India has made a significant progress in the
reduction of annual under five child deaths in the last few years.
However, the absolute number of annual child deaths still remains high
and achieving Millennium Development Goal 4 for India may not be
possible at the current rate of child mortality reduction. The deaths due
to the easily preventable and treatable causes indicate that either
health services are not being made available or are ineffective (poor
quality) or the people are not using these services (perceived poor
quality) or any combination of these factors. A few studies from India
have revealed that many sick children are not taken to health providers
and those taken to providers, only a proportion of them are properly
assessed and treated by these healthcare providers, and that their
parents are poorly advised [1-2]. These findings raise a few questions
about the quality of already scarce and inequitable child healthcare
services in the country. The evidence are increasingly accumulating that
the access to poor quality providers leads to child morbidity and
mortality [3].
The health care quality has been defined as "the
degree to which health care services for individuals and populations
increase the likelihood of desired health outcomes and are consistent
with current professional knowledge."[4]. The ‘Quality of care’ has at
least three measurable aspects: structure, process and health outcomes
[5-6]. The ‘structure’ aspects mean infrastructure, staff, services, or
drug availability etc. The ‘process’ aspect of quality measures the
extent to which a practitioner appropriately applies his/her medical
knowledge and resources to improve health. The ‘outcome’ aims to measure
the results of physician and other provider activities i.e. number of
patients successfully treated and the experience with health care and/or
the level of satisfaction with care[6-7].
In the more practicable way the quality of any
service is best understood as ‘its ability to satisfy the need and
expectations of the user of that service and to meet the purpose for
which it is designed’. In the context of health services, aim of quality
care is to be effective, safe, timely, efficient, community centred and
equitable [8].The attention on the health service in India has been
moved from quantity only to both quantity and quality; however, the
phenomenon is in the nascent stage. The Government of India under its
flagship National Rural Health Mission (NRHM) still has focus upon
increasing human resources and infrastructure; however, the need for
improving quality of available services is increasingly being
identified. Nonetheless, the systematic efforts or attention on these
efforts is something emerging. In the governments sector, there has been
emphasis of implementation of Indian Public Health Standards (IPHS) and
ISO standards. The large scale private sector hospitals have received
accreditation from the agencies such as Joint Commission International
(JCI) and National Accreditation Board for hospitals and healthcare
providers (NABH) etc. However, the number of facilities in both
government and private sector which meets the laid down healthcare
standards (and thus can be considered of assured quality) and received
accreditation remains small.
Unfortunately, the focus on quality improvement in
India is largely restricted to clinical care and grossly missing from
the preventive healthcare. Another major challenge in healthcare in
India is poor referral. The discussion on quality of care is on-going for
long but has not received sufficient and due attention. The quality of
care should be made a part of the health culture: should be taught
during the undergraduate and postgraduate programs, during conferences
and continued medical education programs and as part of on the job
trainings for health professionals. The major hospitals and big
facilities need to lead the way for improving quality of care in India.
I earnestly request all IAP members to take a lead in these efforts, at
all possible fora.
The Indian Academy of Pediatrics aims to lead the way
by bringing attention on the quality of care in Paediatrics and hopes
that it would act as a catalyst for entire system to think and act for
improving healthcare quality in India. In the recent years, the quality
is continuously encouraged to be improved by adopting the ‘Quality
Management System’ (QMS)approach. The core approach in QMS consists of
constant ‘process management’. This approach is simple and can be used
by all pediatric facilities without much investment and is assure to
improve the outcome. The steps in QMS approach [8] are:
a. Document: write down what you plan to do
for a patient;
b. Implement: do what you have wrote down or
planned;
c. Record: showing visible evidence that you
are doing what you wrote down. And for monitors/audits to identify
and measure the gaps; and
d. Improve: take corrective actions to
rectify gaps and preventive actions and thus constantly improve.
I strongly recommend each IAP member to follow these
steps in their office practice and to pilot the approach in inpatient
and other larger facilities also. IAP will plan to conduct a few courses
on capacity building in this area to facilitate the process.
My vision is that in coming months and during the IAP
Mission Uday, we will have more focus on improving quality of pediatric
care in India. IAP will be formulating committee on quality of
healthcare in coming months and would release guidelines for
implementation. I envision more CMEs being done on this topic and this
is one of my priority areas of attention. The Government of India should
also have sufficient focus on quality of healthcare in the proposed
universal health coverage scheme and IAP is more than willing to commit
for its all possible support in this endeavour. This will not only
improve patient satisfaction in India but would also accelerate the
reduction in child morbidity and mortality in India to achieve MDG4,
well before time.
References
1. Government of India. Coverage Evaluation
Survey-2009. Government of India and UNICEF, New Delhi. 2010.
2. Lahariya C, Dhawan J, Pandey RM, Chaturvedi S,
Deshmukh V, Dasgupta R,et al for INCLEN Program Evaluation
Network International (IPEN). Inter-district variations in child health
status and health services utilization: lessons for health sector
priority setting and planning from a cross-sectional survey in rural
India. Natl Med J India. 2012; 25:137-41.
3. Barber SL, Gertler PJ. Child health and the
quality of medical care. Berkely:University of California; 2002.
4. Institute of Medicine Committee on the National
Quality Report on Health Care Delivery. Envisioning the national health
care quality report. Washington (DC): National Academy Press; 2001.
Accessible at: http://www.nap.edu/books/030907343X/html.Accessed 4 Feb
2013.
5. Peabody JW, Gertler PJ, Liebowitz A. The policy
implications of better structure and process on birth outcomes in
Jamaica. Health Policy. 1998; 43: 1-13.
6. Peabody JW, Taguiwalo MM, Robalino DA, Frenk J.
Improving the quality of care in developing Countries. In:
Disease Control Priorities in Developing Countries. 2nd Edition.
Washington; 2006.p. 1293-1307.
7. Donabedian A. Evaluating the quality of medical
care. Milbank Mem Fund Q. 1966; 44: Suppl: 166-206.
8. National Health Systems Resource Centre. Quality
management in public health facilities - traversing gaps. New Delhi:
National Health Systems Resource Centre, Ministry of Health and Family
Welfare, Government of India;2009.