Editorial Commentary

Strategies for Ensuring Quality Health Care in India:

Experiences From the Field
Health care is one of India’s most rapidly expanding sectors recommended key determinants, in which health care is simply
both in terms of revenue and employment. However, the an element. Besides, the health services, quality health needs
question of whether the expanding industry size translates into interventions influencing other determinants of health such as
better quality services and improving outcomes for patients still culture, attitudes, income levels, nutritional status, hygiene and
remains. In this regard, the government released the National sanitation, lifestyle, social support, and among other things.
Health Policy (NHP) 2017 to serve as a guiding document
for the policymakers in the achievement of India’s national Assessing Ground Realities: Experience from
goals and international commitments. NHP recognizes some
key dimensions of high‑quality healthcare – consistency, Banda
positive health outcomes, patient‑centeredness, equity, and Access to health care in India is scattered across geographical and
trustable service delivery.[1] Improving the quality of health income differentials. Therefore, each region’s unique context
care is also essential to meet the health‑related targets of the is largely determinative of the success of any intervention.
Sustainable Development Goals (SDGs). SDGs lay importance For informed policymaking and the implementation thereof,
on improving indicators relating to maternal, fetal, and neonatal a deeper understanding of the ground challenges is essential
care, which are areas where continuous quality enhancement is to ensure efficient and adequate delivery of health services,
necessary to bring down the maternal mortality rates (MMR), especially in areas where quick and quality service delivery
infant mortality rates (IMR), neonatal mortality rate (NMR), is imperative like maternal and child health. A field visit
and under‑five mortality (U5MR).[2] undertaken to the Banda district in Uttar Pradesh with the
objective of assessing the utilization of the maternity services
On the one hand, India has made ground‑breaking progress at both public and private facilities brought to light significant
in recent years in reducing the MMR by 77% (from issues in infrastructure, human resource management, process
556/100,000 live births in 1990 to 130 in 2016) and child integrity, and monitoring. In the case of referrals for high‑risk
deaths by approximately 57% (from 14 million child deaths pregnancy (HRPs), for instance, data analyzed from private
in 2000–2005 to 6 million in 2011–2015).[3] However, on the hospitals suggested a delay in referral and complacency on the
other hand, progress on both these key accounts missed the part of medical and antenatal staff in detecting such pregnancies
targets set under the 12th 5‑year plan (2017) goals as well as that may pose grave danger to both mother and child if
the Millennium Development Goal. From the WHO Health undetected. To be more specific, in October 2018, 41,887
Statistics 2016, one can find India lagging behind its neighbors pregnant women in their last menstrual cycle were registered
such as Maldives, Sri Lanka, Nepal, and Bhutan in terms of on the central server for the district, with 13,419 tagged as risk
indicators such as incidence of tuberculosis and premature cases and only 1907 as high risk. This immediately catches
deaths due to noncommunicable diseases.[4] India’s average attention since in any usual context; about 10% of cases are
life expectancy (68.3 years) is some 10 years shorter than HRPs. Thus, there is substantial under‑detection of high‑risk
Maldives, drawing attention to some shortcomings in India’s cases despite the presence of incentive‑based programs for
strategy for quality health. This is despite a decade of the accredited social health activist (ASHA) workers in the state.[5]
ambitious National Health Mission implementation. Perhaps,
patching the gaps in the ground‑implementation of the pioneer Even in cases that are identified, there is usually a very late
programs of the government needs a determined revisit. referral that may put the mother and child at risk. These issues
remain even though routine antenatal care (ANC) is mandated
On maternal and child health, the NHP aspires to reduce U5MR and promoted under the Pradhan Mantri Surakshit Matritva
to 23 by 2025 and MMR from current levels to 100 by 2020. Abhiyan (PMSMA). The situation is exacerbated due to a lack
It also aims to reduce IMR to 28 by 2019, NMR to 16 and of institutional capacities and monitoring systems. For instance,
stillbirth rate to “single digit” by 2025.[1] In this regard, the while the medical college hospital and district hospital in Banda
government’s key intervention, i.e., universal health coverage have qualified Obstetric (OB)/Gynaecology specialists as well
under the Ayushman Bharat – Pradhan Mantri Jan Aarogya as anesthetists on their rolls, emergency medical OB care is
Yojna (AB‑PMJAY), has caught onto the right priorities. not available at these facilities, forcing patients to be referred
However, ensuring replication of broader policy objectives to other centers. Moreover, a disconnect between community
onto the ground requires sustained effort and smaller reforms to health centers (CHCs) and district hospitals means that majority
ensure effectively translation of national goals into local realities. of the referrals either land up in private hospitals in Banda or
Effective health planning requires a consideration of the WHO have to go to the nearby city of Kanpur.

© 2019 Indian Journal of Community Medicine | Published by Wolters Kluwer ‑ Medknow 1

 Gopal: Strategies for ensuring quality

To alleviate the situation, some short‑term action points were Hence, to address these challenges and meet the objectives
suggested in the governance model to address key challenges. set out in NHP, India requires significant investment and
Primarily, a review of the existing quality of ANC, with special upgradation of quality standards. While the government is
emphasis on the identification of HRPs, needs to be undertaken. constantly increasing its financial input into health systems
Thereafter, localized plans, at the primary health center (PHC) reform, focus needs to be on quality consciousness and assurance
level need to be developed for registration, follow‑up appointments mechanisms, especially since there has been a growing demand
and timely referral of HRPs to appropriate facilities (public or from consumers for better quality healthcare. There needs to be
private). To ensure synergy with the AB, focus on developing a marriage between quality assurance and quality improvement.
model for referral arrangements with private health providers at While the former’s focus is on ensuring requisite infrastructure,
PMJAY rates is a must. This localized system would also require supplies, and trained workforce, the latter relies on the process
institutionalization of a monitoring system. This model would of equipping the health‑care workers and managers with skills
also need support in the form of capacity building initiatives for to identify and solve problems at their level. Access to quality
ANMs and ASHA workers, including mentoring for detection healthcare can also go a long way in reducing the overall cost
of HRPs. Overhauling the implementation of the PMSMA for of health care, by reducing complications, reoccurrence, and
detection of HRPs and ensuring availability of iron and folic acid treatment periods. To ensure continuous progress toward both
and oxytocin are other focus areas. regulations and accreditations are key.
Regulations needed include a re‑assessment of existing
Putting Field Learnings into Action policies and programs to see what works and what needs
It needs no reiteration that bridging the gap between the rework. For example, the National Health Mission’s inability
aspirations of NHP and AB‑PMJAY and the ground reality to achieve targets relating to IMR and MMR despite high
requires a systematic approach, involving both private service budgetary allocation is a key priority. Quality controls in
providers and government institutions. The experience from the form of accreditations, like the ones established by
Banda is unique but overall has some essential learnings for National Accreditation Board for Hospitals and Health‑care
the Indian health‑care system as a whole. Providers (NABH), also help ensure a strong focus on
patient rights and benefits, safety, control, and prevention of
First, challenges of inadequate facilities, infrastructure, coverage, infections in hospitals, and proper protocols such as special
access, and quality continue to plague the health system. care for vulnerable groups, critically ill patients, and better
Over 95% of facilities function with less than five workers, and controlled clinical outcome. The existing accreditation
and only 195 hospitals in the entire nation operate with quality ecosystem and quality frameworks in India are quite robust
certifications. Essential diagnostics such as mammograms and comprehensive, and hence, it is pertinent to promote their
have scant coverage of only 1%. Second, the complacency adoption. Interventions into quality promotion, such as Indian
of the medical staff in discharging their duties is a universal Public Health Standards 2008, National Quality Assurance
reality in the nation. Empirical studies indicate that health‑care Standards (NQAS) 2013, Mera‑Aspataal (My Hospital) 2016,
professionals in rural areas with requisite formal medical LaQshya (Labour room Quality Improvement Initiative) 2017,
training do not provide any significant higher‑quality care when and National Patient Safety Implementation Framework (2018–
compared to informal providers. This is further complicated by 2025), can also help jumpstart the journey in this direction.
the fact that there is a persistent shortage of human resources
in health in India – 0.7 doctors available per 1000 population Quality is also a function of equity. Put differently, regional and
as compared to the WHO recommended 1:1000 ratio. income disparities should not hinder access to quality health
care. NITI Aayog’s Health Index places Kerala on top and Uttar
While one would expect private sector care to have higher Pradesh at the bottom across indicators such as IMR, sex ratios
quality, there is increasing evidence suggesting poor quality at birth, immunization, proportion of people living with HIV/
in the private sector. Problems with the public and private AIDS, and incidence of tuberculosis.[7] Uniform regulation,
health setup are largely the same – gulf of difference between implementation, monitoring, and accreditation coupled
the reported and actual diagnostic and treatment facilities, with a study into and attempts to address the region‑specific
the tendency of over‑prescribing and subjecting patients challenges can help reduce geography‑based imbalances. The
to unnecessary interventions, lack of efficient monitoring AB‑PMJAY already attempts to tackle the economic inequity
mechanisms, and poor implementation of regulatory controls. to accessing quality health care through universal health
Moreover, the lack of universal coverage, access, and coverage but needs more effort in securing efficient translation
on the ground. Banda’s experience also highlights the need for
affordability across regions also hampers attainment of
elaborate and systematic stakeholder management, especially
high‑quality health outcomes. As per the 2016 Health Access
the need to onboard the private sector on the technical and
and Quality Index, India performs only averagely in South
informational aspects of the national program.
Asia with a score of 41.2 (leading marginally from Pakistan,
Nepal and Afghanistan) but lagging far behind Bhutan (47.3), For central policy focus and assessment, international targets
Bangladesh (47.6), and Sri Lanka (70.6), even though India and standards might serve as a credible guide. The WHO Global
performs better than these nations on economic indicators.[6] Nutrition Targets for 2025 deserve mention here, and India

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 Gopal: Strategies for ensuring quality

should aim to achieve them, especially those highlighted in the our end goal, which is to attain and build the trust of the
Comprehensive Implementation Plan on Maternal, Infant and consumers. Quality is an invisible thread tying all these
Young Child Nutrition. This plan lists out a set of six global elements together and needs constant focus. This can be
nutrition targets to be achieved by 2025, including a 40% achieved only by simultaneous and synergistic implementation
reduction in the number of children under‑5 who are stunted; of the tools elaborated above, continuous learnings from the
a 50% reduction of anemia in women of reproductive age; and field, and most importantly, a receptiveness by all stakeholders
reduction and maintenance of childhood wasting to <5%, among to change for a healthier country.
others – all imperative for a developing, young nation like India.[8]
Disclaimer: The views expressed are personal.
Finally, receptiveness to and quick adoption of innovations can
aid quick acceleration to the ambitious goal of quality health K. Madan Gopal
care. This, in turn, needs investment into and institutionalization Health Vertical, National Institute for Transforming India NITI Aayog,
New Delhi, India
of innovative approaches in the existing system.
Address for correspondence: Dr. K. Madan Gopal,
Way Forward Room 364, National Institute for Transforming India Aayog, Sansad Marg,
New Delhi ‑ 110 001, India.
Above suggested changes can act as a catalyst to achieving E‑mail: kmadangopal@gmail.com
the medium‑term goals set out by NITI Aayog in its 2022
Health Care Strategy which focuses on four crucial parameters, References
foremost of which is the revamp of the public and preventive 1. Ministry of Health and Family Welfare, Government of India. Specific
health systems. This is planned to be achieved by co‑location Targets Under National Health Policy 2017. Ministry of Health and
of AYUSH services in 50% of PHCs, 70% of CHCs, and 100% Family Welfare, Government of India; 2017.
2. An Overview of Sustainable Developmental Goals: Available from: http://
of district hospitals, instituting public health and management www.niti.gov.in/content/overview‑sustainable‑development‑goals.
cadre in states, and creating a focal point for public health at the [Last accessed on 2018 Dec 12].
central level with state counterparts.[9] Thereafter, the strategy 3. Causes of neonatal and child mortality in India: A nationally
calls for promoting a new vision for comprehensive primary representative mortality survey: Million Death Study Collaborators.
Lancet 2017. DOI: 10.1016/S0140-6736(17)32469-8.
health services using health and wellness centers (HWCs). 4. The Lancet Global Health Commission on High Quality Health systems
Therefore, the strategy calls for accelerating the establishment in the SDG era; 2018. https://doi.org/10.1016/S2214-109X(18)30386-3.
of a network of 150,000 HWCs through commensurate 5. Field Visit Report. Banda UP: Dr K Madan Gopal; December, 2018.
enabling mechanisms for rapid scale‑up. The strategy then 6. GBD 2016 Healthcare Access and Quality Collaborators. Measuring
performance on the healthcare access and quality index for 195
turns focus to developing able human resources to operate these countries and territories and selected subnational locations: A systematic
revamped networks. It calls for achieving a doctor‑population analysis from the Global Burden of Disease Study 2016. Lancet
ratio of 1:1400 and nurse‑population ratio of 1:500 through 2018;391:2236‑71.
reforms in the governance of medical, nursing, dentistry, 7. National Institution for Transforming India Aayog, Government of
India. Health States Progressive India. Report on the Rank of States and
pharmacy councils, and transforming the curriculum. This Union Territories. National Institution for Transforming India Aayog,
would need to exist within a framework of a comprehensive Government of India; February, 2018.
human resources for health policy in states. Finally, the 8. World Health Organization. Global Nutrition Monitoring Framework:
strategy focuses on boosting coverage of the publicly financed Targets for 2025. World Health Organization; December, 2017.
9. National Institution for Transforming India Aayog, Government of
health‑care system. The same can be achieved by covering 75% India. Strategy for New India@75. National Institution for Transforming
of India’s population under AB‑PMJAY with inbuild quality India Aayog, Government of India; November, 2018.
improvement and assurance mechnism and strengthening
public sector health facilities – something that India is currently This is an open access journal, and articles are distributed under the terms of the Creative
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While all these are apt pillars for a medium‑term roadmap for is given and the new creations are licensed under the identical terms.

the Indian health system, the strategy also assumes a bedrock of

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quality assurance and adherence. Ensuring high quality implies
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achieving improvement in health outcomes, consistency in Website:
those outcomes, valued and trusted systematic processes, and www.ijcm.org.in
institution of structures that are able to effectively respond to
changing population needs and dynamics. Measurement and DOI:
monitoring initiatives are essential to fix accountability. In 10.4103/ijcm.IJCM_65_19
this regard, institutional‑level input measures such as NABH
and NQAS, and district level outcomes like National Family
How to cite this article: Gopal KM. Strategies for ensuring quality
Health Surveys are pertinent to be noted. health care in India: Experiences from the field. Indian J Community Med
While coverage and quality might seem like a trade‑off, an 2019;44:1-3.
effective amalgamation of the two is imperative to achieving Received: 10-01-19, Accepted: 21-02-19

Indian Journal of Community Medicine ¦ Volume 44 ¦ Issue 1 ¦ January-March 2019 3