Standardised patients could improve primary healthcare evaluation across India

India needs a national strategy to institutionalise Standardised Patient-based monitoring, including training, ethics, and policy integration

On October 9, the Government of India released Rs 151.04 crore under the XV Finance Commission health sector grant to West Bengal to enhance rural diagnostics, advance healthy panchayats under the Localisation of Sustainable Development Goals (LSDGs), and the vision of ‘Viksit Bharat @2047’.

The XV Finance Commission has recommended Rs 70,051 crore health grants via local governments, approved by the Union government, to be disbursed from the FY 2021-2022 to 2025-2026, to strengthen grassroots health systems nationwide. These grants aim to strengthen health systems by addressing critical gaps at the primary healthcare level. It is, therefore, crucial to regularly assess the quality of public health services across rural and urban India.

One effective approach is the standardised patients (SP) methodology, where trained individuals simulate real patients visiting healthcare providers. Standardised Patients are individuals recruited from the local community and rigorously trained to consistently present a predetermined medical condition to different healthcare providers. These simulated patients allow objective measurement of provider behaviours, as healthcare workers are unaware they are being evaluated, offering a reliable assessment of the services delivered by both providers and local governments at the community level.

India possesses the infrastructure to implement simulated patient–based in-service training for primary healthcare doctors, though its application so far has been largely limited to pilot initiatives. This approach is particularly valuable for assessing health service delivery in regions with limited healthcare infrastructure and suboptimal health outcomes. A limitation of this tool is that it does not aim to represent the typical patient experience; rather, it seeks to accurately measure the performance of the average public health service provider.

Globally, the Standardised Patient method has been used to evaluate the quality of public health services provided in developing countries in tackling infectious diseases. For example, this method is used in the case of tuberculosis, and has been adapted and contextualised for implementation in countries such as China, South Africa, and Kenya.

The limited case studies conducted in India using this approach have largely been concentrated in urban areas. This is primarily attributed to operational difficulties within the rural areas. In a large country like India, a Standardised Patient-based evaluation at the rural level, within the panchayati raj institutions, can effectively assess multiple dimensions of public health service quality.

The use of Standardised Patients as a monitoring tool is gaining traction, particularly for assessing the performance and quality of rural health systems. By simulating patient interactions, Standardised Patients can evaluate the performance of local bodies, ASHA workers, and other community health workers in delivering essential services, thereby enhancing preparedness for future health crises. This approach also enables the assessment of healthcare providers’ skills and behaviours, including their adherence to National Health Mission (NHM) guidelines and Indian Public Health Standards (IPHS) protocols for specific health conditions.

To successfully introduce the use of Standardised Patients in India’s healthcare system, the government needs a comprehensive strategy that combines policy formulation, strong training infrastructure, pilot initiatives, and ethical oversight. A specialised unit within the Ministry of Health and Family Welfare or the National Health Systems Resource Centre could be established to monitor all Standardised Patients programmes in India. Hospitals and clinics, especially at the local level, can integrate their participation in these evaluations with existing quality assurance frameworks, such as those of the National Accreditation Board for Hospitals and Healthcare Providers.

Moreover, the government should develop standardised clinical scenarios for common, high-incidence conditions, such as diarrhoea, asthma, and tuberculosis, based on protocols from the National Rural Health Mission. Together, these measures would help institutionalise Standardised Patients-based monitoring in India, improving accountability and enhancing the quality of public healthcare delivery across rural and urban settings.

Megha Jacob is assistant professor, Department of Economics, Jesus and Mary College, University of Delhi.

Sukanya Das is professor, Department of Policy and Management Studies and Dean (Research & Partnerships), TERI School of Advanced Studies, New Delhi.

(Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.)