With a new government in the offing, all suggested agendas for health are talking of an increase in health budgets and the fact that at 1 per cent of the GDP, government spending on public health in India is one of the lowest in the world; the rest is out of pocket expenditure. The US is a prime example of the fact that an increase in health budgets is no guarantee of better healthcare. Until such time as we are able to achieve some transparency in pricing and some standardisation in hospital processes, there is every likelihood that a mere increase in budgets would only mean healthier balance sheets for hospitals.
Today, almost 72 per cent of healthcare-spending in India is in the private sector, and all indications are that this is going to be the case in future too. The private sector today accounts for almost 52 per cent of all inpatient care and 82 per cent of outpatient care. There is nothing wrong in such a trend: if private hospitals deliver better value for money, certainly they should be funded. However, a mere look at how private hospitals and health insurance function makes this a questionable proposition.
Health premiums have skyrocketed in recent years. This, however, has not meant that the policy holders are any better off. Grievances have increased at practically the same rate as health premiums. The rise in premiums mostly has to do with hospitals. Most health insurance companies in India have adverse claim ratios of over 100 per cent, which means that the entire premium is swallowed up in claims. Audit reports routinely say that the public insurers should reduce the costs of medical services by standardising procedures and costs. This is something that neither private nor public insurers have been able to do.
One reason for this has been that hospital charges for procedures are not transparent. Hardly any hospitals have standardised packages for high-cost procedures, like bypass surgeries, which include all costs from start to finish. Unless the consumer knows for instance that a bypass in a five-star hospital costs Rs 4 lakh in contrast to Rs 1.5 lakh in a smaller hospital, there is no way that he can compare the two. The insurers, for their part, have clearly said that they are unable to persuade the hospitals to offer package rates.
Second, and more importantly, even if one’s health insurer is willing to pay Rs 4 lakh for that heart surgery, the quality of service provided is uncertain. There is no central data repository in the government or with the insurers on the relative health outcomes for these procedures. So we have no way of comparing the performance of any given hospital over time to say whether patient survival rates have improved or whether infection rates have come down.
Few people know that hospitals simply do not keep the kind of records that might provide them feedback on the quality of patient care. For example, in case any incidence of infection is recorded, it would be recorded on the case paper of the individual patient. This information is not filed in any central registry. Correspondingly, no corrective action at the institutional level is possible other than that which the immediate caregivers might offer. Merely keeping such records would in itself create an incentive to improve patient care. No doubt, anonymity should be maintained about medical errors outside the hospital. But surely, the caregivers should know what went wrong and where.
The world over, research has shown that meticulous record-keeping and following of standard operating protocols bring down mortality rates and infection rates and improve outcomes. Doctors, nurses and paramedics all have to function on a zero-error basis. To help things along, healthcare tries to reduce most tasks to standard protocols.
The quality of care standards in hospitals rarely focuses on the patient or functions in the interest of the patient. From a demand side perspective, the reason for this could be that we as patients tend to associate quality with infrastructure. Commonsense says that an expensive hospital is better than one’s neighbourhood clinic.
However, health care is so dependent on human beings that price is no index of quality. Unfortunately, doctors alone cannot ensure success; institutional backing is needed. If only hospitals were to be evaluated just as much on the incidence of post-operative infections as on the reputation of the doctor, hospitals would be much safer places for all users.
From a supply side perspective, hospital managements do not invest much in observing rules and protocols. The reason is not so much the cost, but because it takes much time and there is no law or rule that mandates this. Unless a hospital is accredited by a regulator or accreditation council, insurance companies would not empanel those hospitals. But in India, there is no such legislation and insurance companies certainly will not take on such a burden of their own volition.
Accreditation and benchmarking is far less about upgrading infrastructure and more about following standard processes. Small can be beautiful in healthcare and excellent quality healthcare can be delivered in low-cost settings too. Most quality of care standards are rather basic: what is the ratio of nurses to patients in the ICU; whether the nurses deployed are actually trained in hospital care; does the operation theatre have an uninterrupted supply of power and water; are lab instruments routinely calibrated, etc.
Few patients realise that many of the instruments used by hospitals are simply not calibrated regularly. No wonder patients who go from one facility to another notice that the results reported for them vary considerably.
India needs an independent regulator to benchmark and grade hospitals. The absence of a health regulator is something that health insurers often bemoan, but like all good businessmen, everyone is waiting for someone else to take the lead. Given the absence of political consensus on this issue, state governments are definitely not interested in taking any lead in this matter. The result is that, rich or poor, it is the patient who gets the short end of the stick, regardless of any increase in budgets.
The writer is currently Secretary, Health, Government of Maharashtra. Views are personal