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The Quality Conundrums of public health services - of NQAS and beyond!!

Prof T Sundararaman (TS) in conversation with Dr. Yogesh Jain (YJ)

YJ: We are together this afternoon to discuss an issue that both of us are very interested in, which is the quality of health care services especially in public health services. We are limiting our discussion to the Indian scenario.  So, if you permit, may I start shooting off questions that I would want you to answer as well as you know.

TS:  Yes, we should focus on the problems and challenges that public providers and health care managers encounter when they work at improving quality of care as well as some of the policy challenges in this area.

YJ: Let me start with a very generic question.  When we talk about quality of healthcare, what is it that you think of?

TS: In a broader sense, quality refers to specific attributes of a process that ensures that user-needs are met.  In the context of health policy, we understand universal access to healthcare services as universal access to quality health services. In other words, the right to health care is a right to quality healthcare. In this context the specific attributes would be:

  1. That the care that was provided was effective– viz- it provided the cure or the optimum improvement or relief from suffering or other desired outcomes. . We have lots of instances where people going to a health facility will get a consultation, receive in-patient care, or medicines, their insurance card is swiped, or payment is made. This episode will be recorded as utilization of services. But was the utilization of services “effective” in terms of outcomes? We have lots of people put on ventilators during the COVID-19 pandemic. Was that effective? Neither the provider nor the patient can be sure of the outcomes in a single case, but evaluating outcomes at an aggregate level helps in assessing effectiveness, making it a key measure of quality.
  2. Another quality attribute is acceptability. Whether the care was provided with a certain sense of dignity and respecting the rights of the patient? Was it comfortable? Was it convenient? Considerations like privacy, confidentiality, adequate and sensitive communication about risks and costs, respectable care of a pregnant woman during labor time etc. which are, not necessarily linked to effectiveness of care, but very much important in the notion of acceptability. The poor may have no options and may have to accept any care available, but that’s not what we would mean by quality care.
  1. The third dimension relates to patient safety. While this could be considered part of effectiveness, there is advantage in considering it on its own merit. We are talking about just patient safety, but sometimes also of provider safety, and facility safety because we have a concern of infection prevention and control across all users of the facility.

There is also the question of affordability, but this is not necessarily linked to quality. In popular discourse expensive care could be confused with quality care- and though good quality care has higher costs, more costly care is not necessarily of better quality. This is one of the issues/myths that would need to be addressed. Related to this is the question of efficiency. If care is of better quality for every rupee spent we are getting a better outcome.

YJ:  I get it. You list effectiveness, safety, acceptability, patient rights, convenience and better use of resources. But are the parameters and measures of quality the same across different public health services: by nature of illness: emergency situations, care for specific groups of diseases like infectious diseases or NCDs, care in pregnancy etc or by levels of care: like primary level, secondary level etc or by category of care: preventive services, rehabilitation services, diagnostics etc?

TS: The principles are the same. The actual measures to assess each of these parameters vary for different level of health facilities and services. For example, for every clinical condition, it is important to have standard treatment protocols, ensure safe medication, ensure privacy, take informed consent and so on. But how these are done in a patient with mental health problems is entirely different from a patient with, say, a fracture or a wound.  But the underlying principles are the same. So normally therefore, when we look at quality in healthcare, we break it up into areas related to clinical care and areas related to supportive and administrative functions and set standards for each area of concern.

Under clinical areas of concern, we would include:

  • Required infrastructure and its safety, including fire safety, human resources and their training, medicines, other supplies.
  • Organization of Clinical Care: different patient services and their requirements, especially treatment protocols, and all aspects of outpatient and inpatient care and referral management.  This would also include quality in the ancillary clinical services like laboratory, imaging, blood bank, etc.
  • Infection Control: Includes processes related to personal and hand hygiene, personal protection, biowaste management etc.
  • Patient Rights: patient communication, privacy, confidentiality, non-discrimination and sensitivity to gender and marginalization issues, informed consent, other ethics concerns.
  • Health Outcomes achieved: Includes treatment complications, relapse infection rates, patient satisfaction with the services etc.

Supportive services encompass procurement, inventory, supply chain management, utilities (water, electricity), sanitation, linen, dietary support, administrative assistance for patient and facility management, financial oversight, governance processes, and public involvement. Quality Management systems must set and meet standards for inputs, for processes, and for outcomes required of or the health institutions concerned.

For each type of facility- primary (Health and Wellness Centres) to secondary(Community Health Centres/Sub-divisional/District Hospitals) – and for each department within each type of facility, the standards  expressing the inputs, processes and outcomes required would be written down. Indicators/metrics to measure compliance with the standard then get specified as checklists.

These standards express quality attributes. For instance, if Clinical Services is an Area of Concern, one standard might be dealing with efficient registration, another with safe drug administration, and another with timely care. But how these standards are met varies between different healthcare settings. For example, the registration process at a district hospital differs from that at a primary care center. Similarly, the protocol for safe medication varies between an emergency ward and a chronic illness outpatient care. Timeliness, such as the duration from a patient’s arrival to treatment in an emergency, is crucial as delays can be life-threatening. So, while healthcare standards address common concerns across different diseases and care aspects, the specific methods and challenges vary.

YJ: Let me ask a pointed question, before we go to more other more general issues. Something that has been bothering us and has been in our public health discourse for the last one year is about quality of branded drugs versus generic drugs. In your opinion are generic drugs inferior in quality when compared to branded drugs?  

TS: Firstly, there is no reason why a state should allow any drug on the market, branded, branded-generic, or generic which is below an acceptable level of quality. That is simply unacceptable. Which means that there has to be a system in place to ensure quality. We are generally being told that ‘corporate mein bharosa’ (trust in the brand name of drugs made by corporates) is the best way to go because an effective system of quality assurance in not in place. But there are obvious problems to this approach. Spurious drug producers often target popular brand names rather than lesser-known companies. Research indicates that corporate-supplied drugs aren’t inherently superior; perceived quality may stem more from marketing than actual effectiveness. Governments often enforce quality protocols for bulk drug purchases, but quality assurance in the private retail market is often lacking. Ensuring the quality of all drugs is essential; otherwise, consumers cannot be certain of their efficacy or safety

YJ: Absolutely. I can cite a study which is published from South Kerala 1, which showed that when they when they measured the quality of drugs in both branded generics as well as in branded drugs, they found that there was an equal proportion of drugs that failed quality metrics. Whether it is a multinational company or an Indian drug manufacturer the effectiveness of regulation is probably the most important determinant of quality.

 But coming back to my first question, what are the key determinants of quality of healthcare in public and private healthcare services and how do they compare?

TS: In the introduction of the UHC paradigm, the problem was often posed as “people having to choose between poor quality public services and unaffordable private sector services.”  This is a false dichotomy. It implies that poor quality in public services is inherent. One reason for this perception is that the term private hospital is equated with the most well renowned hospital brand name and not with the thousands of private clinics and hospitals that provide the majority of the care. Systematic reviews at international level have shown no significant difference in quality. A recent study based on NFHS data from India2  showed that choice of private or public site of institutional delivery did not make a difference to newborn mortality and in many states, outcomes could be better in the public hospital.

Perceptions also differ due to way markets work. In private sector, branding, and advertisement of high quality are required to attract patients and increase profits. This also means an adverse risk selection and very sick patients could get referred away.  In a public sector, claims of good quality does not attract budgetary allocation.  Public financing often increases in response to a crisis rather than an achievement. Further the facility is already overcrowded, attracting patients is not a driver for improving quality.

Another major determinant of quality are the inputs- an adequate quantity and quality of infrastructure, human resources, equipment and consumables. Under-resourced infrastructure and inadequate human resources and poor supplies has been a major determinant of poor quality in public services.   In India with the coming of the NRHM, a serious effort went into creating an Indian Public Health Standards that clearly defined the desirable physical requirements of each category of facility. Though considerably improved since then, it is still a long way to go to achieve these standards.

But beyond inputs, quality is also a function of provider behaviour and the organization of care which can ensure that for every level of inputs deployed there are better quality outcomes. This plays out differently in public and private services.

YJ:   Champions of privatization like to suggest that given the problem of poor quality in public hospitals we should move the role of government to only purchasing care. But we both grew up in, in those times, like in the 70s and 80s when, if someone wanted effective care for a more complicated problem one went to the public systems. Possibly it’s still happening in many places. So would you like to explore this- would movement to more private provider- public purchase of care lead to better quality.

TS:   In popular discourse and in media perception, there is an assumption that private sector care is better quality care.  However, in healthcare services due to information asymmetry and market failure, increased profits are not necessarily aligned with increased patient welfare. Market-driven care has led to more excessive and irrational consumption of diagnostics and drugs and unnecessary procedures. This can make the private sector very inefficient in terms of “health for money”. But the greater danger is that that sort of excessive care becomes the mindset of what is equated with good healthcare quality. So, if I need a blood urea and creatinine test, and I go to a private sector, I could land up with a package of 35 tests done. Excessive use of CT scans, MRI, whole battery of tests and procedures gets equated with good care to such an extent, that even an ethical doctor is forced to bend to patient perception to keep their clientele. Perceptions of quality can therefore be so misleading.  

The average patient in a private sector hospital could get a greater time and attention and more appropriate provider behaviour than in a public hospital.  Such provider behaviour happens even in the public sector if the client is more educated and of higher status. And in both settings, power dynamics in the patient-provider relationship is such that patients can seldom interrogate the doctor in terms of what is the care provided or his choices. Exclusions and poor provider behaviour are a feature of both sectors, and unlikely to go away with purchasing care.

In public sector, there is overcrowding. If quality was the main determinant of utilization, why is it overcrowded? It is overcrowded because in these hospitals the required health care is available, affordable and effective. Now, unfortunately, availability and effectiveness of care need not go along with patient convenience. Typically, in the large public hospital, whereas the quality of the clinical advice may be more reliable since it is not driven by profit motive, and the required specialists are available, issues of patient convenience are given very slight regard. Patients will be required to stand on queue for a long time and queue maintenance and amenities would be poor. In fact, most processes that do not fall within the doctors clinical domain do not get the attention they require- and this could be true for many private hospitals as well. One reason for this is the poor recognition that non-clinical processes also need considerable professional knowledge, technique and innovation, and cannot be managed by common sense alone.

Take something as simple as keeping the toilets clean in a crowded outpatient department catering to a large number of rural patients. Disciplinary action alone will not achieve it. It requires planning the human resources and the protocols and the tools required. Or if you require clean linen sheets, getting rid of blood stains and stains of body fluids is a very different proposition from keeping sheets clean in your house. These require professional technical inputs. And that’s is why it is essential to have a quality assurance or improvement system which attends to every component of the healthcare process. It is not about motivation alone- it requires capacity building, process re-engineering, behaviour change and innovation.

This is true for both public and private sector, though the determinants of poor quality and the drivers for good quality could be different. Witness for example the frequent outbreaks of fire accidents in both public and private hospitals, or eyes lost due to blotched cataract operations or rates of post-operative infections. The emphasis should be on having externally certified quality assurance and improvement processes in place it both public and private sector.  However, in public services the need for such quality improvement systems, is urgent because the problems of overcrowding increase the complexity of assuring quality.

YJ: You have extensively visited public health facilities. Can you mention a few high-quality public health facilities which could be exemplars of what can be achieved in public services?

TS: Many primary healthcare facilities and district hospitals in Kerala and Tamil Nadu, especially those who are NQAS certified or of NABH entry level have achieved a good quality of care. Kerala in particular had the Aadram programme which systematically improved quality of care in many facilities. I have seen similar improvement even in states like Meghalaya ( the  Ganesh Das district hospital in Meghalaya which is in Ri Bhoi district) and in states like Odisha, Chhattisgarh, Maharashtra, Himachal Pradesh. In fact,most states have a few NQAS certified district hospitals that they show-case. In a relative sense, there are now good quality district hospitals and PHCs even in states like Bihar which at the onset of NRHM were mostly dilapidated.

If we are looking only at effectiveness of care, the big public health hospitals, AIIMS, PGI Chandigarh, JIPMER, NIMHANS, Tata Memorial Cancer Hospital (which is often presented as a private hospital), which it is not), the Armed Forces Medical College Hospitals and leading super-speciality hospitals in many states like the Omandarur super speciality hospital in Tamil Nadu are known for providing the highest quality of care. However, when it comes to patient experience in terms of convenience many of these would not qualify, not only because of the over-crowding, but also because patient centred quality of care systems are still required to be put in place.

YJ: Let us discuss the evolution of quality assurance systems in public health services.  Prior to NRHM, partly in response to quality assurance component of the Reproductive and Child Health Programme and partly in response to the Supreme Court Ruling in the Ramakant Rai vs Union of India case, the main form of quality assurance was the setting up of quality assurance committees for female sterilization procedures, for the RCH programme and for immunization. Then with the coming of National Rural Health Mission the Indian Public Health Standards (IPHS) Guidelines were launched in 2007 and this laid down the requirements or standards for District Hospitals, Community Health Centres, Primary Health centres and Sub Centres. The standards related to the physical infrastructure, human resources, equipment, drugs, etc.

Then at the initiative of the National Health Systems Resource Centre which set up the ministry’s first quality assurance division, pioneering work began on evolving Total Quality Management Systems.  Initially it was decided to leverage flexibility of ISO 9001 Quality Management System (QMS).  Public Health Facilities were audited against six mandatory requirement of ISO 9001 System and 24 hospital specific procedures. In 2008, pilot project was started in 8 Empowered action group (EAG) states for implementation of Quality Management System using ISO 9001 standards with quality management consultancy firms providing technical support.  Few   good performing states such as Kerala, came out with their own standards. A few states undertook NABH (National Accreditation Board for Hospital & Health Care Providers) Accreditation.

Given the wide variations in standards adopted using the ISO approach, and the difficulty of scaling up based on NABH the Ministry, supported by the NHSRC and in consultation with all stakeholders the Ministry of Health and Family Welfare developed its own National Quality Assurance Systems (NQAS) meant exclusively for public health facilities. In 2013, the first operational guidelines and assessor guidebooks3 for this was released and was later updated in 20214.

What is the current state of this programme?

TS: The process of arriving at NQAS took a decade of learning and adaptation, and for it to become mainstream and accepted for scaling up as the main approach took at least another 5 years.

However implementation has been slow. As of January 2024, a total of 2954 healthcare facilities are NQAS certified and many more are in the process. As a proportion of total facilities it represent 161/ out of 740+ district hospitals, 91 out of 1130 sub-divisional hospitals and 229 of 5624 CHCs, 1416 out of 25,743 PHCs, 387 urban PHCs and 695 out of 158,417 sub-centres. Progress across states is also skewed with about half the certified facilities coming from just the five southern states 5

In 2015, for addressing the priority issue of cleanliness, infection control, biomedical waste management and environmental sanitation the “‘Kayakalp Award Scheme’ was launched and as of now over 12,603 facilities have been certified under this.

Another priority was LaQshya, the Labour Room Quality Improvement Initiative was initiated in 2017 and under these 540 centres have been certified.  Its focus is to reduce preventable maternal & new-born mortality, morbidity, & complications. Ensuring Respectful Maternal Care (RMC), is a critical element under LaQshya. For newborn care the Musquan scheme was launched and under these 360 facilities are accredited.

Though progress has been slow, the acceptance of both the Indian Public Health Standards (IPHS) and Quality Management System (QMS) in the form of National Quality Assurance System (NQAS) as essential requirements of public health services is a significant achievement. It took time to learn that quality assurance needs to move beyond a check-list based monitoring approach with discipline and punish as the main form of enforcing quality to a comprehensive QMS. It also took time to understand that market-based accreditation like NABH were difficult to implement and the department needed its own standards and systems. In terms of scale the roll out is still too small to make an impact across the country. But where it is in place, it does make a difference.

YJ: We have both described this historical evolution.  But frankly at the operational level NQAS is also just another set of checklists. More elaborate and including patient satisfaction surveys- but still a check-list. Reports are that facility managers game the system and the focus is only on the act of certification. Once this is achieved it becomes forgotten. Also, private healthcare facilities do not opt for NQAS- they prefer the industry standards – NABH or JCI. So before going to the issues of scaling up, does NQAS accreditation really help with quality assurance?

TS: An important clarification. NQAS is currently not available for the private sector. It is not even on offer. There is a case for making it available, but the ministry is hardly able to cater to even public sector requirements. I agree that there is a major danger of NQAS being reduced to showing compliance to a checklist just at the time of the audit. That’s a distortion when NQAS is used, primarily as a governance or monitoring tool with discipline and reward as the basic motivators.

Checklists only remind you of all the different standards. The facility has to map performance in each standard and work out why these are not being met, and then plan how to meet them. Someone must be assigned as process owner and accountable for it. And they must be trained to implement the re-designed process and take pride in getting it right. And both the desired process and adherence to it should be documented so that there is clarity, and surprise checks are not required. There are myriads of important processes and if these processes are followed, we can see where quality requirements are not being met and make corrections. Corrections may require training or technical innovation or assignment of responsibility and accountability or governance measures. Ask any airlines: even a simple problem like managing the queue requires considerable thinking and study. So, it is not just an auditor and fulfilling the checklist.  For instance a recent publication related to LaQshya initiative highlights the importance of overcoming governance barriers to improve the ability of the program in assessing quality improvements 6. Capacity building and innovation and behaviour change interventions are also often required.

 We had this as the problem  at the ISO phase itself.  Common sense and motivation help, but is far from sufficient. What we recognized was that change management required hand-holding. it required a supporting technical agency with experience in quality management and hospital administration. Discovering the gaps and remedies for each process for yourself is wasteful. Then and now there is a great degree of reluctance to sanction the management support that is required to make this transition. And without this support  NQAS certification can get trivialized to actually somehow getting the auditor convinced on a given day.

To speed up quality accreditation, government has introduced modest monetary incentives for hospitals that achieve certification. While such recognition is welcome, there is a danger that this monetary incentive could act perversely to give importance only to the act of getting the certificate, rather than a sustained change in the way of providing care.. Certification of NQAS achievement should mean that the hospital has now in place a mechanism and the habit of constantly learning and adapting and improving on its quality of performance.

The ministry is perhaps aware of it and has assigned this support to technical agencies supported by development partners- but this is an ad hoc solution and many of these agencies have really no experience or recognition of this. It is just a bureaucratic requirement they have to fulfil to be allowed to do whatever is their main objective.

NQAS certification is not a bureaucratic obligation. For it to work in the public services it must be perceived as an essential tool for ensuring human rights and health rights. It is about ensuring that the care they receive is effective, that it is gender sensitive, that is child friendly, that is friendly to handicapped and marginalised persons. It is about making care patient centred. About ensuring privacy and confidentiality. Every aspect of quality is a human rights issue and the management support must somewhere be inspired that in the public hospital they are actually securing the rights of patients. And without the spirit of why quality is required, it has little chance of succeeding.  If we are to universalize NQAS and maintain the spirit of the enterprise then one must build institutional mechanisms that can deliver this. Our contention is that a reliance on monetary incentives and patient choice will not be able to deliver this. However patient voice is important-but not as individuals polled through a satisfaction survey. More as a process of community engagement.

In this understanding every public health facility should already be a party to the NQAS process, and we should not measure it only by their achieving the full certification. The readiness for Certification may vary, but the process is there before and after.

YJ: I hear you loud and clear.  But this is a tough area. Quality is actually a culture issue.  We are now getting into the soft areas of health systems. How do we go about ensuring this culture, which can sustain and which can grow further?

TS: So, you touch a good point. We’ve seen these soft problems in achieving community engagement also.  Leaving it to the administrative process even with technical support is not enough. For community engagement we required civil society participants who have a sense of the spirit of the enterprise, who understand the values that are associated with community processes.  The equivalent for quality assurance is quality circles. In addition to the development of the standards, the management support, the training, and the audits,  it is useful to encourage quality circles where professionals in each domain who are professionally interested in quality form a peer support group providing encouragement and acting as role models. For example, outcomes for heart attacks in terms of mortality and in terms of long-term complication can be widely different across different ICUs. The health outcomes of special newborn care units can be very different. In quality circles professionals discuss the problems they are facing and they see it as a professional issue. There is a peer review and sharing and there are motivated people in the quality circles who are who are able to communicate it as part of good professionalism and as part of creating a culture. This requires involvement of professional associations, hospital administrators associations and quality professionals.

Will rewards help? To some extent, but it is limited by the fact that it does not reach out to those who are not already good performers and within the culture. In some countries and even in states like Tamil Nadu visits by senior respected professionals of medical colleges inspire their former students working in the public hospital to aspire for better quality of care.

Another important support mechanisms is community engagement. One useful step in that direction is the public display of a patients’ rights charter, a measure that civil society organizations and National Human Rights Commission has been promoting.  By itself it will have limited impact. The participation of members of local self-governments and well-chosen representatives of the public in the hospital development committees can however make a big difference. These committees should be geared to local problem solving and voicing issues that affect people’s satisfaction with the services and meet their requirements. In other words, people-centred, responsive services. In many states (like Kerala and Odisha) training/ orienting such representatives on quality management systems along with hospital administrators have yielded very good results

YJ: But there is this deadline that is given to most hospitals to achieve quality assurance certification? Is that a good thing?  How does one scale up, without losing the spirit of the QA process?

TS:  One important element of any scaling up is getting the unit of scaling up right, and documenting the principles and objectives and processes clearly. And building a core team to lead this. All this has been done and NHSRC does have the conceptual clarity. This is seen in their publications.

 For scaling up, deadlines for achievement are required. But the emphasis should be on recruiting all facilities into the process of quality improvement rather than enforcing a deadline by which quality achievement is certified. Time should be the variable, not the level of quality achieved. For example, in health and wellness centres, the process of certifying quality could certify each service included in the package whenever they are ready for it,  instead of an all or none approach where all services have to be certified at one go, makes sense, since the baseline readiness is so varied. So too for department wise achievements. While progress requires to be insisted upon, achievement of quality has also differing objective barriers in different contexts- and one should allow for this.

Then there is a need to invest and develop separate institutions at the state level- one for management support and another for external audit and certification. While there has been a welcome build up in capacity to audit and certify, it needs much more scaling up to meet the requirements. On management support the lack of capacity is even more serious.

And finally, we need to establish state and district level quality circles for professional oversight and measures of community oversight.

All of this takes time and effort, but these are essential requirements. I also note that a lot of effort is going into digitizing quality metrics. I am not sure whether they are helping or adding an additional layer of work disproportionate to the use of information. While digitization will help, projecting it is as the game changer could be misleading.

YJ: Let me switch gears and ask you about the private sector. What are the challenges of accreditation in the in the in the private sector? When you answer this can you also answer what are the what are your answer your impressions about the differences between NABH and NQAS. How do these systems compare?

T.S. Given the considerable effort that is required for ensuring quality on scale, governments often toy with the idea of going for NABH instead. But this has seldom worked. NABH has its own problems.

I am not sure about the current situation with NABH. But when NQAS was being set up, NABH had three problems- their standards were not transparent and there was considerable subjectivity in assessment; entry level standards were not established; and management support agencies had to be contracted through them which for an accreditation agency is a conflict of interest. Today, the NQAS is accredited with ISQua the international agency for quality accreditation, but NABH is not. Therefore, for medical tourism needs, private sector still goes for Joint Commission International (JCI) and other accreditation mechanisms are required. My information may be outdated- and NABH may have addressed these issues. But this was the considerations for which the ministry set up its own quality process. However, when it comes to government engagement with quality in the private sector even today, NABH is the only option available.

The drivers and determinants of quality are different between public and private sector. Whereas in public sector it calls for administrative action, in private sector it requires regulatory action. In public sector the consequences of failed certification can lead to immediate and appropriate administrative action to close the gap. In private sector an agency separated from the process of certification must deliberate on the action required- relaxation in standards, warnings, or support or closure etc, based on context. In a remote area where you are not going to get a radiologist on a site, managing by tele consultations could be permitted which would not apply to the city. Care must be exercised that the regulatory mechanisms do not, in the name of quality, push out affordable,  acceptable and accessible care in remote areas and for under-serviced communities.

For these reasons, it is a bad idea for the same regulatory mechanisms to cover both public and private sector and for the process of certification to be linked to the process of appropriate administrative or regulatory action that follows certification..

YJ: We often see that NABH is being used to sort of, as part of branding for advertisement and marketing.  Do you think that the NABH standards are more stringent and harder than NQAS.

TS: They are not so different. In fact, the NQAS standards are tougher on patients’ rights issues. NQAS has standards related to social exclusion, it has standards related to, the priorities of women and children. Standards are also more appropriate. For example, air conditioning of operation theatres is not essential in many settings and should not be insisted on. The standards on infrastructure are required but should be appropriate and not over-emphasized

YJ: How has the situation in improving quality in private sector changed with the coming in of National Health Authority and PM-JAY?

TS: Those who argued for insurance have always posed it as the better option because it allows patients to choose better quality services. This clearly was not happening. Now the argument is that the purchaser ( viz. government/insurance agency ) must build in monetary incentives so that private hospitals are encouraged and rewarded to provide better quality services. Hospitals were graded for quality and for urban locations and provided a higher benefit package if they were quality certified by NABH. Then facing the limitations of NABH, the PM-JAY has introduced its own quality grades. It is not clear that this has helped improve quality, but it is nearer the expectations of  monetary reimbursement of the larger more successful hospitals. Many schemes for quality incentives, de facto become schemes by which the expectations of higher requirements from the corporate sector can be met. While corporate multi-speciality hospitals benefit from these higher pay-outs, their usual rates are still higher and it is not sure whether problems of cherry picking, supply side determined care, double billing and exclusions which are the bane of private sector participation in PM-JAY will be overcome by these higher payouts.

However, independent of the PM-JAY there is a big trend to improve quality and achieve quality accreditation in the private sector. Both professional and business motives drive this trend and to the extent that it does not drive out smaller more affordable and ethical players, this is a welcome trend.

Which reiterates our central point- that quality accreditation is a great tool to help a willing professional to ensure better quality care and ensure patient rights. But it is a poor tool of governance, monitoring or incentivisation if the intent to achieve quality is not internalized by the provider.

YJ: Before we close what would be the experience with specific quality assurance systems like Kayakalp, LaQshya and Muskan. And what about the state directed schemes. 

TS: Kayakalp is interesting. It is an disaggregation of NQAS standards related to cleanliness. Thanks to a much greater awareness of the issue, cleanliness was identified as a government priority and that aspect was selected for a rapid scale up.  About 12,000 hospitals are Kayakalp certified which is good- but it needs to be much better.

LaQshya deals with the labour room quality- and again this was identified as a government priority for scaling up earlier. However only some 550 labour rooms are quality certified. And when it comes to MusQan the quality certification for newborn and child care, only 360 are certified. The old problem of the difficulty of achieving quality in only one department of the hospital, when the rest of the hospital is not under a quality assurance scheme is re-asserting itself. It is not clear why the achievements on these are even less than the achievements on NQAS. Should not have NQAS certification made the others redundant.

When it comes to state quality assurance schemes, a few were proposed, but none took off. It takes time to establish, and stabilise standards and this is a dynamic process. States are possibly better advised not to push for their own standards- but rather choose benchmarks for each of the NQAS standards which are more appropriate to their needs and combine this with state level support and certification institutions that can help them accelerate towards universal quality.

YJ: What is the government policy if there is one, on universalizing, quality. Or if not, then what are you suggesting?

TS:  The National Health Policy 2017 clearly articulates: “Public hospitals have to be viewed as part of tax financed single payer health care system, where the care is pre-paid and cost efficient. This outlook implies that quality of care would be imperative and the public hospitals and facilities would undergo periodic measurements and certification of level of quality…. The policy seeks to eliminate the risks of inappropriate treatment by maintaining adequate standards of diagnosis and treatment.” This clarity makes quality improvement and certification an obligation. But it left the question of how to achieve it quite open.

 But on the ground, the perceptions around public sector changes more slowly. The culture is that “if you want all this quality, you should go to the private sector. The public sector is only “residual care.”. It is meant only for the poor who have no where else to go.”  Such a culture, acts as a barrier to giving quality of care the importance and investment it needs. If on the other hand the public services are seen as the main vehicle for financially protected services for the entire population, then quality becomes a central concern. For private sector quality accreditation is a branding and marketing strategy. But in public sector it is required to ensure health rights. Its trivialization into a branding strategy is a terrible waste.

There is a need to make government policy with regards to quality of care in public services much more explicit with details of the institutional and financing framework that would be required to achieve this. And the principles and values that drive the quest for quality.

YJ: Okay. Let me wind up with a final question.  Would you mention the 3 or 4 points that you would list as the most important to improve quality of public health services? Or is that a difficult one?

TS: It is always, to summarize in that form. But let me try. First, I think the important thing is to really strengthen the conceptual understanding of NQAS by making sure that while all facilities enter the process of getting NQAS, there is no pressure to get certified before the requirements are established. Also to ensure that for public services quality accreditation must not be trivialized into a branding exercise. It is not even a good governance or monitoring tool and weakly influenced by incentives.  It builds motivation and is most effective where motivated providers use NQAS as a tool to ensure the fulfilment of health rights- in terms of effective care, safe care and respect to patient rights.

Second, it is difficult for facilities to change without external support. It is necessary to provide a system of support both, professional voluntary support in the form of quality circles and management support in the form of consultancies or quality professionals to actually help them make the transition and the technical inputs which are required on that. Hospital administration is complex and must be professionalized. Learning and adaptation should become institutionalized.

Thirdly- there must be state level governance institutions that will use the standards of NQAS but establish their own benchmarks, ensure regular external audits, ensure timely certification and timely renewal of certification and fulfil other such governance requirements.

And last but not the least, there is a need to engage communities in the process of, quality improvement, and create in them a sense of ownership and pride in quality improvement. There are many things like patient amenities, child care facilities, physical access to the hospitals which a community can do to improve the quality of care. This requires local self-governments and public associations to engage in this quality process.

YJ: Alright, I think, all this is so well said and summarized. But we as who speak up for public systems, we should not forget nor we don’t stop interrogating our own public systems for their limitations and deficiencies.  And in fact, the entire effort to discuss about quality of public systems was meant to acknowledge the lack of quality and find solutions to improve that.


  1. K L Sharma. Healing the Pharmacy of the World (pg 98) Accessed May 7, 2024.
  2. Dixit P, Sundararaman T, Halli S. Is the quality of public health facilities always worse compared to private health facilities: Association between birthplace on neonatal deaths in the Indian states. PLOS ONE. 2023;18(12):e0296057. doi:10.1371/journal.pone.0296057
  3. Operational_Guidelines_on_Quality_Assurance_in_Public_Health_Facilities_2013.pdf.
  4. National Health Systems Resource Centre, Ministry of Health and Family Welfare. Operational Guidelines for Improving Quality of Care in Health Facilities 2021 |. Accessed August 3, 2023.
  5. National Level Certification | National Health Systems Resource Centre. Accessed May 7, 2024.
  6. Singh S, Hasan Z, Sharma D, et al. Appraising LaQshya’s potential in measuring quality of care for mothers and newborns: a comprehensive review of India’s Labor Room Quality Improvement Initiative. BMC Pregnancy and Childbirth. 2024;24(1):239. doi:10.1186/s12884-024-06450-x

Note : This article is posted at the website For more background resources on this issue you could visit conversation Health Policy in the same website.

Acknowledgements: My thanks to Ms Roubitha David, research scholar in health policy based currently in Chennai for her assistance in recording and transcription of the conversation and to Dr. Shalini Singh, public health researcher based in Bengaluru for her help with peer review, editing and referencing

Comments (1)

Vaishnav sundari

Bahut hi achhi tarah s Nqas ek ek points pr bariki se dekh kr jab score krti h islia m y vinati karna chahungi ki y assessment all facilities pr comparsary ho jay ,jisase har ek ko nqas ka mean bhi pata lag aur unk benifit bhi thank you regards vaishnav sundari, Senior nursing officer Phc panasichhoti block partapur chc dist Banswara Rajasthan 327001

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