2. Dimensions of Health Care Quality
Health care is a service but has become a business following economic liberalization. In comparison with other commodities or goods, health care needs specialized human resources. Mwachofi 2011 summarized health care as a service for ill or sick people, and normally nobody can predict service needs, the outcome of care cannot be assured, most of the industry is dominated by nonprofit providers, and payments are made by third parties, mostly by government agencies
[40]. Other market products are typically consumed on a daily basis; industry produces agency or vendor supplies and wholesalers or retailers sell those to the consumers.
Quality health care can be viewed from different angles. One, it needs to make health care/service safe, patient-centered, timely, effective, efficient, and equitable. Allen-Duck 2017 described ‘right theory’ as doing the right thing, the right time, for the right patient, in the right way to achieve the best possible results
[42]. Similarly, the quality strategies published by Centers for Medicare & Medicaid Services (CMS) stated that quality health care strategies provide assurance of safety by reducing harm caused in the delivery of care, strengthening person and family engagement as partners in their care, promoting effective prevention and treatment of chronic disease, and effective communication and coordination of care
[43].
There is a large difference in quality health care from the patients’ perspectives. A study by Sixma et al., 1998 concluded that there are two components that profoundly affect the quality of health services: performance components and behavioral components
[44]. A meta-analysis by Hall and Dornan 1998 from 221 studies explored the relationship between patient satisfaction and medical care
[45][46]. Another study from Hall 1998 from 41 observational studies showed that patient satisfaction was related to objective measures of information giving, technical and interpersonal competence, providers’ partnership-building, and socioemotional behavior, such as a provider’s nonverbal behavior, social conversation, and positive talk
[47]. Apart from the patient satisfaction, there is a umbrella concept consisting of 11 aspects that include humaneness (65% of all studies), informativeness (50%), technical skills of the health care provider (43%), bureaucratic procedures (28%), access to and availability of health care services (27%), costs of treatment and flexibility of payment mechanisms (18%), the comfort of seating, attractiveness of waiting rooms, clarity of signs and directions, quietness and neatness of health care facilities (16%), continuity of care (6%), outcome of the health care process, in terms of usefulness or effectiveness (4%), and attention to psycho-social problems (3%) and overall quality of care (45%).
3. Quality Health Care, Application of Technology and Price
Innovation in health care technology is linked to improved health care quality. In most cases, new technology is required to reduce the cost of human resources while also providing quick results in disease diagnosis and treatment. The application of new machines in health care settings begin after the economic evaluation of health care, which includes cost benefit, cost effectiveness and cost utility analysis. Geligns 1991 and Tabis 2005 concluded that if the new technology could not minimize the cost, had a short life span, was difficult to maintain, and had a high environmental hazard, it was not acceptable
[50][51]. A study by Ben-Israel et al., 2021 found that unruptured intracranial aneurysms (UIA) was a new innovation in open surgery and application of this technology is economically feasible
[52]. Similarly, a study by Mohammad ZahedulAlam et al., 2022 found that mobile health (mHealth) wan not associated with price of health care in developing countries
[53]. Fundamentally, the application of new technology that does not increase the price of health care is a onetime investment with the aim of reducing the cost of health care. Research by Belfiore et al., 2018 showed that Human Body Posturizer (HPB), an innovative therapeutic tool used in lower back pain and its use reduced the cost of treatment by one-third
[54]. Kos (2018) noted that new technology in health could be adopted after evaluating the health problem and current use of technology, the technical characteristics of technology, its safety, clinical effectiveness, costs and economic evaluation, ethical analysis, organizational aspects, patient and social aspects and legal aspects
[55]. They concluded that new technology is seldom responsible for increasing the price of health care.
Health care is a service industry, and receiving good service is part of quality care. Kos 2018 investigated the five major costs associated with providing health care services: labor, materials, overhead, fixed costs, and variable costs
[55]. Elisabeth Engl et al., 2019 concluded that the friendly behavior of health care providers is the major factor in quality care from the patient’s perspective
[55][56]. A systematic review by Ahmet Nacioglu 2016 showed that clear communication about patient safety enhances the quality of care, which is related to effective communication and practice of professionalism
[57]. Another important factor in quality health care is physical infrastructure. A cross-sectional study of 4300 facilities from 8 countries by Leslie et al., 2018 showed that ensuring adequate space for care was available in every department and waiting room, hygiene and sanitation, greenery, and space management provided quality care and a pathway for sustainable health care
[58]. An editorial by Luxon summarized the characteristics of quality health care in eight areas; built environment or adequate infrastructure, medical equipment, access with service, technology, governance and organizational structure, staff structure and team work were the foundation of sustainable health care
[59].
4. The Health Care Market, Issue of Quality Health Care, and Price
The revenue from the health care industry worldwide is projected to be about 50 billion, annual growth is 12%, with a projected market volume of USD 15,830.00 m, with most of the revenue generated in China by the end of 2022
[60]. Ignoring the few exceptions, the health care industry is similar to other industries, and most of the economic rules match
[61]. As in other industries, the inflation rate, demand and supply, market competitions, and price elasticity all apply. However, the health care profession or industry is more specialized than other daily goods consumption because it requires highly skilled human resources, sophisticated diagnostic laboratories, and scientifically-proven drugs to treat disease. Martin Gaynor 2023 concluded that there are few agencies entering the market due to its complexity. A special agency responsible for monitoring and oversight of health-care markets is necessary, but the market rules are similar in health care industry as other industries
[62]. Moreover, patients need special care from highly-skilled nurses and medical assistants for a speedy recovery. Branning 2016 stated that in spite of the special characteristics of the health care industry in the USA, the costs of care could be split as follows: up to 30% in physician costs, 10% in pharmaceutical cost, 21% in administrative cost and up to 36% in new innovation and technology
[63]. It seems that the administrative cost is similar with other industries, while cost for new innovation and technology obviously pays back and does not necessarily increase the price, but a review by Ogura et al., 2014 concluded that to enhance the quality of care, human resource costs are higher than in other industries but somehow, these can be balanced by appropriate supply chain mechanisms
[64]. Barber et al., 2021 carried out country case studies concerning health care services’ price setting and regulation approaches and concluded that collective negotiations and unilateral price setting have the potential to control price levels and avoid price discrimination
[65]. As a result, the main issue is not price increases, but cost adjustment in the health care industry.
5. Menu-Based Health Care and Quality
There is a practice of menu-based health service, and any client/patient can choose additional services. During a hospital stay, there might be sophisticated services for those who can afford them. These menus are mostly in private health care facilities. Some patients may want large rooms with television, Wi-Fi, a spa or sauna, physical therapy, different ways of entertainment, etc., during their hospital stay
[66]. Moreover, there are several health centers and clubs that are a part of health care. Every health service provided by health facilities is not essential. They may not significantly cure diseases and they are only supportive, but Currow 2016 revealed that the additional cost/price may affect with patient outcomes, and it can be linked with quality of care
[67]. There are specific clinical procedures, protocols, standards and guidelines in medical practice, and World Health Organization (WHO), frequently updates them. Heymann 1994 highlighted that those clinical protocols are keys to maintaining quality health care, and adopting those protocols is a professional ethic for health care providers
[68]. Neff et al., 2009 noted that there is no mandate to follow the protocols and guidelines in those health care menus and ultimately those optional services increase the health disparity
[69]. The price difference of those menu items obviously reflects the economic class, creates a situation of selection bias, and may result in catastrophic health expenditure
[70].
6. Sustainable Health and Health Care Quality
Sustainability refers to meeting the needs without compromising the ability of future generations to meet their needs, and quality care should lead to sustainable care. Sustainability can be conceptualized as an area of the quality of health care, extending the responsibility of health services provided to patients from now to the future. A sustainable approach maintains the value of health care, directs for positive treatment outcomes and ultimately reduces the financial burden. Hovlid et al., 2012 concluded that quality health care is a prerequisite for sustainability
[71]. A study by MacNeill et al., 2021 highlighted that failing the challenges of sustainable health care would result in poor quality of health care and large amount of money wasted in the USA
[72]. An analysis by Clery et al., 2021 suggested that quality improvement in health care accelerated the sustainability in every perspective and maintained the good relationship between health care providers and patients
[73]. Maeda et al. concluded that Universal Health Coverage (UHC) not only assures access, equity, and protection in health care but also ensures quality health care and a road to the sustainable health care
[74]. A qualitative study by Anam Parand et al., 2012 explored that a Safer Patients Initiative is one of the best strategies to ensure the quality health care pathway to sustainability in health care
[75].
7. Expectational Situations
There are exceptional situations that do not occur normally. The preceding facts demonstrate that high-quality health care does not always come at a high price. Nonetheless, Jacovljevic 2022 and Park 2022 found that there are some situations that become out of control for some period of time, such as global crises such as pandemics and wars, and some supply chain restrictions, a scarcity of expert service, and high market liquidation
[76][77]. Zeus Aranda, Thierry Binde et al., 2022 showed that there were significantly reductions in maternal health service due to disturbances of supply chain in 37 low and middle income countries
[78]. Efrat Shadmi, Yingyao Chen et al., 2020 examined 13 countries and found that during the COVID-19 pandemic there was profound disruptions of health care access, equity, and quality in primary care
[79]. Roberton et al., 2020 revealed that there was a 27% increase in the under 5 mortality rate, and a 23% increase in maternal mortality due to the 2014 Ebola virus epidemic, and the influenza pandemic of 2003
[80]. Miljeteig et al., 2021 reported that there was a scarcity of human resources such as physicians and nurses and a need to pay high salaries, ethical violence in medical practices and insufficient personal protective equipment, and ultimately, a need to pay high even for primary care during the COVID-19 pandemic in Norway
[81]. The above studies show that there can be significant compromises in health care access, quality, and price in exceptional situations such as pandemics, and health care management should be handled carefully.