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Indian Pediatr 2013;50: 269-270

Improving Quality of Pediatric Care in India: A Call for Action


CP Bansal

President, Indian Academy of Pediatrics. Correspondence to: Shabd Pratap Hospital, Gwalior, MP, India.
Email: [email protected]
   


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.

 

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