) have achieved much better health indices as compared to India. This pushes the focus on to the problems of the existing health care delivery mechanisms and models.

The discussion around Universal Health Care (UHC) offers an opportunity to rethink the model of health care delivery and debate the core issues of good quality services. Perceived ‘quality’ constitutes one of the important reasons for increasing utilisation of health care services from the private sector. Poor impression of ‘quality’ of services in government hospitals is increasingly becoming the rationale for introduction of market mechanisms and privatisation of different services through mechanisms such as public–private partnerships. The underlying assumption is that quality of services provided in private hospital is good. Along with the logic of ‘quality’, the other reason influencing the principles and philosophy of proposed models of health service delivery for UHC is that the resources of the existing large private sector should be used in a ‘meaningful’ way to provide services.

The revealed preferences (in the form of large scale use of the private sector) of people, along with quality criteria like patient satisfaction, are increasingly being used to justify the continuation and augmentation of the private sector in a significant way. The High Level Expert Group (HLEG) and Steering Committee recommendations now make provisions for this through public money. The convenient assumption among dominant players in policy-making, the economists, is that the revealed preferences are a reflection of what people really want (Adam Smith’s ‘rational man’). However, as Thomas Rice argues, preferences are neither static, nor inborn nor given. Preferences are influenced by past experiences, expectations, peers, community pressures and expectation, marketing and media. Rice further argues that people often do not get the information that they need to maximise their preferences. Many a times even when information is available they might not use it to their maximum benefit (Rice & Unruh, 1998). The information asymmetry in the health sector accentuates this problem and the intermediate player—the doctor—makes many choices on behalf of or for the patient. This makes health services different from the rest of the service industries.

The literature on quality of health care shows different streams of thought; some with prime focus on quality of care delivered to ‘a patient’ while others delve into quality of ‘health service system’ providing care services to a population. Both are interdependent but involve different perspectives for addressing quality improvement initiatives. The history of the discourse on quality shows that the shift towards purchasing, rather than funding, health services has resulted in increased attention on ways of measuring hospital performance and quality of hospital care (Draper & Hill, 1996). Increased governmental and societal focus on health service quality demands nuanced understanding of different concepts of health care and quality of care. A different definition or conceptual understanding may lead to different policy paths, strategies and active measures (Priya, 2005).

Evans et al. note the following:

In 1980 Donabedian defined quality of care as ‘that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts.’ Ten years later, the Institute of Medicine (IOM) defined quality of care as ‘the degree to which health services for individuals and population increase the likelihood of desired outcomes and are consistent with current professional knowledge.’ The IOM narrowed the goal from improving total patients welfare to improving health outcomes but moved the focus from patients to individuals and population thus allowing quality of care to incorporate promotion and prevention and not just cure and rehabilitation. It also added two qualifiers: ‘desired health outcomes’, to emphasize the need to consider the perspective of recipient of the service and ‘consistent with current professional knowledge’ to define standards of the service. Donabedian’s initial definition was absolutist, reflecting what was maximally feasible for the patient given the current medical knowledge. Subsequently he allowed for an individualized or socially optimal definition, incorporating the concept of value so that the quality was the maximum possible for the inputs available. The IOM returned to the original definition of quality by Donabedian and explicitly rejected the inclusion of resource constrains in the definition on the grounds that it should not fluctuate just because resources are constrained and unavailable. (Evans et al., 2001)

Neoliberal economic policies are known to have a negative impact on the welfare and income of vulnerable groups. In the present era of ‘reforms’, the claims of providing universal access to health care and efforts of improving quality of health care, therefore, raise the question—What quality criteria of health services and which models of health service delivery will contribute to health of the population, especially the vulnerable groups?

Conceptual Underpinnings of ‘Quality’ in Health Care

Much of the literature on quality has been derived from management studies meant for the industrial sector (Anadaleeb, 2001). We have an intuitive understanding of the meaning of quality, yet when one sets out to study and to apply concepts of quality, it becomes very elusive. One of the reasons for this difficulty is that quality is multifaceted. It is also important to understand the concept of quality before attempting to implement quality improvement initiatives in our daily work. Many such efforts fail, or degenerate, because of the failure to understand the multi-dimensional nature of quality. It is important to accept that quality is best defined and applied in the context of a specific time, space and activity (Hock, 2005).

The definition of quality takes on a new meaning, depending on the approach taken to attain quality. Garvin suggests five main approaches to attain quality (Garvin, 1988: 40). ¹ Different stakeholders (users, clinicians, payers) have different definitions and views on quality of care. For example, the management cares more about efficiency and profits over costs, while the users care more about whether the health system could provide patient-centred services according to individual needs (Yang, 2007). Then the question arises, who judges quality?

In a complex health care sector with hegemony and power of medical professionals over knowledge on the one side and patients whose knowledge is limited on the other side, one can encounter situations where wants (felt needs) and needs (clinically assessed) may be divergent. In a situation where an insurance company is paying for the services, the purchaser (insurers) and user (patients) may have dissimilar needs and concerns which will lead to conflicting definitions of quality. Something of high quality, therefore, is one that best meets the needs of majority of users, most of the time.

When assessing quality in health care, one must look beyond the actual delivery of services and incorporate those factors that facilitate delivery and the inherent consequences. These have come to be known as the structure, process and outcome of care, and the quality of care should be analysed through these three aspects (Donabedian, 1966). Under special circumstances, the significance of each aspect could be different. If the purpose of measurement is to improve the operation of the health service system then process is a better index, whereas if the purpose is to assess the contribution of the health services system to individuals or even society as a whole, the focus should be the outcome index (Yang, 2007).

Not only is the technical domain consisting of infrastructure, knowledge and skill of a provider, but also the interpersonal relationship between patient and caregiver equally important. Donabedian’s deliberations brought the patient’s perspective into consideration for the first time while assessing quality. Quality in health care has several dimensions, which he later developed into what is known as ‘seven pillars of quality’. ² Pursuit of each of the several attributes of quality can be mutually reinforcing, but the pursuit of one attribute may also be in conflict with another so a balance has to be achieved. He suggests that while assessing quality a health care professional must take into account preferences of both patient as well as society. When there is a disagreement between these two sets of preferences health care provider faces the challenge of reconciling them (Donabedian, 1990).

Levels of Quality in Health Care Services

M. I. Roemer and C. Montoya-Aguilar have analysed the concept of quality of health care at two levels. First, at a more general level, where resources or inputs, processes and outcomes of health care are involved, quality becomes an attribute of the system as a whole. When appraising the quality of health care system to an individual, it is natural to take into account the results of such care. However, in quality assessment from the point of view of the population, what matters most are changes in survival, morbidity, disability, etc. Thus, according to these authors, ‘quality signifies proper performance (according to standards) of interventions that are known to be safe, that are affordable by the society in question, and that have the ability to produce an impact on mortality, morbidity, disability, and malnutrition’ (Roemer & Montoya-Aguilar, 1988).

Yang Hui suggests different definitions of quality at different levels, namely, one at an individual level and another at a population level and these are discussed below (Yang, 2007).

Challenges to Assessment of Quality in Health Care

Health care services are different from other service industries. Quality in health services needs spelling out of product attributes, whereas other industries get along by simply meeting customer requirements. This is because health services both in their production and consumption are far more complex than other kinds of industries. The standard industrial quality management approaches cannot deal with this complexity. Each individual patient–health service interaction episode consists of unique, intangible, highly variable and contentious process that cannot be compared with the market. Unlike many products and services, health care has intrinsic moral and ethical dimensions in its production as well as delivery (Walsh, 1999).

The principles of universality, equity and comprehensiveness are integral if public health perspective is used for conceptualising quality. This perspective makes it necessary to ensure that quality services are available, accessible and responsive to the felt need of different sections of the population. Baru and Kurian highlighting the importance of public health perspective divide the different aspects of quality as tangible and intangible dimensions ⁷ which are interdependent and interlinked (Baru & Kurian, 2002). The intangible dimensions make quality measurement and comparison a difficult task.

Much of the discussion of quality involves different kinds and types of ‘standards’. The standards used to assess quality of care come from the dimensions of care under study and values that one uses to judge them. The standards can be either selective or inclusive depending upon the selection of dimension of care for assessment. Selection and defining the boundaries of dimension of care selected for setting up standards, the number of dimensions selected, and exhaustiveness with which performance in each dimension is explored affects the quality assessment. Judgements of quality are incomplete when only a few dimensions are used and decisions about each dimension are made on the basis of partial evidence. Some dimensions, such as preventive care or the psychological and social management of health and illness, are often excluded from the definition of quality and the standards and criteria that make it operational. The dimensions selected and the value judgements attached to them constitute the operationalised definition of quality in each study (Donabedian, 1966). Donabedian’s work contributed to the argument that quality cannot be judged by health care professionals alone but must include the patient’s views and preferences as well as those of society in general because ‘standards’ used in quality assessment are heavily influenced or rather come from three sources, namely,

the science of health care that determines efficacy;

Social Determinants of Quality of Health Care

Considerable progress over the past decade in the provision of quality health care is not equitably distributed.

Quality is thus a relative concept that is influenced by complex social determinants. Disparities in the quality of care provided can be noted according to gender, class, race, ethnicity and religion across most of the dimensions of the health care process (effectiveness, safety, timeliness and patient centeredness) and across most of the four patient perspectives (staying healthy, getting better, living with chronic illness and coping with the end of life) (Fiscella, 2003). The review work done by Kevin Fiscella shows the above-mentioned disparities in different medical, surgical and counselling treatments for different types of diseases.

The causes for disparities in provision of health care and its quality can be broadly classified into two groups: recipient side factors and provider side factors. Recipient side factors can be analysed at individual level and at community level, whereas provider side factors can be analysed at individual provider level factors, institutional level and at health care system level. For instance, people from the poorer sections may delay treatment seeking while the health care providers would also give them lower priority, later and lesser attention as against middle class patients.

Tracing ‘Quality’ in Health Care Services Development in the Indian Context

Historically, various Health Committee recommendations have touched upon quality issues of specific health programmes and on dimensions which impact upon quality of the public health service system as a whole. Institution level quality of services has also been addressed to some extent. However, there has been no regulation or quality assessment of the private health care sector till the recent past.

The Bhore Committee (1946) recommendations for health services development represent the most comprehensive system design. At the time of Independence, by accepting the Bhore Committee recommendations the State took up the responsibility of providing comprehensive health care to all irrespective of their ability to pay. The health services planned and recommended in it represented a comprehensive health service system to be developed within the resource availability of the country by giving health services a priority. The design of health service system and organisational set up recommended was internally consistent with requirements of health service delivery and was externally consistent by addressing the social determinants of health. Much of the components of what constitutes ‘quality’ in health care at health care system level are directly or indirectly addressed in this report, whose recommendations and principles of health service delivery are relevant even today. The recommendation of developing comprehensive multi-tier health services system becomes an important prerequisite for providing quality health services and constitutes structural aspect of quality as suggested by Donabedian.

After a decade of adopting Bhore Committee recommendations, a review of implementation of those recommendations was given in Mudaliar Committee (1962) report. It recommended stopping the expansion of services and improving the services delivered through existing institutions. It represents an important shift, where expansion of services and improving coverage of service were considered less important as compared to increasing performance of already existing institutions. The Jungalwala Committee (1967) recognised the multiplicity in health services delivery and recommended integration of health services for optimising resources and improving the health service delivery. The Mukerjee Committee (1966–69) recommendations correspond to identification of basic health services that need to be delivered on a priority basis.

The Kartar Singh Committee (1973) recommendations constituted the creation of intensive and twilight zones, based on distance around sub-centres in order to rationalise and optimise the work load for the then deficient number of Auxiliary Nurse Midwives (ANMs) available. It also brought into the picture a new cadre of health workers, the Multipurpose Worker (MPW), by doing away with multiple individual programme health workers. This was an important development in optimisation of existing health resources and providing better quality services to the community. The Shrivastava Committee (1974) recommended having an additional doctor at the PHC. Recognising the importance of referral services in the multi-tier health services system, it recommended a referral service complex. Importance of better monitoring, supervision and assistance to the MPW was to be provided with a new cadre of Health Assistants (HA). Access to basic health services for vast sections of rural population was dealt with by bringing in Village Health Guides which also served the purpose of involving and empowering community in the health care process to some extent within the then resource availability of the country. Thus, many of the issues of quality addressing structural, procedural and resource optimisation factors were addressed through these recommendations.

The Alma Ata Declaration (WHO, 1978) on primary health care gave principles and basic elements of primary health care. It defined essential services to be delivered. This constituted minimum services that are to be ensured, and also served as a starting point for building up comprehensive services. The declaration brought forth very important ideas on health service delivery and development. Primary health care approach was about community ownership and participation, sustainability, i.e., ability of the community to run such services in the long run, rationality and appropriate technology, accessibility, comprehensiveness, inter-sectoral coordination, etc., and all these are attributes of the ‘means’ for the ‘end’ of providing ‘health for all’. Therefore, much of the discussion in Comprehensive Primary Health Care (CPHC) is about the ‘means’ and ways, principles and philosophy of providing the pre-determined goal of health for all. India was signatory to the Alma Ata Declaration but chose to follow completely different trajectory of Selective Primary Health Care with UNICEF in the form of strategies like GOBI-FFF. ⁸ Despite recognition of failures of vertical programmes, the new strategy of GOBI-FFF complemented the further growth of disease-specific, techno-centric vertical national health programmes.

The Health Policy 1982 and Health Policy 2002 laid down policy guidelines for health services. These two policy reports represent a policy shift in health services delivery. During Health Sector Reforms (HSR) in the 1990s, Public Private Partnerships (PPPs) were all in the name of improving health services and making services more efficient. These PPPs led to promotion of private sector and downplaying of the general health services in the public system. HSR along with its different policies such as PPPs brought about an important shift in the notion of quality from systemic to institutional level. It represents the neglect of state-run health service system and increased attention being given to the stand-alone private institutes providing health services. This era brought into focus quality assessment and accreditation of hospitals and health care institutes through different mechanisms propounded by different accreditation organisations, discussed in the subsequent section.

Meanwhile there were other attempts at improving health services delivery which can be considered as important for quality of health services. It includes rational drug therapeutics or Standard Treatment Guidelines (STGs) developed by the Delhi Society for Promotion of Rational Use of Drugs (DISPRUD). Following Delhi, a few other states developed STGs. Different national health programmes have had standard operating procedures and treatment protocols developed for the conditions covered under those specific national health programmes. Syndromic approaches for diagnosing and treating different sexually transmitted diseases (STDs)/reproductive tract infections (RTIs) have also been developed. Other examples include the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) for neonatal and childhood illnesses. National Institute of Health and Family Welfare (NIHFW) has developed many management training modules for different health functionaries like district health officers. Most of these endeavours represent attempts at improving process-related dimensions of quality.

There were no separate internal systems for quality improvement other than the departmental supervisory structure. Efforts to assess the quality of health services or improve their quality were largely undertaken through the external committees set up from time to time for review of health services development and functioning, and their recommendations provided the guidelines and pathways for further development. Often, they were set up when a particular change was already envisaged.

Though largely systematic (applicable for larger systems), many of the recommendations made by different committees at different points of time and other guidelines made by different institutions/organisations and committees are also applicable for improving the quality of care at the level of institutes of health care delivery, for example, the Medical Council of India (MCI) guidelines for medical colleges. Different programmes like the Family Planning Programme, the Maternal and Child Health (MCH) programme, the Child Survival and Safe Motherhood (CSSM) programme, the Reproductive and Child Health (RCH) programme, the National Tuberculosis Programme (NTP), the Revised National Tuberculosis Control Programme (RNTCP), the National AIDS Control Programme (NACP), the National Vector Borne Diseases Control Programme (NVBDCP), etc., have had their own monitoring and evaluation mechanisms or quality assurance mechanisms in the recent past.

Contemporary Currents of ‘Quality’ in Indian Health Services

With some new ideas and strategies, the National Rural Health Mission (NRHM) is addressing many of the recommendations made in different committees over a period of time. It is a positive step in terms of addressing the issue of ‘quality’ of health care. While addressing the quality dimensions of larger health service systems in terms of comprehensiveness of services, integrated service delivery, access to services, finance, design and planning, NRHM has undertaken measures to improve quality of the services that are being delivered through each facility up to the district hospital level. The systemic issues are addressed by intervening in input and process factors of health service delivery, as well as through demand generation by demand side financing. It also uses outcome data of health services to assess their performance. It has developed dedicated mechanisms to address the quality dimensions of health service delivery at institutional level through its Quality Management System (QMS), though it has a long way to go. NRHM addresses the concerns of quality of the system as a whole as well as quality of the services through institutes of health care delivery.

The attempts to improve quality of health service system get reflected in a variety of strategies such as increased financial allocation, ASHA, provisions of increased manpower, community involvement, decentralised planning through some of the initiatives like Program Implementation Plans (PIPs), removal of bottlenecks in financing, flexibility for expenditure, Rogi Kalyan Samitis (RKS), strengthening procurement and supplies, research, constant monitoring and evaluation (Joint Review Mission [JRM], Common Review Mission [CRM], concurrent evaluation), Health Management and Information System (HMIS), Janani Suraksha Yojana (JSY), ⁹ equity and special programmes for vulnerable groups. ¹⁰ However, some of the policies like public–private partnership and medical insurance deployed to fill in the gaps like availability of specialists in government hospitals have resulted in strengthening of private hospitals through public money. There have been no concrete and large scale attempts to employ the required specialists and filling these vacant posts through regular employment. Another concern is of casualisation of labour through contract-based temporary employment of a large number of health workers as well as of medical and paramedical workers. How far these interventions have contributed in improving health status of the population and in improving the quality of services provided is yet to be seen.

HLEG and Steering Committee Recommendations for UHC: Implications for Quality

The proposed UHC by HLEG (GoI, 2011b) strongly advances the logic of ensuring end-users’ access to health care services. However, ends do not justify the means. HLEG report claims allegiance to the principle of primary health care. But primary health care approach was about community ownership and participation (community being seen not just as passive recipient of services, or just the ones making grievances at some grievance redressal cell), sustainability, that is, the ability of the community to run such services in the long run, rationality and appropriate technology, accessibility, comprehensiveness, inter-sectoral coordination, etc.—all these are prescribed attributes of the ‘means’ for the ‘end’ of providing ‘health for all’. Much of the discussion in CPHC is about the means and the ways, the principles and philosophy of providing the predetermined goal of health for all. The HLEG report seems to focus only on the end goal of health for all while making significant departure from the principles of the ‘means’ and the spirit of Alma Ata CPHC.

Even though the HLEG recommendations take a stand against insurance-based system, the theme of recommendations is ‘public funding’ and ‘guarantee of financial provision’. The actual service provision is left to either public or ‘contracted-in’ private sector. In the current policy ethos, the assumption that there will be encouragement of service provision through contracted-in private providers and will result in further strengthening of private sector through public money is not entirely misplaced. This is despite the established fundamental problems with the health services being delivered based on market principles (Light, 2000; Rice, 1997).

Monitoring each instance of patient interaction with every private provider would require an equally mammoth bureaucracy equipped with the facility to make assessments and intervene in the complex and highly technical health care delivery systems with the given information asymmetry which is favourable to doctors. At the very least, this would require specialists/doctors who have the pre-requisite skills to monitor service provisioning by contracted-in private providers. This becomes even more difficult given the complete lack of regulatory frameworks, monitoring and evaluation mechanisms and absence of culture of medical audits in government as well as private sector health services. Coupled with the lack of manpower, trained doctors, paramedical workers and managerial staff in health sector, the task of monitoring of service delivery through contracted in private providers becomes even more difficult.

Medical audits, systems of monitoring and evaluation, guidelines and audits for appropriate and rational usage of medical technology, quality management/assessment/assurance and accreditation systems are in their infancy in the government sector and are alien to the most of private sector as well. In such circumstances, would it be possible to control unnecessary investigations and treatment administration from contracted-in private sector? There is a similar question mark on assuring implementation of rational treatment protocols and standard operating procedures through such private hospitals given the profit-seeking principle of their operations, as can be seen from the epidemics of hysterectomies among insured patients under Rashtriya Swasthya Bima Yojana (RSBY) in Bihar and Chhattisgarh and in Arogyashree Scheme of Andhra Pradesh (Editorial, 2012; Shukla et al., 2012).

The proposition in HLEG recommendations to get IPHS or ISO standards implemented for those hospitals getting contracted-in raises a plethora of questions. In what percentage of private hospitals are standards related to buildings, infrastructure, organisation of service delivery, manpower, and government of India stipulated wages being currently followed? How many of them will be ready to enrol on UHC? (In fact, the HLEG recommends that the standards will be applicable for non-UHC private providers also.) The profits in many of the private hospitals at district and sub-district level are driven by unethical practices and by compromising on many infrastructural, material and manpower standards (less human resources, less qualification, more work hours along with unsatisfactory salaries). Another source of earning is through commissions/cut practice by referring patients, and through sale of medicines, drugs and other medical consumables. So the assumption in the proposed UHC recommendations that highly powerful and unregulated private hospitals will part with easy profit-making avenues and opt for price regulation and follow government-stipulated rates of treatment seems untenable given the ground reality.

The IPHS standards are for SCs, PHCs, CHCs and for hospitals with 30–50 beds, 50–100 beds and onwards. These standards are said to be utilised for quality improvement and accreditation of hospitals delivering the proposed National Health Package (NHP). Before commenting on the composition and nature of standards used in IPHS, it is important to remember that these are standards for public institutions. There are no standards laid down for private hospitals. IPHS standards for hospitals with 30 beds and above can be considered as useful for similar type of private hospitals. However, there are no standards for private hospitals with bed strength below 30, and this constitutes the bulk of private providers. Standards used for sub-centre, PHCs, CHCs cannot be used for small private hospitals as the mandate, composition, objective and circumstances of service delivery are different.

The standards for 30-bed hospitals and above are also for a specific composition of services with particular kind of specialist mix and balance. Will the prescribed standards be relevant and acceptable to private sector hospitals having 30 or more beds? The specialisation and composition in terms of skill mix availability in such private hospitals are very different in different settings. This sector may comprise a small segment of the private sector but there can be no doubt about its significance and power. The biggest section of the private sector would include individual general practitioners, specialists running their own hospitals, doctor couples with different specialisations running nursing homes or hospitals and then there are private hospitals, nursing homes or polyclinics owned or run by groups of different types of specialists. The mix of specialisation in such private hospitals is based on social, physical, geographical, economical and other considerations and not primarily on epidemiological and public health considerations. Is it at all feasible to develop standards which will be applicable for such varied types of hospitals and permutations-combinations of skill mix? More importantly, will they be applicable and acceptable to the private sector? It is important to address this question as this constitutes the bulk of the total private sector.

The area requirement for 30-bed hospitals as per IPHS standards is around 15–20,000 square feet. What will be its implications in terms of availability of such land and prices? Along with other material requirements there are huge human resource requirements of trained manpower which is not available in many of the district and sub-district towns. Implementation of standards related to area, building, human resource standards along with their working hours and minimum wages would increase the costs of running the hospital phenomenally as compared to what it is now. Will this be acceptable to the private sector? If such standards are necessary, will the government allow private hospitals to overlook them even if they are not part of the proposed UHC? Even if it is a dream-come-true situation and all these hospitals implement the prescribed standards by investing huge resources, the likelihood of these financial investments being recovered from the patient is far too obvious to be ignored.

There is also the question of whether the proposed price regulation will be acceptable to the private sector, and for how long. Capital costs, concurrent costs as well as the cost of trained human resources with standard salaries in the context of proposed price control and regulation would be seen as threatening the economic viability of private hospitals unless there is sufficient business turnover. This scenario, in turn, raises more questions about who will ensure the desired business turnover to private providers and how. Increasing the business turnover of such individually or couple-owned hospitals raises the risk of defeating the purpose of providing quality services, as there is a limit to the workload a single doctor can handle while assuring the provision of rational and quality services.

In this context, it is relevant to recall that the government could not enforce even the much watered-down bill regarding registration of hospitals, that is, the Clinical Establishments Act. This Act has been challenged by the Indian Medical Association (IMA). These are the real-life power dynamics in which the proposed recommendations of HLEG will have to be negotiated. Needless to say, such circumstances challenge the larger goal and modalities of providing universal access to rational and quality health care services.

The recommendation to introduce three new categories in the public health cadres, namely, all India public health services cadre, health systems management cadre, and hospital managers’ cadre (GoI, 2011b), is riddled with ambiguity and overlap in their roles and responsibilities (unclear responsibilities of public health cadre). Most importantly, it would be interesting to see how the power dynamics within these proposed different cadres of health professionals will unfold. Health services are presently dominated by the clinical specialist and super specialist. The proposed recommendations call for a change in this power dynamics by replacing it with new professionals. In a highly technical and complex field like health, and in the context of the given power dynamics where specialist doctors dominate the health sector, it would have been logical to develop these cadres and define their roles, responsibilities and power dynamics through appropriate operations research.

The HLEG proposes that District Health Managers will manage the government-run health service system as well as purchase of services from contracted-in private providers (GoI, 2011b). Quality assurance, performance management (that involves recruiting and deciding career trajectories), purchasing health services, etc., accord a disproportionately powerful position to the health system management cadre. These managers will be in position to cater to management needs like supply chain maintenance, financial calculations, etc., but the technical component of care delivery and rationality of care are tasks that are way out of the league of district health system managers unless they are trained medical doctors. Further, even if this cadre comprises medically trained doctors, there is no certainty about their understanding and perspective about AYUSH treatment systems.

Quality assessment and quality assurance cannot be left to health system managers alone. Quality in health care is unique conceptually and would need a different approach for assessment and improvement. The management trained professionals will not be in a position to assess the clinical services provided by medical and paramedical professionals. In addition to developing inbuilt mechanisms of regular medical audits, death audits, clinical audits and their use for quality assessment, overall quality assessment should be done through a team consisting of clinicians from different disciplines, paramedical workers, experts in management and administration, epidemiologists, public health specialists, economists, representatives of Civil Society Organizations (CSOs), patients, relatives or attendants of the patients, community representatives, etc.

The HLEG recommendations acknowledge the difference between hospital services and hospitality services and allow for extra charges for providing services not covered under the proposed NHP and for hospitality services (GoI, 2011b). Allowing a dual system with public system and private system providing hospitality and luxury services will, in the long run, have its implications for UHC as well as for public health systems. Supply creates its own demand. Over time a five-star hospital with luxury hospitality services will have changed the perceptions about what constitutes hospital and health services. Will such luxury hospital providing hospitality services act as a role model for what constitutes hospital services? Will it increase pressure over time on government-run health services? Will these hospitality services become part of ‘quality’ assessment and the accreditation process? Will presence or absence of it affect the process of empanelling private hospitals in UHC or any other private insurance scheme?

Are hospitality services limited to tertiary level/multispecialty corporate hospitals alone? Single specialty individually or couple-owned and run nursing homes at district and sub-district level also provide hospitality services. The most important task is to define and distinguish between what constitutes hospitality service and what constitutes necessary hospital service. Will talking to the patient nicely and spending some time explaining the condition of illness and line of treatment constitute hospitality service or necessary service? Will access to safe drinking water and hygienic food and sanitation facility, and arrangements for attendants accompanying the patient constitute hospitality or necessary hospital service? Prompt or timely treatment constitutes hospitality service or necessary service? To define the boundaries of what constitutes necessary service and hospitality service is a difficult task; it is not static and will differ in different socio-political and cultural contexts.

The whole idea of defining the health package (NHP of the HLEG and the Essential Health Package [EHP] of the Steering Committee; GoI, 2011b, 2012) needs to be reconsidered. It is impractical to define boundaries for diseases given the fact of co-morbidities and complications associated with even simple illnesses. Universal access to comprehensive services for all illnesses needs to be guaranteed. A more holistic approach, that is, the entire human body being treated, is in sharp contradiction with the present endeavours to define the boundaries for health and progression of disease based on NHP or EHP. This nature of planning is not only impractical but also unethical. Furthermore, a payment for treatment of diseases up to certain boundaries (as pre-decided in packages) within the arrangements of PPPs leaves significant scope for financial irregularities.

The HLEG as well as Steering Committee recommendations vis-à-vis public private partnership where health services will be delivered on market principles as well as the idea of a health package are antithetical to the idea of ‘quality’ in terms of universal access to comprehensive services. Many of the dimensions of quality as discussed above such as efficacy, effectiveness, efficiency, optimality, acceptability, legitimacy, equity, intangible dimensions like reliability, responsiveness, assurance, relevance, empathy provided by caregiver, issues like time taken, queues, organisation of services, administrative procedures, services being comprehensive, ethical, safe and patient centred have not even been touched upon or adequately addressed in the recommendations of HLEG as well as the Steering Committee. The technical domain of quality which will deal with rationality of treatment process has been recommended to be developed in both set of recommendations. However, the Steering Committee recommendations do not make any provision for that. The quality of clinical processes and the interpersonal dimension of quality are untouched in both sets of recommendations.

Mechanisms for addressing the issue of quality at the systemic and at individual service delivery level are thought about in HLEG recommendations but need further deliberations. Though Steering Committee recommendations project responsiveness to service as an important principle (along with its elements like choice, communication, confidentiality, dignity, amenities, prompt attention and autonomy), there are no concrete suggestions and pathways on to how to achieve this. Steering Committee recommendations do not have any specific systemic recommendation which addresses the issue of quality directly.

The Steering Committee proposes that the existing NRHM governance mechanisms be continued and accommodates some other suggestions like developing a public health cadre while maintaining total silence on a health system management cadre and on other institutional arrangements like the National Health Regulatory and Development Authority (NHRDA) along with its important subsidiary institutional mechanisms suggested by the HLEG report. It recommends continuation of existing public private partnerships and has nothing new to offer to the UHC except the Bachelor of Rural Health Care cadre that is being offered in some states already. Creating competition between public and private sector services, as in the pilots recommended to be conducted in one district of each state, may theoretically be seen as one way of forcing quality improvement in both. However, there are serious doubts about whether it will work on the ground.

It can be seen from both the Committee recommendations that just to accommodate the idea of ‘PPPs’, a plethora of other institutional arrangements have to be developed and used, such as the National Health Entitlements Card (NHEC), packages like EHP/NHP, the cut-offs like 70 per cent spending on OPD services and 30 per cent on indoor services, empanelment mechanisms, prescription audits, huge monitoring bureaucracy, bureaucracy to settle financial mechanisms with proposed private partners, private Jan Aushadhi stores, performance and health outcomes assessment of the families registered under each of the health care providers, etc.

The Way Forward

The existing health service system is a result of three decades of neglect and two decades of active dismantling. In such a situation, the sudden attention to the issue of providing universal health care nationally as well as globally needs to be understood in a wider perspective. Many countries are opting for arrangements of health care insurance following the United States model of health service system. However, the US model is proved to have failed in providing universal access to health care despite spending a huge amount of money (around 12–15 per cent of their GDP). Health service system models of countries like UK and Australia have much more to offer principally as well as for the system designs for providing UHC. The farcical emergency situation created to provide universal health care needs to be countered, as it can be used to push in unscientific and irrational models under the disguise of UHC. It should be acknowledged that it would need realistic time frames for materialising health services system designs developed on the principles of public health and epidemiological rationale and evolved through wider public discussion.

The foremost issue is to define and lay down the concept of ‘quality’ in health care for UHC, along with its different dimensions and determinants. The objectives and implications of that particular definition and quality improvement efforts should be deliberated upon as there is a risk of quality assessments and accreditation systems being used for closing down public facilities and favouring corporate hospitals as against the primary and secondary level private services. This has a direct impact of making services more inaccessible. While increasing access to services at all levels, medical rationality and ethical practice have also to be built into the quality criteria. Within the public system itself, there is a need for both the general systemic strengthening measures and a specific mechanism for facility-based quality improvement. Existing mechanisms as implemented under NRHM should be reviewed and wide discussions held to design quality improvement systems in each state.