Padma Prakash: Quality concerns

MOOT POINT

The recent announcement that the Mumbai-based, influential Association of Medical Consultants (AMC), a group of over 5,000 specialists, has prepared a tariff chart for the 1,500-odd medical institutions in Mumbai is good news.

So now we know how much we have to pay to access particular services in the specified hospitals. What does it really imply?

Will it eventually lead to citizens making better-informed decisions so that everyone, across the social and economic divide, can access quality care of their choice at affordable prices?

Predictably, there has been opposition to the rate list from many quarters. Fellow doctors not in the association have objected to what they see as an interference that will "kill creativity and innovation".

Moreover, according to a medical consultant, the use of superior-quality inputs "leads to a higher price, which seekers of high quality would be willing to pay".

Insurance companies and third-party administrators (TPAs), who have been insisting on rate standardisation, are not too happy, either.

The main issue is, however, a little different, with the missing element being quality norms. Without a standardisation of the quality of services, a rate card serves a limited purpose.

Today, even in Maharashtra, which is among the oldest states to have passed a Nursing Homes Registration Act, quality norms have not been fully worked out.

For example, after a prostrate surgery, should the patient stay in hospital for six days or 10 days? There is no consensus on this issue, not even on more basic quality norms.

The Indian standards for nursing homes and hospitals, formulated only recently, do not cover nursing homes with less than 30 beds, although such establishments form the significant majority of institutions.

In a quality study, 62 per cent of a sample of 50 random hospitals in the Mumbai were located in residential buildings and 12 per cent in sheds roofed with asbestos or tin.

Of 23 hospitals claiming to have operating facilities, only 15 had a designated theatre. Most did not have sterile rooms, or emergency equipment.

Leaking roofs, poor ventilation, filthy surroundings and wards with no room for emergency intervention were a common feature.

This was 10 years ago, but going by the numerous news reports of mismanagement and negligence in nursing homes, little has changed.

Quality assurance in medicare services has largely been a non-issue, except in the media off and on.

While the erosion of quality in public institutions consequent on shrinking health budgets and a general disinterest has been well-documented, the fact is that the growing plethora of non-government institutions that are serving huge sections of the populations across income classes have been left well alone by all regulatory authorities.

Partly this lack of focus on the non-government sector in health care is a hangover from the early days of planning, when the sector was deemed to exist only on the fringes.

With no regulations except those formulated by the lethargic Medical Council of India, non-government medicare institutions flourished.

By the time the state woke up to the anarchy in the private health sector, it had to confront a well-organised and influential professional community that resisted all attempts at state regulation.

Today neither the state governments nor the central health ministry has reliable and comprehensive information on the number of private hospitals in the country, the quality of care delivered, or charges administered.

For instance, according to the Central Bureau of Health Intelligence (CBHI), there are only 1,319 private hospitals (1992) in Maharashtra.

However, an independent research survey reported 907 such institutions in Mumbai alone. This too is held to be an underestimate.

Similarly, in Andhra Pradesh the CBHI reports 1,722 private hospitals while a detailed study of facilities in Hyderabad alone was 2,858, a large proportion of which were less than 30 bed-institutions.

Several large studies have shown more than half the people looking for indoor services and about 70 per cent of those seeking outpatient care go to private facilities.

A 1992 NCAER household survey confirms this pattern; with over 55 per cent of illnesses being treated by private facilities, this proportion is rising.

But the cost of medicare has been climbing steeply. The World Bank noted in 1992 that across income classes one episode of hospitalisation accounted for 58 per cent of per capita annual expenditure.

More than 40 per cent of indoor patients had to borrow money to be there.

Why are people seeking private care? Is it because there is a greater assurance of quality? Sporadic evidence shows this is not the case.

When asked why respondents were migrating out of the public system, the commonest answer was that equivalent treatment was not available in public facilities.

Equivalent treatment is not specialised service, but wide-ranging facilities that are available only on paper in public facilities.

In sum the uneven quality of private medicare and the anarchy of prevailing rates affect not only a vast section of the middle class, but also, with deteriorating public services, the poorer classes as well.

Regulatory norms of the quality of care and its cost to patients are urgently needed.