India has made significant progress in healthcare delivery systems in the last two decades. However, the country still struggles with substantial issues and gaps. Skilling and quality are the main challenges in standardising and managing population health efficiently. Quality of care is still questionable and hindered by limited accreditation and adoption of basic technologies. 

According to NATHEALTH Aarogya Bharat Report, India will require nearly 2 million more doctors and 4 million nurses to achieve a doctor-to-population ratio of 1:1000. Currently, the available talent is highly skewed towards a few states and urban areas. Healthcare services are expected to demand 15 million new jobs for doctors, nurses and allied health professionals by 2025. Moreover, 100,000 jobs are expected to be created from Ayushman Bharat and other government healthcare-related schemes.  

The healthcare market is expected to reach USD 372 billion by 2022, while medical devices market is expected to cross US$ 11 billion by 2022, as per Industry estimates. (ASSOCHAM-RNCOS Report). In the projected growth trajectory quality and skill would be the most critical component to achieve the target of universal health coverage. Conventional institutions and processes had to give way to more efficient models to improve the systems. 

In Skilling space, the medical curriculum can play the role of a powerful catalyst. We need to impress upon various stakeholders including regulators to incorporate the adoption of newer skill sets like Medical IT in the existing curriculum. Hospitals with appropriate facilities can start paramedical programs that would yield positive and desired results. The Healthcare Sector Skill Council (HSSC) should be industry-driven also and we need to guide and impress upon them to come up with simple methodologies for inspection/ accreditation of paramedical courses. As technology is driving the sector, encouraging short courses/ online programs/ courses for doctors/nurses & paramedics will certainly help enable them to use technology.

The government has been undertaking various measures to increase intake to MBBS courses. However, the focus needs to be on allied healthcare professionals as well. The Nursing council should revisit the Nursing graduation programme. Instead of a five-year programme, it should consider splitting it into three years of college studies and two years of internship and study in hospitals.  

In addition to the existing paramedical courses, the HSSC should also develop one year modules for the emerging streams such as biostatistics and research methodology, Guest relations, Medical Tourism, Hospital Safety & Quality, Supply Chain Management, Counselling, Marketing, Emergency medical technologists and in these areas there is really a need to have trained manpower. These courses can be developed with support from large medical colleges, reputed medical research institutions, Hospital chains, and other stakeholders from the industry. For example, for biostatistics and research methodology, there can be an 18 months programme after graduation on any stream such as basic statistics, biostatistics, clinical research methodology, medical ethics, clinical trials, and ICMR guidelines. 

National Board of Examinations (NBE) under the Union Ministry of Health and Family Welfare awards Diplomate of National Board (DNB) title to candidates who complete their postgraduate or postdoctoral medical education under it. DNB in smaller hospitals is not able to get accreditation even though they have all the required facilities. Hospitals incur a cost for running the program and paying stipends which may deter them from increasing the seats. The industry should engage with the National Board and impress upon them to revise the criteria on a minimum number of beds to start the DNB program. Encouraging the faculty to actively participate in academics & research which will also help in increasing the DNB seats and provide high-quality training. 

Improving Quality is even more humungous task. Patient safety and quality improvement programme have become terms used by doctors and other healthcare workers with very little understanding. Though national and international quality certification organisations have brought a quality focus, the gap still exists, especially in rural areas. 

To improve quality, several reform measures need to be implemented urgently. First, clinical quality and patient safety should be part of the curriculum in all healthcare-related courses. Secondly, there should be minimum quality standards that all organization must follow which should also include surgical safety checklist, infection control and antibiotic stewardship. Thirdly, outcome indicators for a few of the common procedures need to be defined and the same should be captured and reported through a portal along with other important indicators. 

Here, the most important task is to create a quality culture in hospitals and encourage hospitals to honestly self monitor the laid down the Key Performance Indicators (KPI). But the tough task would be creating an environment of confidence and encourage hospitals to voluntarily report the identified KPI. The hospitals who report the data voluntarily shall, in turn, get an update on the national averages on KPI’s for various categories of hospitals. This will help them to internal benchmark themselves. 

On various forums, NATHEALTH strongly recommended that the KPIs need to focus on parameters such as Compliance, Patient Safety Measures, Quality Parameters, Clinical Outcomes, and Patient Experience. The healthcare outcome measures shall include mortality, the safety of care, readmission, patient experience, and timeliness of care. There should be a process to sensitise and educate hospitals on the laid down parameters and help them implement the same. Based on the above parameters there should be a methodology that would quantitatively assess the overall hospital quality. There is also a need to come up with guidelines & criteria for centres of excellence. 

It is time to review and restructure the current health systems especially to improve quality and skills. Quality and skilling standards need to be defined and institutionalised. India must take lessons from advanced systems but need to India-centric system that is capable of providing quality and affordable healthcare to all.