T HE L ANDSCAPE OF Q UALITY OF C ARE IN I NDIA D R. S UNEETA S INGH M S. A NJALI K RISHAN M S. K RITI K AUSHAL

THE LANDSCAPE OF QUALITY OF CARE IN INDIADR. SUNEETA SINGH

MS. ANJALI KRISHAN MS. KRITI KAUSHAL

Who practices QoC in IndiaWhat they measure and

don’t

OUTLINE

Purpose of the Study

Identify and describe innovative efforts to measure QoC in the Indian RMNCH+A context

QoC Frameworks Findings Summation

QOC in the Indian context

What tools are used

QOC FRAMEWORKS

WHAT IS QOC?

Effectiveness

Efficiency

Equity

Patient Centeredness

Safety

Donabedian

Bruce - Jain

Maxwell

UK-Dept. of Health

Council of Europe

WHO

Institute of Medicine

JCANO

Systems Framework

Frameworks Consulted

Health Outcomes Efficacy Technical Competence

Supporting Services

Follow Up/ Continuity

Access Availability Choice

Respect Information Satisfaction Acceptability

Safety

Identified 5 Characteristics

Cost Timeliness Avoidance of Waste

QOC IN THE INDIAN CONTEXT

Health Outcomes Efficacy Technical Competence

Supporting Services


Access Availability Choice

Respect Information Satisfaction Acceptability

Safety


Functional Infrastructure

Utilization

Effectiveness

Efficiency

Equity


Safety

TOPLINE FINDINGS

WHO IMPLEMENTS QOC IN INDIA?

Supply SideDemand Side

Supply and Demand Side

Only 5 out of 32 projects work on the demand side

PublicPrivate

Public Private Partnership 2

20 out of 32 projects are public sector projects. Only 2 are PPPs.

Simple

Complex

23 of the 32 projects are relatively simple projects

Mostly Supply Side Mostly Public Sector Relatively simple projects

WHAT DO THEY MEASURE IN QOC?

Demand side projects focus on measuring patient

centeredness of their interventions

Supply side projects measure characteristics of efficiency and equity.

Interventions that measure equity tend to be public ones

PPPs and private sector are more focused on measuring characteristics of efficiency and patient centeredness.

Simple projects are more likely to measure efficiency than complex projects.

Complex programs tend to measure more characteristics of effectiveness and equity

Demand and Supply Side Public, Private and PPP Project Complexity

Patient centeredness & efficiency arerarely measured in the same

project

Private sector interventionsare not measuring equity

Complex programs are morecomprehensive in QoC

measurement

All projects measure effectiveness Only 1 of 32 projects measures safety

Average Number of Characteristics measured# of projects Effectiveness Efficiency Equity Patient Centeredness Safety

Demand Side 5 2 0 0 2 0

Supply Side 18 2 1 1 0 0

Demand & Supply Side 9 2 0 0 2 0Average Across interventions 2 0 1 1 0

Most QOC projects function on the supply side. About a quarter are both supply and demand interventions. Only 16% or 5 out of 32 projects purely work on the demand side.

While demand side projects focus heavily on measuring patient centeredness of their interventions, supply side projects measure efficiency and equity characteristics. You have to be supply side to consider measuring efficiency.

There is no discernable difference in measurement for characteristics of effectiveness and safety across demand and supply-side programs.

Patient centeredness and Efficiency never seem to be measured in the same project

DEMAND AND SUPPLY SIDE X QOC CHARACTERISTICS

Average Number of Characteristics measuredTotal # of programs Effectiveness Efficiency Equity

Patient Centeredness Safety

PPP 2 3 1 1 2 0

Private 10 2 1 0 2 0

Public 20 2 0 1 1 0

Average across interventions 32 2 0 1 1 0

Almost 70% of the projects have an explicit aim to improve health outcomes for marginalized populations, but only 50% of all interventions measure characteristics of equity.

Interventions that measure equity tend to be public ones, and on an average measure one characteristic of equity. Private are not measuring equity.

Public-private partnerships and private sector organizations are more focused on measuring characteristics of efficiency and patient centeredness.

PUBLIC AND PRIVATE XQOC CHARACTERISTICS

WHAT QOC PARAMETERS ARE NOT BEING USED?

Effectiveness

28

0

17

10

5

13Efficiency

8

62

Health Outcomes

Cost

Equity

6

4

1

7


5

11

8

9

Safety

1

Efficacy

Technical Competence

Supporting Services



Access

Availability

Choice

TimelinessAvoidance of Waste

Utilization

Respect

Information

Satisfaction

Acceptability

Safety

WHAT TOOLS ARE USED TO MEASURE QOC?

Most QoC measurement tools are quantitative.

Impact Assessment Studies are used to capture health outcomes.

Observation Studies and Behavior Surveillance are used to measure technical competence.

Satisfaction Surveys and Community Monitoring are used to capture Patient Centeredness.

Audits and Community Monitoring are used to capture infrastructure.

There are few attempts to measure safety and avoidance of waste.

There are no examples of measurement of the efficacy of medical treatment.

SUMMATION

32 PROJECTS PROFILED

Mobile Monitor for Quality of Maternal Care* Project Ujjwal* Safe Childbirth Checklist in Rajasthan* Sitaram Bhartia Institute of Science and

Research* Tamil Nadu Health Additional Financing* USAID ASSIST Project - India* Adolescent Girls Anemia Control Programme Ekjut Ensuring Reproductive Rights of Women Home Based New-born Care Plus Improving Healthy Behavior Project Improving Maternal Health and Strengthening

Midwifery in India Increasing Access to Comprehensive Abortion

Care in the Public Health System Indian Healthcare Project ITC e-Choupal Health Initiative

Karnataka Beneficiary Verification System Lifespring Hospital Pvt. Ltd. Making It Happen- EMONC Capacity Building

Program Merrygold Health Network Mobile Money Transfer for ASHA Mother NGOs MP Health Sector Reform Project Odisha Health Sector & Nutrition Plan Pre-service Education for nurses and midwives Project Bachpan Quality Standards Manual Pilot in Kerala Rachna Project Repositioning Family Planning in PHCs Revitalize and scale up PPFP/ PPIUCD services Sick Newborn Care Units Plus SWASTH Vaatsalya Hospitals

* In-depth Case Study

QOC PARAMETERS ARE USED TO

Access

Availability

Choice

Health Outcomes

Utilization

Technical Competence


Cost Timeliness

RespectInformationSatisfaction

Acceptability

Supporting services

Follow Up

Avoidance of Waste

Safety

Measure for QoC

Measure QoC

Patients and medical staff understanding of QOC does not match.

There is a scarcity of skilled medical professionals.

The lack of supporting infrastructure curtails QOC.

Creating an atmosphere for QoC is difficult.

BARRIERS TO QOC IMPROVEMENT ARE

In RMNCH+A alone, there are over 32

projects working within QoC.

Programs have adapted the characteristics of QoC measurement to

suit the Indian context.

While all other QoC characteristics are often

measured, safety is neglected.

Projects need to consciously measure QoC

through MLE.

The nature of the intervention determines the nature of the QoC.

FINALLY

THANK YOU

ADDITIONAL INFORMATION

PRIVATE VS. PUBLICPRIVATE :: PROJECT UJJWAL

PUBLIC :: TAMIL NADU HEALTH SYSTEMS PROGRAM

Efficacy Technical Competence

Follow Up Functional Infrastructure


Access Availability Choice Utilization Respect Information Satisfaction Acceptability SafetySupporting services

Effectiveness Efficiency Equity Patient Centeredness Safety


Follow Up Cost Timeliness Avoidance of Waste




SUPPLY VS. DEMANDDEMAND SIDE :: MOBILE MONITOR FOR QUALITY OF MATERNAL CARE

Health Outcomes





SUPPLY SIDE :: USAID ASSIST PROJECT

Health Outcomes







ANNEXURE 1 :: ABOUT AMALTAS

QOC TEAM MEMBERS

Dr. Suneeta Singh

Lead Researcher

A public health expert with over 30 years of work

experience spanning across multiple domains, she is the

Chief Executive Officer of Amaltas.

Ms. Anjali Krishan

Senior Researcher

A specialist in research and evaluation, she is a key

member of the Amaltas team and has been a senior

researcher for several large projects.

Ms. Kriti Kaushal

Researcher

An international development professional, she is a

researcher on multiple evaluation and research

projects.

OUR MISSION

Amaltas is a research and consulting firm in the development sector. It was set up as an effort to develop intellectual capital and innovative approaches for development in the global South.

The mission of Amaltas is to work in the development sector to provide high quality research and consulting services directed to accelerate improvements in the lives of people.

Monitoring & Evaluation

M&E of ADB funded Rural Water Supply and Sanitation project, Cambodia

Research

Governance and Social Determinants of persisting poor Child Health in India

Analytical reviews

Mapping of Institutions, Researchers and Funders: Sustainable Cities and Rapid Urbanisation

Policy Advice

World Bank Mission for a Health Sector Support Program II in Cambodia

Documentation support

‘State of the Girl Child report 2009’ for Plan India

Proposal Development

India’s application to GAVI for Health Systems Strengthening

Transaction advisory

Development of strategy/models for PPP in diagnostic services for the GoUP

OUR SCOPE OF WORK

The World Bank, BMGF, IDRC, UN agencies, WHO, USAID

etc. are among our 27 clients.

Since it began work in 2008, the organization has

completed over 40 projects.

Amaltas is an organization born and located in India. We have worked widely with international clients and delivered to the standards demanded for international work.

OUR FOOTPRINT

Scoping exercises

Innovative Qualitative research including formative research

Quantitative research studies

Monitoring systems development

Bibliometric analysis

Evaluation across a number of domains

OUR EXPERTISE

Documents

T HE L ANDSCAPE OF Q UALITY OF C ARE IN I NDIA D R. S UNEETA S INGH M S. A NJALI K RISHAN M S. K RITI K AUSHAL