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.