Quality healthcare in private and public institutions.

We have proposed a framework for assessment of healthcare quality consisting of achievement of health attainment goal (technical quality) and responsiveness (interpersonal quality). Both technical quality and responsiveness ought to be measured using structure, process and outcome criteria. Unfortunately the quality of healthcare assessment subsystem is yet to develop in India. There is hardly any licensing requirement for health care institutions in India. Health care accreditation systems are yet to develop. India is yet to develop any national program for development of practice guidelines, medical review criteria, etc. Research capacity for measurement of medical outcomes and risk rating of patients is yet to develop in the country. Most quality of care related information in the country is about the interpersonal aspects of care. Without the integrated framework for assessment of health care quality, one may assume the information on interpersonal aspects of care to be the whole information on quality. So the important policy recommendation emerges even without looking at the available information on interpersonal quality of care. That is the need for systematic development of a quality of health care assessment infrastructure in the country.

Available evidence from the US suggests there is no clear difference in quality of healthcare delivered by forprofit, nonprofit or public HCIs. Note, however, that the healthcare quality assurance infrastructure is well developed in the US. Studies in India suggest that technical quality of care may be slightly better in public sector HCIs and interpersonal quality, may be slightly better in private sector. But the more important finding from Indian studies is the poorly developed healthcare quality practices both in private and public sector.

Only some rudimentary information on infrastructure, and process of care could be collected in this study. Approximate data on premises collected by this study showed that public sector HCIs are generally better endowed with land and floor space. Comparatively more number of public HCIs, particularly the PHCs and small hospitals reported that they use written medical protocols and therapeutic guidelines. More than 90% public HCIs reported that they maintain medical records, compared to only 65% in case of private HCIs. Comparison of the availability of auxiliary services in private and public HCIs gives a mixed picture. More public HCIs (85%) provided pharmacy services compared to private HCIs (42%). Prevalence of 24 hour emergency services was similar (about 40%) among private and public HCIs. Prevalence of telephone facility was much more among the private HCIs (88%) compared to public HCIs (29%). Results from the patient exit interview showed that the level of patient satisfaction was generally low in both private and public HCIs. Overall level of patient satisfaction was similar in the private and public sector HCIs. However, the private HCIs received better scores on access, availability and convenience, communication and general comfort. On the other hand, the public HCIs received better scores on the technical skill and interpersonal sub scales. The private HCIs received significantly more number of "very good" and "excellent" ratings on (a) manner of physician, (b) technical skill of physician, (c) getting an appointment, (d) convenient location. Most of these are on interpersonal aspects of care. The limited data available from this study suggests that the interpersonal quality of care in private HCIs is comparatively better than that in public HCIs, which tend to show slightly better ratings about infrastructure, and technical aspects of care. Most importantly the level of patient satisfaction was generally low in both private and public HCIs, suggesting an environment of poor client orientation in the health sector.