Finger on the Pulse
K Srinath Reddy
President, Public Health Foundation of India
Whenever Universal Health Coverage (UHC) is discussed, the dimensions that usually feature are access (population coverage), range of specific services included in the funded package (service coverage), and the quantum of financial protection offered under the scheme (cost coverage). Quality of healthcare is not explicitly addressed. Even under specific health programmes, coverage is reported as an indicator of success, while quality of services is often assumed to be adequate.
However, even when the coverage of services is good, poor quality of whatever is delivered results in poor health outcomes. In a clinical setting, this extends across a wide range of services—from accuracy of diagnostic tests to the quality of surgery performed by a team. In the public health setting, the concerns may range from the quality of vaccines and drugs being used to the quality of health messaging to the public.
The four major facets of quality of care in a clinical facility are: benefit, safety, cost optimisation and satisfaction. How much benefit does the test or treatment confer in diagnosing or improving the course of a disease? Often, multiple studies are collectively analysed to obtain fairly precise estimates of effectiveness and clinical benefit. This evidence is then incorporated into standard management guidelines. Benefit may vary across different clinical or ethnic sub-groups. Focus on quality ensures that the best available research evidence guides the choice of the most beneficial test or treatment in each situation.
Safety is also an important attribute of quality. An effective treatment or test may produce adverse effects, which may diminish or outweigh the benefits. While information about the safety of a drug is usually obtained from animal and clinical research involving pre-licencing drug trials, much more extensive information flows from post-marketing surveillance of reported adverse effects after the drug is released for use in clinical practice.
This is because the trials themselves may have adequate statistical power to measure efficacy, but lack the numbers needed to quantitatively estimate the probability of serious adverse effects. It is not surprising, therefore, that we see some highly efficacious drugs, that emerge from clinical research, being withdrawn when widespread use uncovers an unacceptably high incidence of serious harm. Similarly, surgical procedures, too, may unmask their harm much more visibly as larger numbers are operated and studied. Safety may suffer either because of the nature of the procedure per se or deficient skills and care on part of the surgical team or poor infection control. Regular safety monitoring helps to detect the cause.
Cost is often posed as a counter to quality. While the need to provide appropriate care to a patient should ideally not be compromised because of the cost involved (here UHC becomes important), quality also demands cost-effectiveness and best value for the money spent. Provision of appropriate care (avoiding unnecessary tests and treatments) is a measure of quality. When multiple diagnostic tests are available, incremental cost-effectiveness of the costlier tests need to be assessed (how much is the added value of this test in making the diagnosis?). Cost-optimisation is thus an essential characteristic of quality healthcare.
Satisfaction is an emotive, but still measurable dimension of quality in healthcare. This needs to be assessed in patients, their families as well as in healthcare providers. Frequent complaints by patients or kin relate to the lack of attention, discourtesy, rudeness and discrimination on part of doctors, nurses or hospital staff. Inefficient systems, which make patients wait for long or provide no proper guidance, create dissatisfaction despite expert clinical care. Well-designed operational systems, nurturing of soft skills and trustworthy grievance redressal mechanisms will improve satisfaction levels in both recipients and providers, whether in a primary healthcare centre or a tertiary hospital.
ksrinath.reddy@phfi.org