Fragmented Healthcare Fragmenting Patient Trust in India

Shalini Agarwal, Professor, Department of Radiodiagnosis

India is on its way to becoming the most populous country in the world. Heroic efforts have also increased life expectancy, leading to increasing healthcare burden and deteriorating patient trust. We are clearly in an emergency that needs immediate intervention. The only solution is a partnership between the public, private sector, government, and industry to provide coverage and quality healthcare.

India's healthcare sector has been deficient for quite some time, and the Covid-19 pandemic has amplified the fault lines. We are not only inadequate in infrastructure but also lack universal coverage and affordability across regions. According to Das and Mohpal (2016), 75 per cent of the total Indian population, mainly residing in Rural India, depend on healthcare providers who do not have formal medical training.

According to the United Nations, India is on the path to becoming the most populous country in the world by 2023. Despite decades of investment, we have consistently missed our healthcare targets, and this situation is likely to worsen. There are already humungous demands on the healthcare delivery system of India, which are expected to increase in the years to come. This situation does not translate into patient trust. Trust deficit also affects the United States (US) healthcare system. Only 34 per cent of the general public had a positive view of the US healthcare industry in 2018, in contrast to 80 per cent in 1975. The situation is much worse in India. The importance of trust lies in better patient outcomes.

Patient Trust
Trust is difficult to define. However, the need for trust stems from vulnerability. According to a study from Tamil Nadu, it is either physician-based or medical institute-based.   Individual-based trust can be either; (a) Comfort-based trust: This group consisted of 11 per cent of the respondents -mainly rural women and older individuals belonging to lower educational and occupational status. (b) Personal trust: This group comprised of 21 per cent of the sample studied belonging to the younger individuals with a higher level of education and occupational status. They trust the individual based on personal involvement. (c) Emotionally assessed trust: 45 per cent of respondents look for common traits in a doctor; caste and cultural belief, language, religion, etc. These usually belong to the marginalised communities and from the lower social strata. (d) Objectively assessed trust: This group comprised approximately 22 per cent of the sample, mainly of lower age groups and women. For them, the ethical character of the doctor was more important.

On the other hand, a patient looks for the following from medical services: (a) doctor-patient interaction, (b) treatment process, (c) waiting time in the hospital, (d) medical facilities, (e ) hospital environment, and (f) medical costs.

These two types often extend into each other’s domain. Patients may forgive an unsatisfactory performance if they believe in the motivations and intentions of the clinician. Also, trust has a ‘cliff effect.’ It builds over a period of time and overextends beyond a clinician’s trustworthiness.

Other factors affecting trust are level of education, socioeconomic status, income inequality, location in rural or urban areas, whether suffering from non-communicable diseases and/or disability, married women and men, mass media, social networks, and overall economic environment. For example, the Urban population trusts the Government hospitals/doctors more than those in the rural areas.

Types of healthcare in India

  1. Public Sector: It consists of a three-tiered system, including institutes providing primary, secondary, and tertiary care. As per a recent Comptroller and Auditor General (CAG) report, there is a 24 per cent-38 per cent shortfall in the availability of medical personnel at primary health centers, subcentres, and community health centers in 28 states/union territories of India. There is also a disconnect between the community health centers and the district hospitals. Inadequate allocation of funds to healthcare which has remained stagnant at 0.35 per cent of GDP, has led to a deterioration in the public sector. India ranks lowest in the percentage of GDP spent on healthcare.
  2. Private Sector: There is a high dependency on the private sector because of the inadequate public sector. However, this sector incurs a high out-of-pocket expenditure, nearly 65 per cent of the expenditure paid in India. In 2014, more than 70  per cent of outpatient and more than 60  per cent of inpatient care were in the private sector. Nursing homes and doctor’s clinics were unregulated for a long time. However, the Clinical Establishment Act (2010) has established standards for all types of therapeutic and diagnostic clinical establishments in public and private sectors from all recognised systems of medicine. These include single-doctor clinics; the only exception is those run by the Armed forces.
  3. Ayush (Ayurveda, yoga, naturopathy, Unani, Siddha, and Homeopathy) and alternative medicine: In an attempt to increase healthcare resources, the National health policy (NHP)-2017 and two bills passed in 2020 provide financial support and infrastructure development for strengthening the ayurvedic sector. Further, the World Health Organisation (WHO) has selected India to set up a traditional medicine center to enhance research, training, and awareness.
  4. Web-based services like telehealth/ mhealth: Guidelines were prepared by the board of governors in association with Niti Ayog of India in suppression of the previous regulations by the Medical Council of India (MCI) on 25th March 2020, which allowed medical professionals to provide healthcare using telemedicine. The aim was to increase the coverage of healthcare. However, a study from Bihar that relied on social franchising and telemedicine to provide healthcare in rural areas failed to achieve the quality of care or any of the healthcare targets.

According to a report by the Union minister of health and family welfare in Rajya Sabha on April 5, 2022, the doctor-population ratio for allopathic doctors in India is 1:834, assuming 80 per cent availability. There is only one bed for 2239 persons, as against the WHO recommendation of 3 beds per 1000 population. Only 20 per cent of the hospital beds are in rural areas.

Quality in Health Care:

Good quality of healthcare also usually translates into a higher level of trust. As per the NHP, the key dimensions of high-quality healthcare are consistency, positive health outcomes, patient-centered, equity, and trustable service delivery. All three, i.e., success, process, and outcome, are necessary for measuring healthcare quality. Zarei, Daneshkohan, Khabri, and Arab (2015) emphasized interaction and process quality to enhance patient trust. They recommended that the quality improvement efforts should focus on service delivery aspects such as scheduling, timely and accurate doing of the service, and strengthening the interpersonal aspects of care and communication skills of doctors, nurses and staff.

There are various accreditation schemes like the National Accreditation Board of Hospitals and Healthcare (NABH), National Accreditation Board for Testing and Calibration Laboratories (NABL), and Joint Commission International (JCI). However, they are merely guidelines and cannot be called prescriptive. Similarly, National Quality Assurance Standards (NQAS), National Family Health Surveys, Indian Public Health Standards, Mera Aspataal (My Hospital), LaQshya (Labour room Quality Improvement Initiative), and National Patient Safety Implementation Framework are also pertinent guidelines in the field of quality assurance in the healthcare.

We should not forget the social and cultural aspects of healthcare quality. These include income levels, hygiene, sanitation, nutritional status, lifestyle, social support, etc. Culture and attitude also affect healthcare delivery. These should be part and parcel of any program for improving healthcare quality.

Several other schemes like the National Health Mission, National digital health mission, universal health coverage under the Ayushman Bharat – Pradhan Mantri Jan Aarogya Yojna (AB PMJAY), Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA). are right steps towards gaining health coverage for all. However, there is still a disconnect between the lofty aims of these schemes and the ground reality. It is essential to involve both the public and the private sector in implementing these schemes.

Reasons for Outburst Against Doctors:
As per The Indian Medical Association (IMA), 75 per cent of doctors have suffered physical or verbal violence during their lifetime. The death of the patient is the most common trigger. Others are delays in giving care, shortage of equipment and drugs, denial of admission negligence, and abuse by staff.

The reasons behind such incidents are a growing supply-demand, high expectations of patients, deterioration in quality, low doctor-patient ratio, lack of security of medical staff, and overcrowded hospitals with limited sanitary facilities. These are just explanations for the underlying malady of distrust in doctors.

On the one hand, there are patients with limited financial and physical means who travel a long distance to a city hoping to access the best healthcare facility for their loved ones. However, they find themselves out of their depths in the middle of a teeming crowd. On the other hand, harried doctors are working long hours in overcrowded and congested conditions. This is a recipe for disaster from every possible angle.

There is usually a trade-off between coverage and quality, but a hybrid system can be the solution. The inexperience of the doctors on the ground can be solved by telemedicine, where consultation can be provided by an experienced clinician wherever necessary. Such collaboration can only be achieved by public-private partnerships between institutions, hospitals, and industry. A patient should be able to easily navigate these corridors of healthcare, which rarely intersect at present. Hence, we need to streamline the bureaucratic, regulatory, and administrative processes to bring more cohesion. Medical education should emphasize patient-physician interaction, ethics, communication, dispute resolution, and above all, humanities. The latest competency-based revised curriculum of MBBS is a step in the right direction. It is best to be proactive and aim to gain patient trust rather than reacting to an incidence of violence.  

References:

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  2. Das J , Mohpal A . Socioeconomic status and quality of care in rural India: new evidence from provider and household surveys. Health Aff (Millwood). 2016 ; 35 (10): 1764 – 73.
  3. Daniel, W, https://www. modernhealthcare. com/opinion-editorial/commentary-erosion-trust-threatens-essential-element-practicing-medicine: March 09/2019. (Accessed 16th July 2022)
  4. Gopal, K.M (2019), Strategies for Ensuring Quality Health Care in India: Experiences From the Field. Indian J Community Med.Jan-Mar; 44(1): 1–3.
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  6. Hall, M.A., Dugan, E, Zheng, B and Mishra, A.K (2001,) “Trust in Physicians and Medical Institutions: What Is It, Can It Be Measured and Does It Matter?” The Milbank Quarterly, Vol. 79, No. 4, pp. 613-639.
  7. Joumard, I and A. Kumar (2014) “Improving Health Outcomes and Healthcare in India,” Economics Department Working Papers No. 1184, OECD, Paris.
  8. Kulkarni, V.S, Kulkarni, V.S, Gaiha, R (2019), Trust in Hospitals-Evidence from India. https://repository.upenn.edu/psc_publications/27
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  12. Zarei, E, Daneshkohan, A, Khabiri, R, Arab M (2015), The effect of Hospital Service quality on patient trust, Iran Red Crescent Med J.  17(1): e17505.
  13. https://www.businessworld.in/article/India-s-Fragmented-Healthcare-System-Filling-The-Cracks/03-09-2021-402985/ (accessed 15thJuly 2022)
  14. https://www.livemint.com/news/india/india-to-surpass-china-as-most-populous-country-in-a-year-un-11657514734097.html (accessed 12th July)
  15. https://www.mohfw.gov.in/pdf/Telemedicine.pdf (accessed 18th July 2022)
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  17. https://timesofindia.indiatimes.com/india/over-75-of-doctors-have-faced-violence-at-work-study-finds/articleshow/47143806.cms (accessed 15th July 2022)
Shalini Agarwal

Shalini Agarwal is a graduate of AFMC and a Postgraduate in Radiodiagnosis from the Army Hospital (R&R) New Delhi. I have been a teacher at my present place of work for the past 18 years. My hobbies are writing and poetry- besides medicine. The only thing that has inspired me more than my students is the hope and resilience of my patients in the most trying circumstances.

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