Currently, India spends about $20 per person per year on healthcare and spending more once seemed like a peripheral concern, taking a back seat to basics like food and sanitation.  However, in the past decade, as the Indian economy has grown and wealth followed, Indians are increasingly demanding access to “high quality” healthcare.  But what does “high quality” mean for a country where a large proportion of the population still goes hungry?  Where access to sanitation is so spotty that the Supreme Court recently had to decree that every school should have a toilet?  What is “high quality” in a setting where so many basics have not been met?

It turns out that “high quality” may mean quite a lot, especially for the poor.  A few weeks ago I spent time in Delhi, meeting with the leadership of the Indian health ministry.  I talked to directors of new public medical schools and hospitals opening up around the country and I met with clinicians and healthcare administrators at both private and public hospitals.  An agenda focused on quality rang true with them in a way that surprised me.

The broad consensus among global health policy experts is that countries like India should focus on improving “access” to healthcare while high income countries can afford to focus on the “quality” of that care.  The argument goes that when the population doesn’t have access to basic healthcare, you don’t have the luxury to focus on quality.  This distinction between access and quality never made sense to me.  When I was a kid in Madhubani, a small town in in the poor state of Bihar, I remember the widespread impressions of our community hospital.  It was a state-run institution that my uncle, a physician, once described as a place where “you dare not go, because no one comes out alive”.

His point was that the quality was so awful that patients were routinely injured or even killed by medical errors.  People avoided it until they were at death’s door.  For the people of Madhubani, was this an “access” problem or a “quality” problem?  It was clearly both and the split between access and quality also made no sense to them.

The Indian parliament is now debating its 12th 5-year plan (yes, the government still relies on Soviet-style 5-year plans) which would increase government spending on healthcare from 1% of GDP to 1.6%, a sizable amount (although I think they should be spending a lot more).  Much of this new spending is focused on access: ensuring “universal health coverage” and strengthening primary care. These are good things. However, at least some part of the spending should be dedicated to measuring quality.   A basic information infrastructure that tracks not just who received care but also the kind of care they received and if it did them any good is vital. Without answers to these questions, we will never know how much of the new investment improved health and how much was wasted.

Measuring quality has to be a part of a broader strategy that closely tracks health of the population.  Health outcomes measures will allow policymakers to decide when additional resources need to go into public health, when they need to be spent on direct healthcare (i.e. improving access) and when they need to be spent ensuring that the care is good (i.e. quality).  Measuring health outcomes and making those data widely available to the public will reduce the risk that the extra spending is wasted by a corrupt political system.  It will hold policymakers accountable to the bottom line:  improving the health and well-being of the population.

Two decades ago, Americans believed that having a licensed physician care for you at an accredited hospital assured quality.  Yet years of relentless data suggesting otherwise has changed the way we think.  We now know that an accredited hospital with licensed physicians can have mortality rates four times higher than another hospital across the street.  This variation has a huge cost, leading to unnecessary deaths and wasted resources.  Regulation, while a prerequisite, does not assure high value healthcare.  That is the most important lesson for Indian healthcare.  If India wants a robust healthcare system that delivers high quality healthcare at a reasonable cost, it needs a quality strategy with robust measurement of processes, outcomes and costs.  This kind of approach is necessary for any society that does not wish to pour large sums of money into wasted care.

My previous question about how we can ask focus on quality when food and sanitation are still not always available, presents us with false choices.  The failure to get clean water to every household is not one of resources, but of effective governance.  Poor quality schools would certainly be made better with more spending, but would be dramatically improved with greater accountability.  The notion that India doesn’t have the resources to measure and ensure quality actually creates a huge risk.  If India goes down the road of widespread healthcare access expansion without concurrently focusing on quality, it will likely waste an immense amount of resources and lives.  For the U.S., this has meant hundreds of billions of dollars of waste and tens of thousands of unnecessary deaths each year.  As India thinks about making greater investments in healthcare, the question cannot be whether it can afford to measure and ensure high quality care.  The real question is – can it afford not to?

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence.

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4 Responses for “Can Quality Be on India’s Health Care Agenda? Should it Be?”

  1. sm2012 says:

    This is a great post, Ashish. But maybe you are more optimistic about India than I am. For all of its technological advances and growing middle class economy, I am shocked every time I visit at the two Indias I see – one that is part of Goldman Sach’s BRIC (brazil, russia, india, china) growing economies that are anticipated to dominate world markets for the next 50yrs and the other one, full of corruption in both the private and public sphere, a painfully slow legal system, government agencies that would make Americans grateful for their political gridlock, and a peculiar combination of inefficiencies.

    Your fundamental point that quality and access are not independent measures, and in fact, are linked in terms of the appropriate management of resources is completely correct. I hope that India is able to have this very reasonable approach and transcend its many weaknesses.

  2. meena says:

    Thank you for a fine read.

    1. I am not very surprised that the docs in Delhi did not see a difference between access and quality. Access of some sort has always been there. They are not ‘accessed’ because of the poor quality. With no one going to them for treatment and with govt funding trickling to a drop, Public Health Centers have rapidly fallen into grave disrepair

    2. The metrics of quality have to vary with the landscape. It is only upon reaching a certain standard of care, can they be universalised.

    3. While technology will certainly aid outcome measures and keep a check (we hope) on inefficiencies; this Big Data model might be more suited for systems that have the general structure of a functioning system in place.
    With us, might it be good money down the wrong drain? The Aadhaar story is a case in point. Although an example of where tech has helped check pilfering from the government’s free drug scheme is Tamil Nadu. Technology might be an uncertain territory. We also have to man these public health outposts with trained staff. Maintaining and upgrading the technology is another worry.

    4. To my mind, what might benefit quality in our particular circumstance is a determined involvement of women in health – At every level of society from the family, community and village upwards through into the districts – in health education, monitoring and administration. Ceding control over health systems to the local population will be an effective way of ensuring the program’s success. In this regard, I wish the Govt ( a country where educational reservation has converted to an entitlement) has announced a 50% reservation for women in its Rural Medicine Program and thrown in incentives for families in order that women enrolled.

    5. On a separate note; the 1.6% that the government has agreed to in a draft reprot of the Planning Commission is to be spread over five years, to attain that figure in 2017! As you said,it is an abysmally low amount of spending and a downward rewrite of the HLEG’s recommendation of 2.5% (which figure HLEG itself considered low but one that they felt the Govt would acquiesce to).

    Thanks much for a good read. Look forward to more!

  3. Peter1 says:

    I also don’t know how India is going to achieve it’s goals in the foreseeable future.

    My short experience here in Chennai, in Tamil Nadu State at the Apollo Hospital show the huge gap in the two Indias. I came here for a hip operation, number one because of a world class surgeon, a JIC accredited hospital and a price less than half the U.S. price. But if Chennai represents the rest of India I also see a massive disfuctional infrastructure with frequent daily power failures, poor roads, little sanitation, inadequate housing and lack of quality water. I can also attest to corruption in government if the local newspapers are speaking fact.

    India has hope though in its young, and so if they engage then the future for India will be bright.

    I hope the best for this country, but realize it will take a massive effort.

  4. Dr M R Kulkarni says:

    Better access means and demands the Quality as quality is inherent in equity distribution of all achievable and reachable to all beneficiary group in sustainable manner. So our planning and execution have to have both parameters in equal measure, Then only it serves the purpose

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