Dirty hospitals, insensitive staff, a lone doctor catering to hundreds of patients, poor diagnosis and wrong treatment are the realities of the Indian healthcare sector. They are mostly seen in the public-funded health facilities, though the private sector is not completely free of these malaises. Healthcare is so scarce in India that over the years barely any attention has been given to the quality of care.
What now comes as a shock is a new analysis published in the Lancet: every year nearly 16 lakh Indians die due to poor quality care. That’s about 4,300 deaths every day due to poor treatment. Out of 86 lakh deaths globally from conditions treatable by health care, poor quality care is responsible for an estimated 50 lakh deaths while the remaining 36 lakh deaths are due to poor access to health care, says the world’s first assessment of the quality of care.
Half of the households in the country report bypassing their nearby public facility, with 80% citing at least one quality concern.
The problem, however, is not unique to India as a third (34%) of people in low and middle-income countries report poor user experience, citing lack of respect, long wait times and short consultations. It leads to gradual lowering of people’s confidence and trust in the health systems.
What constitutes poor quality care? No doubt wrong diagnosis and poor treatment lie at the core, but they are not all. “The underlying argument behind the study is that clinical care is too often simply inadequate in low and middle-income countries. Diagnoses are frequently incorrect and are too speedily made. Care itself is slow. Disrespect towards patients is commonplace. Communication with patients is often poor. And abuse of patients is frequent,” says an accompanying editorial in the Lancet.
Additionally, safety is threatened by hazards and injury arising from poor care, financial insecurity, and treatment that is not evidence-led. “Quality care should not be the purview of the elite, or an aspiration for some distant future; it should be the DNA of all health systems,” said Margaret E Kruk of Harvard T H Chan School of Public Health, Boston, USA, who led the study. “The human right to health is meaningless without good quality care. High quality health systems put people first. They generate health, earn the public’s trust, and can adapt when health needs change. Countries will know they are on the way towards high-quality, accountable health systems when health workers and policy makers choose to receive health care in their own public institutions.”
In the Indian context, that’s a pipe dream. Barring a few exceptions, policy makers mostly shun the public sector. The preferred options are either flying out of the country or checking into an expensive private hospital. Government hospitals are left mostly for the poor, though the doctors in the government sector are often consulted for a second opinion.
There are multiple reasons for falling standards of government hospitals in India, chronic under-funding being the most important one, says K Srinath Reddy, president, Public Health Foundation of India. Because of the resource crunch, the hospitals cannot have state-of-the-art equipment on par with private hospitals, which have the capital from domestic and foreign investors as well as bank loans.
“Also, the private sector’s business model of profit-making care enables them to hire talented experts at higher salaries and provide more attractive ambience and hospitality. As a result, there is an increasing flight of talent from public to corporate hospitals,” he said. “More importantly, most states permit private practice (including private hospital consultancies) by government doctors. This reduces their time and attention to their work in public hospitals. The quality of care invariably suffers,” notes Reddy.
The over eight million excess deaths globally due to poor quality health systems led to economic welfare losses of $6 trillion in 2015 alone. The commission found systematic deficits in quality of care in multiple countries, across a range of health conditions and in both primary and hospital care. These include approximately one million deaths from neonatal conditions and tuberculosis in people who used the health system but received poor care.
Poor quality is a major driver of deaths amenable to healthcare across all conditions in low and middle-income countries, including 84% of cardiovascular deaths, 81% of vaccine preventable diseases, 61% of neonatal conditions and half of maternal, road injury, tuberculosis, HIV and other infectious disease deaths.
Data from over 81,000 consultations in 18 countries found that, on average, mothers and children receive less than half of the recommended clinical actions in a typical visit, including failures to do postpartum check-ups, incorrect management of diarrhoea or tuberculosis, and failures to monitor blood pressure during labour.
Thirteen years ago, India began its Janani Suraksha Yojna to encourage institutional delivery by providing cash incentives to pregnant women to deliver in healthcare facilities. No doubt it increased the coverage of facility births to 50 million women, but it didn’t lead to a drop in the maternal and neonatal death rates -- due to the lack of quality care. Many of the births occurred in primary care centres that did not have sufficiently skilled staff to address maternal and newborn complications.
The report sourced the information from Indian studies carried out in 2014-15. One of the studies, conducted by researchers from Karolinska Institute in Sweden, Madhya Pradesh health department and R D Gardi Medical College, Ujjain, did not detect any association between reduction in maternal mortality rate and the JSY in MP.
“Our analysis shows that poor quality of care will limit the mortality reduction possible from greater (healthcare) coverage. Countries pursing universal healthcare must put better quality on par with expanded coverage if they are to substantially improve health,” says the Lancet report.