35 Health care delivery in the public and private sector

Dr. SAA Latheef

epgp books

 

Table of contents

 

1. Learning outcomes

2. Definition and Scope

3. Models of health care systems

4. Evolution of health care system in India

5. Health care system in India 

6. Components of healthcare system evaluation

6.1. Efficacy

6.2. Effectiveness

6.3. Evidence based treatment and outcome management systems

6.4. Quality of care

6.4.1. Structure

6.4.2. Process of Care

6.4.3. Outcomes

6.4.4. Audit and quality assurance

6.4.5. Appropriateness

6.4.6. Inappropriateness

6.4.7. Health related quality of life

 

 

  1. Learning outcomes:

By studying the module:

 

  • You will learn definition and scope of health care system
  • You shall know the models of health care system
  • You will know the evolution of health care system in India
  • You can understand the health care system in India
  • You will get educated on the components of health care system evaluation
  1. Definition and Scope:

A health system or health care system is the sum total of all the organizations, institutions and resources that deliver service to cater the health needs of target population (WHO, 2005). Health care systems are influenced by each nation’s history, traditions and political system, resulted into variations in health care systems throughout the world, and contributed to different types of social contract between citizens and their countries. It operates in the context of the socioeconomic and political framework of the country. In some societies, health care system is viewed as social good demanding benefits to all stakeholders, whereas, in other societies, it is considered as commodity to be owned by payments (Park, 2007 and Lameire et al., 1999). In the world scenario, four types of health care systems are observed. They are the Biveridge model, the Bismarck model, The National insurance model and the Out-of-pocket model. This classification is based on the source of funding.

 

  1. Models of health care systems:

The Beveridge model also called socialized medicine model, was proposed by Lord William Beveridege. This model is a public health care model, where in, the health services are provided through National Health services. The fund for the services is provided by the government by levying taxes on the public. This model is in use in countries like United Kingdom, Spain, New Zealand and, Cuba. The Bismarck model is named after the Prussian Chancellor ‘Otto von Bismarck’. The funding for the services is provided through an insurance system by employees and employers through payroll deduction. Doctors and hospitals are private in nature. This model allows flexibility in spending money on healthcare. The countries following this model are Germany, France, Belgium, Switzerland, the Netherlands, Japan and Switzerland. The National insurance model was proposed by Tommy Douglas. The services are provided by private people but financed through a government sponsored insurance programme which requires that every citizen pay through premium or tax. This model in practiced purely in Canada. The out-of-pocket model is found in countries, where there are no health care systems to meet the health needs of its citizens. In this model, those who can afford get the health care and those who are unable to pay, stay sick or die. Example: Rural areas of India, Africa, China and South America (Lameire et al., 1999; Wallace, 2013; Reid, 2009)

 

  1. Evolution of health care system in India:

It was reported that preventive and curative care practice in centres equivalent to modern day health centres were existed during the period of emperor Asoka(Zimmer, 1948).Existence of teaching hospital at Nalanda University equivalent to modern day health centres were also cited in literature (Mohapatra et al., 2015). The health services commitment to the people of India was made in the Directive principles as a state policy. The Bhore and later the Mudaliar committees made recommendations for comprehensive preventive and curative services under the leadership of skilled clinicians. The Chopra committee advocated exchange of knowledge between allopathy and Indian systems of Medicines and the Sookhey committee enlisted the requirement of skilled persons from grass root levels. India launched Family planning in 1952 initially targeted for birth control , later focused on maternal child health, nutrition and family welfare. Departments of Social and preventive medicines were commissioned following the recommendations of Medical Education Conference held in the year 1955 to bring social orientation in the medical education. The Indian public health association was started in 1958 (Thakur et al.,2001).The number of beds and urban dispensaries were increased. The National Malaria Control Programme was started in 1953 and the Small pox eradication initiative was made in the year 1963. The BCG vaccination to cover entire population was attempted in the year 1973.

 

Srivastava committee has proposed three-tier approach for rural health care in 1975. Government of India had started Rural Health Scheme in 1977 using village level, sub centre and primary health centre approach to manage rural people health. The Programmes against leprosy, filariasis, trachoma and cholera were also launched by the Government of India. The integrated child development programme was started in 1975 for the children aged less than six years, to provide preventive services and non-formal education. In pursuit of Health for all, Government of India proposed National Health Policy in the year 1983 with specific goals for the next 15 years under the framework of five-year plans. The National AIDS Control Organization was launched in the year 1992 as a division under the Ministry of Health and Family Welfare to formulate policy and implement preventive and control programmes of AIDS in India. Department of Indian system of medicine and health was commissioned by Government of India in the year 1995 under Ministry of Health and Family Welfare and was rechristened as Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in the year 2003.

 

In the year 2002, National Health Policy was presented by the Government of India, with an objective of attaining acceptable standard of health in the population and emphasized on increasing access to public health system by establishing new infrastructure in deficient areas and upgrading infrastructure in the existing institutions. The new National Health Policy of 2015, was drafted by the Government of India. This document is in circulation for comments with a goal of attaining the highest possible level of good health through preventive and promotive health care orientation and increased access to good quality health care services without financial hardships (Benerjee, 1974 and 1976; Apte et al.,1994; Gangoli et al., 2005; Park, 2007, National Health Policy Draft,2015).

 

  1. Health care system in India:

In India, health care system is organized into five sectors or agencies based on the application of health technology and source of funds for operation.

 

1. Public sector

 

  1. Primary health care
    • Primary health centers
    • Sub centers
  2. Hospitals/health centers
    • Community health centers
    •  Rural hospitals
    • District hospitals/health centers
    •  Specialist hospitals
    • Teaching hospitals
  3. Health insurance scheme
    • Employees state insurance
    • Central government health scheme
  4. Other agencies
    •  Defense services
    •  Railways

2. Private Sector

  1. Hospitals, polyclinics, nursing homes, dispensaries
  2. General practitioners

3. Indigenous systems of medicine

  1. Ayurveda and Siddha
  2. Unani and Tibbi
  3. Homeopathy
  4. Unregistered Practitioners

4. Voluntary health agencies

  1. Indian Red Cross Society
  2. Hind Kushant Nivaran Sangh
  3. Indian Council for Child Welfare
  4. Tuberculosis Association of India
  5. Bharat Sevak Samaj
  6. Central Social Welfare Board
  7. The Kasturba Memorial Fund
  8. Family Planning Association of India
  9. All India Women’s Conference
  10. The All India Blind Relief Society
  11. The Indian Medical Association
  12. The All India Licentiates Association
  13. All India Dental Association
  14. The Trained Nurses Association of India
  15. The Rockfeller Foundation
  16. Ford Foundation
  17. CARE (Cooperative for Assistance and Relief Everywhere)

5. National health programs

  1. National Vector Borne Disease Control Programme
  2. National Anti-Malaria Programme
  3. National Filaria Control Programme
  4. Kala-Azar Control Programme
  5. Japanese Encephalitis Control
  6. Dengue Fever Control
  7. National Leprosy Eradication Programme
  8. Revised National Tuberculosis Control Programme
  9. National AIDS Control Programme
  10. National Programme for Control of Blindness
  11. Iodine Deficiency Disorders Programme
  12. Universal Immunization Programme
  13. National Rural Health Mission
  14. Reproductive and Child Health Programme
  15. National Guinea-Worm Eradication Programme
  16. YAWS Eradication Programme
  17. National Cancer Control Programme
  18. National Mental Health Programme
  19. National Diabetes Control Programme
  20. National Programme for Control and Treatment of Occupational Diseases
  21. Community Nutrition Programmes
  22. National Surveillance Programme for Communicable Diseases
  23. Integrated Disease Surveillance Project
  24. National Family Welfare Programme
  25. National Water Supply and Sanitation Programme
  26. National Programme for Prevention and Control of Deafness (Apte and Kerkar,1994; Park, 2007; Ministry of Health and Family Welfare, Government of India, website)

Primary health centres (PHC) covers one lakh (0.1million) population spread over 100 villages. One medical officer, one block extension educator, one female health assistant, one compounder, one driver and one laboratory technician staff them. At PHC, minimal procedures like tubectomy, vasectomy, medical termination of pregnancy and minor surgical procedures are carried out. As on September, 2005, 23236 PHCs were functioning in India (PHC National Portal). As per Medical Council of India, three PHCs should be attached to one medical college. Community health centre (CHC), is an upgraded PHC, covering a population of 80,000 in hilly/tribal/desert areas and 1, 20,000 population in plain areas. This unit is 30 bedded facility covering specialties like Medicine, Obstetrics and Gynecology, Surgery, Paediatrics, Dental and AYUSH. As on March, 2010, 4535 CHCs were functioning in India (IPHS Guidelines, 2012). These specialists in CHCs may refer a patient directly to the state level hospital or the nearest appropriate medical college hospital, as may be necessary without the patient having to go first to the sub divisional or district hospital (Apte and Kerkar,1994).

 

Other types of hospitals which come under the purview of public sector includes Rural hospitals, which are proposed to cover a population of 5,00,000; District hospitals having curative services and no target population; specialist hospitals(Chest hospital) and teaching hospitals(medical colleges and institutes)(Apte and Kerkar,1994 and Park,2007).

 

6.Components of healthcare system evaluation:

  • Evaluation of goals ( Patient safety in medical procedures, effectiveness in interventions, availability of timely care, personalized patient care based on patient’s needs, values and preferences and efficiency in health care and equity).
  • Investigation of application of tools (Evidence based treatment and outcome management system)
  • Assessment of quality of care((structure, process of care, outcomes, audit and quality assurance, appropriateness, inappropriateness and quality of life) (Bowling,2002;Steinwaches and Hughes,2008).

 

6.1. Efficacy: Efficacy is evaluation of interventions in improving the clinical outcomes. Efficacy is evaluated by using randomized clinical trials (RCT). RCTs are applied in case of medications. RCTs  were never been used for testing efficacy of surgeries, clinical set-up like intensive care units, medical devices and nursing staff decisions (Steinwachs and Hughes,2008).Example: testing of efficacy of acyclovir in patients with acute Herpes Zoster(HP). Patients diagnosed with HP were randomized in two groups based on rashes duration of less than or greater than 72hours and were administered acyclovir 800mg five times a day for first four days followed by three day treatment free days. The second course was followed with the same dosage when there is an evidence of pain reduction but not complete pain response. These patients were followed for three months without medication. The severity of symptoms was evaluated using four point verbal rating scale. No significant difference in the efficacy of treatments between the groups was observed (Rasi et al., 2010).

 

6.2. Effectiveness: The study on the effectiveness is undertaken when the particular intervention is efficacious. In general, for the most of the treatments, there is no evidence of efficacy but accepted as a common practice. Effectiveness in health services and cost of care can be compared using randomized clinical trials. Two or more groups are included in RCT to ensure comparability and to avoid selection bias. Effectiveness research is being carried out in community settings (Steinwachs and Hughes, 2008).Example: Cost effectiveness of Ivabradine. Cost effectiveness of Ivabradine was compared using Markov model, in two groups of heart failure patients, who were in sinus rhythm, left ventricular systolic dysfunction and a base line heart rate was either >75 or >75 base per minute. Ivabradine in combination with standard care including β blockade, was found to be cost effective than standard care alone, in HF patients (Griffiths et al., 2014).

 

In the absence of evidence of equivalent nature of treatments, RCT is used to compare the effectiveness of treatments. Example: weight loss interventions. Four hundred fifteen obese persons were divided into three groups: control, online intervention (telephone, e-mail and webpage) and in-person intervention ( group and individual sessions) in randomized controlled trial and were studied for the period of one year. The weight reduction in control, online intervention and in–person interventions were 1.8kg, 4.6kg and 5.1kg respectively (Appel et al., 2011).

 

In non-randomized studies involving groups receiving different treatments, risk adjustment is done .For example in comparison studies, the adjustment of factors affecting the outcome explain the variation among the groups. The non-equivalent groups are compared to know the effectiveness of alternative treatments; impact of poor access to care and; to assess the cost effectiveness of each provider (Steinwachs and Hughes, 2008). Example: cost effectiveness of soft tissue injury management. Patients with soft tissue injury presented to the emergency department were randomized for management to nurse practitioners, extended scope physiotherapists and to routine care to doctors. No difference in clinical outcome was observed but the management by of practitioners other than doctors was found to be cost intensive (McClellan et al., 2013).

 

Operation reach methods also used to compare provider practices, health plans and to control the cost of health care. These methods are used in designing payment systems and resource based relative value scales, the later are useful in standardizing patient care in outpatient settings. The sources of data for effectiveness research are case sheets, billing data and survey questionnaires. If patient don’t follow-up care and approach multiple provides, case sheets are of limited use. The drawback of billing data is lack of clinical data. The effectiveness of Survey questionnaire depends on the patient recall (Steinwachs and Hughes, 2008).

 

 

6.3. Evidence based treatment and outcome management system:

 

Health services research tools like evidence based treatment and outcome management system are used to improve the clinical practice and patient outcomes in settings like hospitals, clinics and health plans. Evidence based treatment information, available in literature, provide a criteria for quality care to judge the current practices. Example: Evidence based treatment information, has showed the benefit of antihypertensive drug treatment in reducing health outcomes in patients with hypertension (James et al., 2014). The reasons cited for non-conformance with evidence based treatment were physicians disagreement with the evidence, perception that patients will not accept the treatment, low rating of efficacy of the treatment by the provider and inability to integrate the evidence based treatment into the existing practice (Steinwachs and Hughes, 2008; Cabana et al.,1999).

 

Ellwood in 1988, has proposed outcome management system as a method to build clinical intelligence on the application of treatments. In this method, along with outcomes of care and information on the diagnosis and treatment, experience of patient is documented (Steinwachs and Hughes,2008).Example: Evaluation of chronic kidney disease (CKD) management on the clinical outcome. Two groups of patients (group I CKD management(n=10552) and group II without CKD management ( n=8509), were evaluated for access to nephrology care, trends in renal replacement therapy(RRT), starting modality and place of death without RRT for the observation period of 2003-2012. Ninety-one percent of patients known to the nephrologists, RRT incidence peaked in 2005 and then declined, percentage of patients undergoing transplant, hemo or peritoneal dialysis was increased to 63% in 2012. Five two percent of patients receiving standard care without dialysis were reported to be died out of hospital. Incidence of RRT and modality of initiation of RRT improved in patients, who were under CKD management (Rayner et al., 2014).

 

6.4. Quality of care:

 

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1991). The main emphasis of quality of care is increasing the likelihood of achieving desired outcome in patient’s perception (Steinwachs and Hughes, 2008). Donabedian in 1991, has proposed the conceptual model for describing, analyzing and evaluating the quality of care using the dimensions of structure, process of care and outcome (Steinwachs and Hughes, 2008).Quality assurance and audit, have been show to maintain quality in health care (Bowling, 2002). Evidence of improper administration of injections by the physicians prompted research on the appropriateness of the procedure(Brook et al.,1986;Kahn et al.,1989) Research on variations in care suggested inappropriateness of care(Brook, 1989).

 

6.4.1. Structure: Structure of health care system includes infrastructure (buildings, beds), manpower (clinical and paramedical) and technology (equipments). For accreditation of health care services, the structure is one of the components taken into consideration. Structural aspects also influence the quality of health care services. The data on structure is collected using questionnaire and analysis of documents (Steinwachs and Hughes, 2008; Bowling, 2002).

 

6.4.2. Process of Care: The Process describes how services organized, delivered and used. Evaluation of process will inform utilization of services and outcomes of care. Process is evaluated by applying six goals of health care like patient safety, timely care, treatment confirming the evidence based practice, patient centred treatment, efficiency of care and equity. This analysis will help to know whether improvement is required and where efforts, should be directed. Process involves collection of data on interactions between professionals, provider and patients, plans followed and documented. The range of data collection covers rates of hospital discharge, number and type of medications given, number and type of interactions between providers and patients occurred, number of hospital visits made, average length of stay, length of consultation, medical and surgical intervention rates, waiting lists, waiting times and accessibility. The data for the process of care is collected from medical records, computer databases and using survey questions (Bowling, 2002; Steinwachs and Hughes, 2008).

 

6.4.3. Outcomes: Outcomes are the effects of health services on patients health as well patient’s evaluations of their health care. Data on outcomes of health services are useful for audit and for purchasing policies (Bowling, 2002). Health outcome measurements includes disease progression, patient reported health status or functional status, satisfaction with health status or quality of life, satisfaction with services, cost of health care, survival periods, biochemical indicators or symptoms rate, relapses, various indicators of physical and psychological morbidity, number of bed days and hospital readmission rates(Bowling,2002; Steinwachs and Hughes, 2008). Evaluation of treatment and care should be done to check whether they are leading to outcome worth living in social, psychological or physical terms. The outcome should also incorporate patient’s perceived health status, quality of life and patient satisfaction with the treatment (Bowling, 2002).

 

6.4.4. Audit and quality assurance: Audit is the reviewing and monitoring current practice and evaluating the predefined standards are met. Audit is of two types, medical and clinical. Medical audit analyzes the quality of medical care like diagnosis and its procedures, clinical decisions about the treatment, use of resources and patient outcome. Examples: Analysis of avoidable deaths, assessment of medical decision making, resources and procedures used in relation patient outcome. Doctors and paramedical staff conduct the clinical audit and analyzes the clinical care ,review the diagnosis and its procedure, clinical decisions about the treatment, use of resources and patient outcome. Quality assurance involves the monitoring and evaluation of predefined and agreed levels of service guidelines. The main goals of quality assurance are setting guidelines and evaluation to improve performance.

Audit is done by analyzing documents, clinical case reviews, collecting information on patients and patient assessed outcome, using questionnaires(Bowling,2002).

 

6.4.5. Appropriateness: There is no internationally agreed definition on appropriateness. In health service research, much emphasis was given on the appropriateness of interventions. All stake holders (providers, patients and policy makers) in health service research attempts to identify appropriate treatments and services to deliver, assessment the outcome, estimate the level of the need in the population for the interventions and evaluate their provision and mode of delivery. Appropriateness may also include organizational factors, for example, length of hospital stays (Bowling, 2002).

 

6.4.6. Inappropriateness: Increased evidence on inappropriateness prompted investigations of health outcomes and appropriateness of interventions. There is an inadequate research on appropriateness of many medical interventions. High levels of inappropriateness and wide variations in the practice of procedures were observed in various countries. Examples: high levels of inappropriateness rates in surgical interventions of coronary heart disease in USA and wide variations in the practice of various procedures in UK, were reported (Bowling,2002).

 

6.4.7. Health related quality of life: Health related quality of life (HQOL) scales measures the impact of disease condition and treatment on the person’s emotional, physical, social functioning and lifestyle. HQOL presents patient subjective evaluation of quality of life of disease condition and after medical/surgical interventions. Disease specific quality of life scales can be useful in assessing clinically significant changes and levels of disease severity. In subjects with multiple health problems, generic HQOL scales are useful (Bowling, 2002; Bowling, 1995).

 

Summary:

  • A health system or health care system is the sum total of all the organizations, institutions and resources that deliver service to cater the health needs of target population.
  • Health care systems are influenced by each nation’s history, traditions and political system
  • Health care systems are categorized into the Biveridge model, the Bismarck model, The National insurance model and the out-of-pocket model based on the source of funding.
  • In The Beveridge model, the health services are provided through National Health services. The found for the services is provided by the government by levying taxes on the public. This model is in use in countries like United Kingdom, Spain, New Zealand and, Cuba.
  • The funding for the services is provided through an insurance system by employees and employers through payroll deduction in The Bismarck model. The countries following this model are Germany, France, Belgium, Switzerland, the Netherlands, Japan and Switzerland.
  • In The National insurance model, the services are provided by private people but financed through a government sponsored insurance programme which requires that every citizen pay through premium or tax. This model in practiced purely in Canada.
  • The out-of-pocket model is found rural areas of India, Africa, China and South America, where those who can afford get the health care and those who are unable to pay, stay sick or die.
  • There are evidences of existence of preventive and curative practice during the reign of the emperor Asoka and the teaching hospitals equivalent to modern medical colleges at the Nalanda University.
  • The modern health care system of India evolved using the inputs of various committees headed by Bhor, Mudaliar, Chopra and Srivastava.
  • In India, health care system is classified into five sectors or agencies based on the application of health technology and source of funds for operation.

Components of health service/health system evaluation include health care system goals(Patient safety in medical procedures, effectiveness in interventions, availability of timely care, personalized patient care based on patient’s needs, values and preferences and efficiency in health care and equity), application of tools(evidence based treatment and outcome management system) and quality of care(structure, process of care, outcomes, audit and quality assurance, appropriateness, inappropriateness and quality of life).

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