Background Note for the Annual Meet, 2006
Quality and Costs of Health Care:
Social regulation in the
context of universal access
The Context
The state of healthcare services is a matter of serious concern in
most parts of the world. For most of the low and middle-income sections in the
low and middle-income countries, ie. the majority of humankind, the issues are
primarily of access to whatever are perceived as good quality basic services.
For the better off across the globe, the issues are more of escalating costs and
over-medicalisation. Inappropriate models of development and organisation of
services as well as alienation of health care providers from the laypeople have
been widely identified as reasons for the present state of the health services.
Therefore quality of health services has to be examined from a public health
perspective, including but not relying upon clinical criteria alone for the
assessment.
However, even
the public health perspective needs to be delineated further. Public Health, as
a field of enquiry and action, has two faces. One is the democratic face with the
potential of its acting as a lever for improving quality of life of the poor and
other marginalised sections of society. It has, historically, focused on the
necessity of fulfillment of basic needs of all, including health care. The
second is the anti-democratic face of public health with its potential for
coercion in the name of 'public good'. Instances abound over the past century–
from eugenics to medical research to disease control strategies– that violate
rights of individuals and marginalised social groups. The definition of quality
of care can also be done in ways that, directly or indirectly, contribute to the
practice of one or the other perspective.
Currently, there is emphasis on healthcare and disease control
programmes of the public sector from several quarters - the World Bank, the
Pharmaceutical and Medical Equipment Industry and Medical Insurance Companies
included. Increasing privatisation of health care has led to recognition of
'market failure' due to the low purchasing capacity of the majority across the
world. Thereby public services provide the answer from both points of view; of
the users who need affordable/free health care, and of the sellers of health
products who need an assured market. While this may seem a win-win situation,
what is most likely to get compromised is the rationality of health care. Panic scenarios and 'social marketing'
build the demand for programmes so that public funds are siphoned into
unnecessary programmes and measures.
The Framework
The framework for assessment of quality has to be able to address
issues related to individual institutions at primary, secondary and tertiary
levels; to take a systemic view with which includes consideration of the
interlinkages between institutions; and to assess quality of specific public
health programmes. It should be applicable to both public and private sector
health care services.
The criteria
and standards set for defining quality of care have to be carefully chosen, and
those in use have to be examined for their implications. The huge diversity of
epidemiological, social and health care context within which the health care
services function means that criteria and standards may not be applicable
universally. Quality criteria for single health service institutions, health
service systems and specific health programmes will differ in some ways and be
similar in others. The nature and load of health problems to be handled, the
level of development of the health service system in the country/state/district,
and the socio-econmic profile of the users will need to be taken into account.
Therefore principles need to be enunciated for assessing quality and for
implementing quality control mechanisms that can then be applied in various
contexts.
The measures
envisaged to ensure improvement in the quality of health care are going to
significantly influence the setting of standards and steps to achieve them. Administrative controls, professional
peer controls, community controls, setting of standard protocols, accreditation
mechanisms to inform users, health insurance systems that set standard
protocols,
The
Principles
Technological
choices
What
principles can be used to guide assessment of quality of services? Efficacy and
safety are essential attributes of any health care intervention, forming the
‘outcome’ indicators. Cost, regularity and sustainability of services determine
adherence to instructions. Clearly resource constraints alone cannot dictate the
assessment since this can mean acceptance of low levels of effectiveness or
safety. If some measures are proven safe and effective for important public
health problems, then the resources must be found for them. On the other hand,
state-of-the art technology cannot, by itself, be the standard of quality either
since, for the above criteria, the implications of its use can be different in
diverse contexts.
Increasing
expenditure on irrational medical care, and increasing hazards to health from
unnecessary medication and medical procedures are being documented, and are
widely known. The extent of malpractice rampant in both the public and private
health services in
Further, the
rationality of public health programmes too has been questioned. For instance
the pulse polio campaign has been shown to be epidemiologically questionable in
its claims, creating a threat of massive paralytic outbreaks in future and the
possibility of individual cases of vaccine virus poliomyelitis persons who may
otherwise have remained healthy.
Similarly, the programme for Control of Iodine Deficiency Disorders, with
a universal ban on non-iodised salt, is also contended to be both irrational and
hazardous. Both interventions also ignore the basic environmental causes of the
problem.
Access
Health care
services are not only about technologies and good management. The Alma-Ata
Declaration on Primary Health Care stated the desirable health care to be that
which is available, accessible, affordable and acceptable to the community,
given their specific social, economic and cultural context. Lack of access of
large sections of the urban poor, rural and tribal populations to basic health
care is a glaring issue, and health sector reforms have worsened the situation,
in the name of improving ‘efficiency’ and quality of health services.
Provider-User
Interaction / Institutional work culture / Infrastructure
The nature of
provider-user interaction is known to determine the outcome as well as the
perception of quality by patients. Rude behaviour, poor communication and
negligence by the providers are well-documented ills of the health services in
both the public and private sectors. Infrastructure planning also reflects the
attitude of the service planners and administrators; whether it is user-friendly
or not, whether it gives importance to facilities such as water and toilets,
catering and space for attendants to stay etc. The adequacy of manpower, its
optimal distribution and work assignment influence the functioning of providers.
The nature of working relationships between providers directly influences the
quality of services. Quality is affected by the work culture; whether it is one
of cooperation or competition; whether the motivation is primarily to provide
the best services or to get the best ratings in accreditation systems; whether
it is profit-oriented, professionalism-oriented or service-oriented. Such
‘process’ indicators are important criteria, just as much as are the outcome
indicators.
Also required
is the definition of the role of the patient in deciding the line of treatment.
Is it an issue in assessing the quality of services? Does the patient’s right to say ‘no’ to
the medically recommended state-of-the-art measures absolve the service provider
of the responsibility or does it mean actively developing the best line of
management in keeping with the patient’s world view? If standardized protocols
are viewed as the solution to some issues of quality of medical care, how will
such issues be addressed?
Questions to
be explored
Some questions
to be examined on the theme would therefore
be:-
What are the
intrinsic components of health care that are important in deciding the quality
of services?
What criteria
should be used to assess these components?
Whose
conditions and perspectives should be given primacy in answering these
questions?
It would be
good to discuss these issues in the context of the reality of the health
services in
Ritu
Priya
April,
2005