3 Reasons why Government Hospitals in India should provide good quality health care

by: Dr Sandeep Moolchandani, MHA-HO (2009-11)

Hospitals form an important arm of the healthcare delivery system. Though the focus of various National programmes may be on primary health but secondary and tertiary public hospitals form one of the largest expenditure category in the national health budget. Over the past decade, inspite of the complexity of hospitals having increased many fold, not many changes have been made in the management structure of public hospitals.

It is very well known that hospitals should be hundred percent clean and hygienic, but in practice government hospitals are generally the filthiest places. Even central level tertiary government hospitals are run on primitive principles; problems of poor governance and administration is not a hidden fact. Waiting times in government hospitals can reach upto two hours just for accessing outpatient services.

Lack of governments’ commitment towards quality assurance in government setups, low management capacities at health facilities, lack of policies and guidelines from the State, as well as structural problems of the centralized health system are key problems in Public Health Sector leading to inefficient use of scarce resources and deficiencies in the quality of services provided (Davey, 2006)

This post enumerates the reasons why the public hospitals should start focusing upon delivering optimum quality of services.

1. Public Hospitals impose significant opportunity costs to the society

The secondary and tertiary care as such has a limited impact on the population health. Inspite of this known fact a major chunk of healthcare budget is spent on secondary and tertiary care which can be upto 40-50% of state healthcare budgets. Thus infrastructure and administrative costs of hospitals carry a big opportunity costs with them.

Maharashtra 2000-01
Public Health Expenditure (Rs. Million) in Urban Areas

In 2000-01, 48percent of public health expenditure in Maharashtra, which amounts to Rs 5396.11 million, was incurred on medical care alone.

2. Decreasing utilization of Public Hospitals for Inpatient and Outpatient Care

Some studies on the patterns of utilization of health care facilities indicate that the private health care provider is preferred for the cost and quality of the health care services provided (Uplekar 1989a, 1989b; Viswanathan and Rohde 1995).


80percent of households prefer to use private sector treatment in India for minor illnesses, and 75percent of households prefer to go to the private sector for major illnesses (M.Uplekar, V.Pathania, & M.Raviglione). Numerous other studies have confirmed the dominance of the private sector and the reasons for this dominance: government health services entailed longer waiting periods, arrogant behaviour of doctors and non-availability of medicines (Ananthakrishnan). Even though the treatment in public hospitals is free, the patients have to pay for tests, and bear the incidental costs of boarding and lodging (Pasricha, 2006).

Chart: Sources of Utilization
of Health Care Services, Maharashtra (Adapted from “Health And Healthcare In Maharashtra: A Status Report”, Ravi Duggal,
2005)

The users don’t prefer to use public facilities for medical services like Inpatient and Outpatient services in contrast to other primary healthcare services especially in urban setup as per the data published by National Sample Survey Organization (NSSO). The major public providers which provide these services in urban setups are teaching hospitals and general hospitals. There is a clear preference towards private providers despite of costly treatments in secondary and tertiary domain. This data points towards the failure of public hospitals in meeting the expectations of the public.

3. Health Expenditure incurred by patients in Public Hospitals vs Private Hospitals

The ratio of hospitalisation expenditures in public vs private hospitals in urban setups ranges between 0.16 in Tamil Nadu to 1.75 in Haryana. The services provided in public hospitals amount to a considerable fraction of the costs in private hospital. Even after spending a comparable amount, all patient gets is dismal sanitary conditions, long waiting times, rude behaviour of staff, high infection rates and substandard clinical care. This is one of the prominent reasons why the patients prefer private healthcare providers more than public hospitals.

A significant dilemma is faced by middle income groups who can spend on healthcare but not as much as charged in good private tertiary setups; while in case of treatments in government hospitals the quality of services provided is too bad to meet their expectations. The middle class comprises to around 25 to 30 percent of the total population of India.

Major State-wise Average
Total Expenditure (Rs.) Per Hospitalisation by
Type of Hospital for Rural and
Urban Areas in India

There are three things which should be clear with respect to the treatment in a government hospital, firstly the treatment in government hospitals is not completely free, secondly apart from these costs there are costs involved due to loss of daily livelihood and thirdly there are potential costs that can come into picture due to bad quality of treatment (improper instructions while prescribing, post op infections, medical errors, medical negligence etc).

Conclusion

A significant amount of taxpayer’s money is spent on Government hospitals which puts these hospitals in a critical position to be accountable for the quality of services and deliver quality services within the constraints of available resources. It should be tried by the public hospitals to prevent diversion of its customer to private setups due bad quality of services. This warrants an existence of a quality management and control mechanism for government hospitals.

Quality of service should not be denied just because the direct consumer is not asking for it; but concrete measures towards quality assurance are necessary because lots of money is being spent in providing the infrastructure and bearing the administrative costs in the public hospitals. A few state governments (Gujarat, Kerala) are coming up with answers to these questions by taking concrete actions towards quality assurance and commitment for continuous quality improvement.

Is rationing a rational option in health care?

by Dr.Arun K. Tiwari

There are two concepts of rationing in healthcare- Conventional Rationing and Price-based Rationing.

Concept of Conventional Rationing can be animated in the function of a sand clock where scarce resource from upper half passes down through a narrow channel and gets distributed to a large base. Similarly price based rationing can be visualized in the form of a coin box telephone, where only those get to make calls who are capable of inserting coin and also in order to maintain it, they are required to keep pushing the coins.

Question regarding which type of rationing seems to be settled in favor of the conventional rationing as it is less offending towards human rights (consider emergency cases being denied for not being able to pay). Looking at various health systems across the world, Rationing is evident in various forms e.g. waiting time, exclusion of drugs from list, gate keeping or even complete denial of services like cosmetic surgeries and dentistry.

Though healthcare sector strives hard to achieve cost minimization, it becomes difficult because of two major reasons: shortage of skilled professionals, which drives the cost of labor high and second, using finished products from other sciences (e.g technology, IT, pharmaceuticals etc) as inputs to produce services, which causes a second level of cost escalation.

Nonetheless, the health systems have their own ways of reducing cost. Primary Health Care (based on the principles of equitable distribution, Community participation, inter-sectoral co ordination and appropriate technology) is the most suited low cost model advocated for most developing countries by WHO. Other prevalent approaches are those of QALY and DALY. It is out of these principles of allocative efficiency that the concept of rationing derives most of its rationality. Development of innovative financing mechanisms to mitigate the risk of catastrophic expenditure during illness is an example of expanded rationality.

There are policies in which rationing is implicitly expressed (such as NHS, UK) and in some others, it is explicit (USA). Market based or non market based means- Rationing as a policy tool seems ubiquitous in all health systems. Interestingly this happens to be the most basic of all tools known to deal with scarcity of resources.

Thus, more than the matter of its presence, it is the form of presence which ought to be subjected to debate. It is now a debate of means and methods by which this particular policy tool is used rather than the rationality and validity of the tool itself.

BRAINSTORMING: Feasibilty of International Health Financing Models in the Indian Context

Dr Arun Jitendra
mailed-by		gmail.com

In first place why do we have to look at international financing models, it would rather be good if we are able to think something out of the box and yet rational which suits our present needs. Considering the fact even the pattern of health education is based on international curriculum its high time we start looking inside our system rather than imposing something which has been tried somewhere else . Even NRHM can be considered such an initiative which i dont think has been borrowed from anywhere.

Dr Khyati Tiwari
mailed-by		gmail.com

Guys
What i think is, considering international models is not a bad option, all we need to take care of is that it is appropriately defined according to the needs and circumstances. The most important aspect being sustainability. For example, micro financing is something which was implemented in extremely backward African countries and was thoroughly successful. You always have a turn to experiment something new, all u need is the guts to justify it, according to circumstances and surroundings.. bits and pieces must fall in place and then the wheel rolls on...

Astha Gupta
mailed-by		gmail.com

In my view, in the current global scenario of interlinked economies and globalization having entirely indigenous health financing models is not possible. To add on there are constraints from donor agencies which influence the health financing model being implemented. On the contrary a blind imitation of the international models without assessing the needs and situation of our set up is also not a feasible option. Instead we need a balanced approach wherein the international models are taken up but remodeled as per our needs after a through needs assessment and then implemented with the scope of revaluation being in place.

BRAINSTORMING - Accreditation of Public Hospitals: Possibilities and Implications ??

Dr Deepthi Alle
mailed-by		gmail.com

Accreditation of public hopitals, there are two basic things to be discussed
1) What are the standards that are to be reached?
2) What is that we are expecting out of it?

If what we are trying to achieve is public welfare, we can achieve that if our governments put in little more interest into public health setups, which starts with providing basic amenities. Well equipped and maintained PHCs alone can work wonders, not even to speak of teaching hospitals.And for governments to be serious about anything, it has to be an election issue, so if our population are informed about, and they become aware of their rights; may be things will take a different turn. So, what i feel is, accreditation is of-course good, but it's not a must.
Rather an integrated approach grounded to basics shall be our immediate remedy, accreditation being a long term goal.

Dr Sandeep moolchandani mailed-by gmail.com

Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”

-International Society for Quality in Health Care (ISQua)

If you ask me about accreditation of public hospitals, i will say that we should have a separate accreditation authority for public hospitals since the standards of quality for public hospitals can not be compared to private hospitals any day because of the big difference in case load and the administrative constraints. But some say accreditation and quality standards are not feasible in a public setup; but mates we should remember that quality is relative, it is an indicator of the efficiency of each unit of an organization and thus it should be monitored with help of suitable indicators both internally and externally where accreditation being an external solution. The data should also be disclosed for public scrutiny.

In short, better quality should be a persistent aim of any responsible organization; be it public or private.