By Soham D Bhaduri
In the 1990s, a number of infamous clinical failures in the UK prodded system-wide rethinking for embedding a continuous pursuit for quality in healthcare delivery. Described as Clinical Governance by the UK department of health, it meant that healthcare providers will be responsible and accountable for ensuring that patients received the highest possible quality of care. For Low-Middle Income Countries (LMIC) like India, on the other hand, a continuous pursuit of healthcare expansion has often resulted in overlooking quality concerns, which are thought of as a luxury when legions of people barely have any healthcare at all within their reach.
The recent decades have seen a systematic push for UHC in India. This has led to an increasing but fragmented emphasis on improving quality of care through proclaimed quality standards (for e.g. Indian public health standards), quality certification initiatives (such as those under Ayushman Bharat Mission), pay-for-performance and quality incentives etc. However, integrated, system-wide quality improvement and accountability have been scarcely underscored in our ambitious UHC agenda. Today, dispersed between some poorly implemented legislative instruments and patchy accreditation systems, healthcare clinical governance in India remains emaciated and disjointed.
It has been found that poor quality healthcare in LMICs contributed more to treatable mortality than non-utilisation of health services, and that poor quality care had worse implications for population health in LMICs than in developed countries. Focusing on healthcare expansion with little attention to quality also entails inefficiencies in health spending due to foregone potential health gains and has significant ethical implications too.
Clinical governance should not be narrowly interpreted as patient safety. The ministry of health and family welfare (MoHFW), in 2018, published the National Patient Safety Implementation Framework (NPSIF) that laid an ambitious framework to reduce clinical risks. India’s flagship health insurance scheme, the Pradhan Mantri Jan Arogya Yojana (PMJAY), has come to embrace a number of quality certification initiatives, and the National Health Authority in 2022 published a policy document proposing a system of value-based care incentives. Though commendable, such frameworks only partly address the broad-based domain of quality improvement. Clinical governance has been described in terms of ‘seven pillars’, namely: clinical effectiveness and research, staffing and staff management, use of information, education and training, clinical audit, patient involvement and experience, and risk management.
As can be seen, it entails overarching reforms and reorientation in systems and culture, rides on effective healthcare leadership, and comprises a multi-level and multi-departmental endeavour that continually delivers and improves care quality. An example is a hospital where directorates are constituted to oversee each of the seven pillars of clinical governance, working on the one hand with clinical and paraclinical teams that implement quality principles in everyday healthcare delivery, and regional, state, and national-level quality assurance/steering committees on the other, which help frame and operationalise policies and monitor their implementation.
India’s ongoing UHC agenda rests on three important pillars: improving healthcare coverage through increasing co-opting of the private sector; leveraging technology and innovation, including health financing innovations; and embracing digital health. The time is ripe to incorporate clinical governance and quality improvement as the crucial fourth pillar. This is particularly felicitous today for two reasons.
First, there is a strong ongoing drive to lay a comprehensive health information technology architecture across the country, which forms the substratum of effective clinical governance and can permit simultaneous planning on quality indicators and deliverables. Second, the public sector appears to be leaning towards greater organisational autonomy and some dynamic reforms (such as outcome- and performance-based payments), which are essential for effective clinical governance to thrive. The expanding scope of publicly funded health insurance schemes and other public-private partnerships will help bring crucial public healthcare providers under the fold.
Obviously, implementing clinical governance cannot be expected to be a straight-out, linear, and inexpensive process, but the costs of poor quality far outstrip these considerations. The traditional cold-shouldering of diffuse and broad-based reforms in this case can mean that UHC fails to deliver on its mandate of efficient, equitable, and ethical healthcare hands down. Particularly in the Indian context of poor consumer demand and awareness, large scale co-opting of the for-profit private sector in public healthcare cannot do without the essential guard of effective clinical governance.
As broad-based as the agenda is, the logical starting point would be to strengthen and integrate the existing diffuse apparatuses for patient safety, quality assurance, accreditation, health technology assessment and other core functions under a coherent clinical governance framework. Different functions would call for different but coordinated strategic and interventional choices between policy and legislation, levels of action (the Centre vs states), and so on.
A governance framework for patient safety, such as that envisioned by the NPSIF comprising of national and state steering and quality assurance committees, can serve as a template whose ambit may be steadily expanded to include broad but effective oversight of the core functions, functioning in unison with other key departments and autonomous bodies under the MOHFW. For this, there is a need for a government white paper that undertakes an exhaustive situational analysis of the healthcare spectrum and lays down a comprehensive blueprint for clinical governance and quality improvement. Such a white paper must also cover necessary financial projections and commitments, human resource requirements, and actionable timelines for implementing the comprehensive quality improvement framework.
The author is Healthcare policy specialist and chief editor, The Indian Practitioner