What does quality of care mean for maternal health providers from two vulnerable states of India? Case study of Bihar and Jharkhand

The utility value of the present study lies in the identification of the perspectives that challenge or facilitate the nesting of quality initiatives in India. These insights gathered from largely challenged settings are valuable since they are likely to be representative of several similar areas within India.

The development of guidelines in India since 2005 has itself been an imperfect exercise [25]. Indian guidelines in the field of maternity management are weak on documentation about the guideline development process, incorporation of patient views, weak emphasis on collection, collation and updating of evidence and formulating recommendations [26]. Additionally, the current study highlights the poor availability of guideline recommendations in the appropriate quick reference formats to the peripheral levels of health providers. No quick response guides are available, and the guidelines in poster formats which paramedical providers find useful may not have been strictly vetted for their quality-based content. Adherence to standard treatment protocols needs improvement across states because they are either not available or poorly followed with no mechanism of quality assurance [27] or quality benchmarks [28].

Good health outcomes require a downstream chain of events beginning with well-developed guidelines. The subsequent vital steps comprise of definition of quality benchmarks or standards that should percolate to providers at all levels and information systems and audits that measure and question health outcomes. In India, HMIS is used more for monitoring of tasks completed by peripheral workers rather than for programme management and designing [29]. Though large volumes of data are recorded, there is poor evidence about the use of this information in decision-making [22] and improvement of service. Facility level audits to analyse elements of causality similar to the set of clinical audits developed by NICE International [30] can also augment HMIS for local and regional improvements and should be adopted as a part of the quality fabric at all facilities. Investment in training for this at both pre and in-service stage is of paramount necessity.

Even if such evidence-based guidelines were made available and the standards defined, well-trained human resource and the lack of adequate infrastructure constitute an obvious potent block in the delivery of quality healthcare [31]. The percentage of shortfall of health facilities in Jharkhand is 35, 66 and 22 at sub-centre, primary health centre and community health centre levels, respectively [27].

Bihar currently has 12 government medical colleges [32] and 18 government ANM training schools [33], whereas Jharkhand has three government medical colleges and ten government ANM training schools [27]. Despite the efforts to increase the number of seats for medical and paramedical courses, the availability of quality trained human resource in the public health sector especially the specialists, MBBS doctors, staff nurses and ANMs is a problem in the state [22]. While in-service training are provided by the states, e.g. Intra Uterine Contraceptive Device (IUCD) training for nurses and Integrated Management of Neonatal and Childhood Illnesses (IMNCI) training for doctors, gaps in clinical as well as communication and counselling skills are recorded particularly among primary care providers. These are crucial especially when providers are expected to deal with tribal and vulnerable population who may be overtly resistant to absorbing health messages and practices. Inbuilt mechanism for training and re-training, supportive supervision and, very importantly, opportunities for knowledge exchange and update are also desirable approaches for inclusion.

In a wider context, the situation on the ground advocates for a timely reform of medical education in India focusing on quality and evidence-based learning. Hopefully, the recent initiative of the Medical Council of India in introducing a competency-based education with learner-centric approaches, integration of ethics, attitudes and professionalism and skill development would address the need [34]. Imparting of communication and behavioural change skills to health providers may be an important incorporation during reforms in medical and paramedical education in both pre and in-service training.

A number of studies in infectious diseases highlight the gap between “know” and “do” with respect to the provider [35]. The inability of education to change provider behaviour may need to be supplemented through more efficient regulation. Clinical governance is the main vehicle for continuously improving quality of care [36] as was acknowledged in the late nineteenth century by the NHS in England. This will be important for adopting universal health coverage as a developmental imperative in India [37].

The current study highlights PPP as one of the potential quality enablers. However, the history of PPP in India with unclear definitions of roles, expectations and poor commitments [38, 39] does not give rise to optimism. It can be used only as a stop gap in a narrow window of time because private participation in public health depends heavily on external funding which drives incentivization inherent in PPP models [39]. The Kerala Government’s partnership with the Kerala Federation of Obstetricians and Gynaecologists for development and utilization of quality benchmarks with inputs from NICE International [28] is an example of well-planned PPP model. Since there has been a systematic commitment from the state for implementing quality, this PPP positively influences the health infrastructure, education and community mobilization for uptake of health services. The accountability for ensuring safe quality care should however ultimately rest with the public health sector.

Community dynamics was mentioned as negatively influencing guideline implementation or quality compliance. How does the doctor continue to exert good practices and good judgement against community demand which may be at variance with good practice? Despite the fact that Kerala has made a firm commitment for quality in healthcare, provider perspectives and community dynamics continue to affect guideline-based clinical practice, e.g. high rate of caesarean section [22]. Community education, provider perspective and quality of provider-patient interaction therefore assume vital importance.

With gaps at multiple levels, the need for strengthening and skill building of human resources for quality healthcare should be afforded the highest priority. Besides the advantages in providing better quality of care, this will also enable the optimal utilization of contemporary point of care technologies poised for health and disease control [40].