JANUARY

INDIA
are provided by other ministries and departments to their personnel (e.g., defense, railways, ports, mines, and
employee state insurance schemes).
Each state has its own State Directorate of Health Services and State Department of Health and Family Welfare,
which is responsible for providing care to its population. District-level health services provide a link between
each state and primary care services.
Other agencies involved in health system governance include the Insurance Regulatory and Development
Authority, which regulates the health insurance industry, and the National eHealth Authority, which is to become
the nodal authority for development of an integrated health information system (MOH, 2015b). There is
confusion in India with respect to which entities are responsible for regulating the private sector and for
ensuring quality of care, as there are multiple agencies under different ministries, with no single responsible
agency. For example, the Bureau of Indian Standards and Consumer Protection Act are under the Ministry
of Consumer Affairs, whereas the Quality Council of India is under the Ministry of Commerce and Industry.
An attempt is being made to bring these agencies under one authority.
What are the major strategies to ensure quality of care?
Over the years, several regulations have been enacted and authorities created at the state and national level
with the aim of protecting patients and improving quality of care. For example, at the state level, the Nursing
Home Act and State Drug Controllers ensure quality of care provided by the private sector. A major impetus to
establishing patient rights was the inclusion of private medical practice under the Consumer Protection Act in
1986 (Balarajan et al. 2011). To ensure quality of care and define standards for health facilities, a number of laws
were introduced, including those creating a national accreditation system, the National Accreditation Board for
Hospitals (NABH, 2006; Gyani, 2015), and the Indian Public Health Standards (IPHS, 1997) for primary and
secondary health care services. In addition, many hospitals undergo accreditation and certification from
international bodies such as the Joint Commission International (JCI) and the International Organization for
Standardization (Wennerholm et al. 2013).
The Health Management Information System was launched in 2008 to monitor health programs and provide key
inputs for monitoring and policy formulation. Currently, about 633 of 667 districts report data by facility (MOH,
2015a). Large-scale surveys like the National Family Health Survey, the District-Level Household Survey, and the
Annual Health Survey are periodically undertaken at the district, state, and national levels. In addition, the
Indian Council of Medical Research (ICMR) maintains disease registries for cancer, diabetes, cardiovascular
diseases, and other illnesses.
The 2010 Clinical Establishments (Registration and Regulation) Act calls for prescribing minimum standards for
all public and private clinical establishments in the country (MOH, 2012; MOH, 2015c). The act has already
come into force in certain states (e.g., Arunachal Pradesh, Himachal Pradesh, Mizoram and Sikkim) and in all
union territories (CBHI, 2013). In addition, facilities shall charge rates as determined by central government in
consultation with the state. The act stipulates fines and penalties if provisions are breached by any facility.
A national council for clinical establishment will oversee implementation and compliance at the national level.
Similar councils at the state and district levels will be established to enforce compliance locally (MOH, 2015c).
Currently, a shift to one comprehensive approach of quality assurance is envisaged to replace the existing
fragmented approach. For public health care facilities, the strategy would ensure that every facility is measured
and scored for quality, and certified and incentivized when it achieves a certain minimum score. Quality
measures would include clinical quality as well as patient safety, comfort, and satisfaction. In the private sector,
voluntary accreditation with certificates like that of National Accreditation Board for Hospitals and National
Accreditation Board for Testing and Calibration Laboratories would predominate. For private facilities that are
part of a public–private partnership, quality certification would be mandatory either through those boards
or through the public system (MOH, 2014).
82
The Commonwealth Fund