India’s health ecosystem is both unimaginably complex and uniquely challenging. Let me illustrate through two recent cases. A 25-year-old Marathi actress and her new-born baby passed away in Hingoli, Maharashtra, because they could not get an ambulance to take them to the hospital . A Rajasthan Hospital was in the news for the deaths of over 110 babies in a month — not only was it ill-equipped with broken windows and no warm blankets, there were also animals running around . A hospital in Uttar Pradesh made the news when over 60 children died due to mismanagement and a lack of oxygen cylinders.
Cases like these serve to underscore the dismal condition of maternal healthcare in India. In the last 10 years, the country has seen some great strides in healthcare, such as the steep rise in institutional deliveries — from 39% in 2005 to 79% in 2015 as per last NFHS data .
On the other hand, there is a long way to go to achieve parity with the developed world. Take, for instance, our maternal mortality rates — still high at 122 per 100,000 live births in 20174. In comparison, Europe registers an MMR of 4 per 100,000 . What’s disheartening is that just two countries — India and Nigeria — account for a third of all women dying from pregnancy complications . Margaret Chan, Former WHO Director-General, had asked a question in 2012 that is still relevant today: “What good does it do to offer free maternal care and have a high proportion of babies delivered in health facilities if the quality of care is substandard or even dangerous ?”
The need for standardized quality care becomes clear when the data for MMR is sliced state-wise. More developed states such as Kerala and Maharashtra have already achieved the MMR target of 70 deaths per 100,000 cases as mandated by the UN Sustainable Development Goals. However, Assam registered the worst MMR at 229, while Uttar Pradesh was second highest at 216 . It’s this wide disparity and the consequent inequality that is a concern. The mothers of Assam or Madhya Pradesh deserve to receive the same level of quality care as their sisters in Kerala or Tamil Nadu.
The reasons for the disparity are many — lack of identification of high-risk pregnancies due to low antenatal registrations, a smaller number of antenatal visits during the pregnancy, resource-crunch at primary health centers, inadequate skilling and the inability to handle complications during childbirth, non-availability of blood components and so on. It is estimated that approximately 46% maternal deaths and 40% of new-born deaths take place on the day of the delivery. Clearly, India’s maternal health imperative is to aim for a single comprehensive goal — improved access to standardized quality maternity services.
The challenge is that there are critical gaps in India’s maternal health system that relate to the inadequacy of India’s standardization in care and services. Quality standards and clinical pathways need to be developed, tested and continuously improved, across service providers, both urban and rural, public and private sector, primary to tertiary.
It’s important to note that some progress has been made in addressing the standardization gap, however it is limited to the public sector. And yet, it’s India’s private sector that is carrying the bulk of the responsibility, having created more than 70 percent of hospital beds added between 2002 and 2010, and continuing to do so . With close to half of institutional deliveries in the private sector, engaging the private sector in adhering to standards has become critical. The contribution of the private sector is also reflective in the National Health Policy 2017 under the strategic purchase of services (where private sector is invited to fill critical gaps).
Given their significance, it would be a missed opportunity if national health systems fail to integrate private providers in policies and strategies to meet health care coverage needs. Already, union and state governments have introduced measures for quality care through initiatives such as the Maternal and Newborn Health Toolkit, standardization of labour rooms, and quality programs including Dakshata, LaQshya and Obstetric HDU/OICU/Hybrid OHDU-ICU as the vital back up. The private sector is working on similar lines with maternal care projects like Manyata, but needs to partner more strongly with the government to optimize resources and minimize redundancies.
The situation takes on significance with the launch of Ayushman Bharat – the government’s health insurance scheme for underprivileged citizens which introduces a new scale of purchasing care from private and public healthcare providers. It brings new opportunities to drive improvements in quality of care, such as LaQshya-Manyata in Maharashtra which is a good example of public- private collaboration. Identifying synergies such as alignment on uniform standards could help in extending initiatives such as LaQshya (a state government initiative for quality maternal care) to private sector counterparts as well as incentivizing and scaling quality maternity services through Ayushman Bharat. More important, promoting quality standardization in services will help India’s neediest community — poor and underprivileged women in semi-urban and rural areas – to get access to safer and respectful care.
To sum up, streamlining and integrating quality standards into national quality improvement and quality assurance systems, will have multiple benefits — the service providers will benefit immensely, mothers will receive safer care services, and India will advance rapidly in its healthcare journey. Another point for India to note is that worldwide, countries are moving towards knowledge-based and data-driven governance. Evidence-based decision-making (based on reliable data and continuous monitoring of ground initiatives) is important in ensuring proper healthcare delivery and informing healthcare policies.
Every year 303,000 pregnant women die in the world (WHO, 2015). It is said that if quality obstetric health care is provided in time, then we could save 80% of these pregnant women i.e. 240,000 women in the world.
It is high time standardized quality care is brought to the forefront in every health conversation. And it is way past time that mothers across India are assured of a minimum quality and respectful standard of care.
The author is the President of Federation of Obstetric and Gynaecological Societies of India (FOGSI). Views are personal.