Results and Cross-Cutting Issues
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To summarize, quality has yet to become a major area of focus for the schemes. Large purchasers of health care in India—including GSHISs, government, and private insurers—have yet to use their financial leverage to improve the quality of care provided at their networked facilities. Data are not demanded on quality of care. Though not atypical of many countries, this failure to focus on quality has multiple causes: ambiguity about the role of a purchaser in influencing clinical decisions, assumptions that such decisions are best left to medical professionals who would also be appropriate managers for quality issues, lack of information about the nature and magnitude of quality problems (and their effects on payers’ costs), and lack of clarity about specific measures that purchasers and providers can take to improve quality. Under their current design, GSHISs may be incentivizing the expansion of small, low-quality hospitals as well as an outdated and potentially unaffordable hospital-centric delivery model.
The Role of Public Hospitals An important policy issue relates to how GSHISs can improve the performance of public hospitals and foster their utilization by beneficiaries. In theory, the new generation of GSHISs is designed to foment competition for beneficiaries among all empaneled public and private hospitals. This competition is based on hospitals’ prestige or perceived quality, since most schemes are cashless for the beneficiary and information on quality of care is generally lacking.62 In most cases, private hospitals, and to a lesser extent public medical colleges, that continue to receive the lion’s share of beneficiaries, are prestigious or higher-end hospitals that cater to the middle class. These facilities are generally located in Tier 1 cities. Outside Tier 1 cities geographical access may play an important role in facility selection: the real choice is among hospitals that are accessible to the patient. There could be a greater role for public hospitals in this system, especially in areas where private supply is nonexistent, inadequate, or of poor quality. This section focuses on public hospitals’ governance and accountability arrangements that may be an obstacle to increasing their participation in GSHIS provider networks. It also reviews potential opportunities based on the Indian experience in promoting more independent public hospitals. However, understanding the challenges and opportunities of public hospitals is constrained by the lack of data in India on the supply of hospital services and beneficiaries’