Opinion India has made great strides in healthcare, challenge now is to improve service quality

We assembled the most comprehensive body of research, including a survey of 50,000 households assessing people’s experiences of, expectations from, and preferences for the health system, as well as a large body of secondary data, both from government and other research groups. What did this research tell us?

In a nutshell, India has made remarkable progress over the past two decades in its mission to realise universal health coverage. There is cross-party consensus on the crucial role of the government, as a financier, provider and steward of the health system. The health sector, probably the largest state-run healthcare operation in the world, stretches from over a million community-based health workers across a continuum of facilities with capabilities to address ever-increasing levels of complexity of health problems all the way to sophisticated tertiary hospitals.

The country is the world’s nursery for human resources for healthcare, churning out thousands of doctors and nurses each year. The pharmaceutical industry is producing medicines and vaccines not only for most of the country’s needs, but also for other countries. People seem to have no difficulty accessing healthcare, from both the public and private sectors, and although out-of-pocket expenditure as a share of total health expenditure remains amongst the highest in the world, there appears to be a decline in recent years.

The single greatest challenge, then, is not the availability of doctors, drugs or facilities: It is the poor quality of various components of the health system, starting from the training of healthcare providers to the production of pharmaceuticals and, ultimately, care received by patients. Estimates presented in the Economic Survey of 2021 suggested that, in 2018, about 1.6 million deaths in India were attributable to poor quality of care. Incredibly, more people died because of poor quality healthcare than because they were unable to access healthcare.

One example of how poor quality of care contributes to mortality is the observation that while there has been impressive improvement in healthcare utilisation for antenatal care, low adherence to evidence-based guidelines — such as childbirth protocols — and unavailability of emergency obstetric and neonatal care have emerged as leading causes of maternal and neonatal mortality.

Multiple studies report serious deficiencies in provider competence, with public and private sector providers often making wrong diagnoses and giving incorrect or unnecessary treatments and diagnostic tests. The widespread irrational prescription of medications and diagnostics not only contributes to an astonishing two-thirds share of total out-of-pocket expenditure, but also leads to worse health outcomes for the patient. Such irrational use of medications is also fuelling resistance to antibiotics.

The uneven quality of primary care is a major reason why most patients skip this level of care for even the mildest health problems, crowding the corridors of higher-level hospitals or simply opting out of the public system. Quality of care is worse for persons from disadvantaged social groups and for people living in rural or poorer communities.

It is perhaps not surprising that, given the historical gaps in healthcare, successive governments have focused on addressing the supply of healthcare goods, from doctors and nurses to medicines and clinics, and generating demand for healthcare. In this respect, what we see in the health system is reminiscent of many other sectors in India, such as road transportation (more kilometres of roads but many are of terrible quality, leading to road traffic accidents) or education (universal enrolment in primary schools but many children are learning well below their expected goals). However, just as with those sectors, the Commission demonstrates that supply or demand are no longer the primary challenge: The focus must now shift to the quality of those goods.

To do this, we need a transformation in the culture of the health system, expanding our narrow focus on targets to ensure that what we deliver is of the highest quality, both in terms of science and the experience of the patient. At the heart of this change is a commitment to accountability and integrity by all actors in the health system.

In practical terms, such a culture change would need to permeate to every corner of the health system, beginning with the training of healthcare providers and ensuring high-quality primary care for every citizen. Additionally, we recommend implementing major reforms of the financing of healthcare and the governance of the health system, remaining steadfast against the inevitable pushback from vested interests who will resist any efforts which threaten their bottom line.

State, district, and local government institutions must be empowered to design and implement responsive reforms and to be accountable to the communities they serve. Informing citizens of their entitlements and on the performance of their healthcare providers is the practical realisation of citizen-centred healthcare. The Commission recognises the unique role of technologies, such as data-driven monitoring of the use of antibiotics or providing digital information to communities about the services in their primary care facility, to catalyse governance.

Finally, the Commission calls for a learning health system, one that continuously learns from and shares health system data, collaborates in learning networks with other health systems in the country and constantly strives to improve its performance.

The English surgeon Thomas Wakley, the founding publisher of the Lancet, was motivated to use the journal to address “the corruption, nepotism, and incompetence in London’s medical establishment”. The Commission reminds us that some of these issues are just as relevant today in modern India.

The writer, Paul Farmer Professor at Harvard Medical School, is a co-chair of Lancet Commission on India