When hospitals call in sick

Dinesh Trivedi, India’s junior health minister, recently said that he feels “safer in a plane than inside a hospital”. As a trained pilot, you would expect Mr Trivedi to feel more at home in a cockpit than in a hospital. But safer?
Mr Trivedi was not being facetious when he said this at a conference on healthcare and global standards organised by the Federation of Indian Chambers of Commerce and Industry (Ficci). A few nuggets I picked up at the conference sent shivers down my spine, too. Only 54 hospitals in the entire country have been granted accreditation till date by the National Accreditation Board for Hospital and Healthcare Providers (NABH) out of a total of some 450 applications. More than half of the accredited hospitals are located in metros — Delhi (and its neighbourhood), Mumbai, Kolkata, Chennai and Bengaluru. Small-town India ha­r­dly has any accredited hospital.
How many hospitals and nursing homes are there in the country? No one knows, because no one has ever counted. The data simply does not exist. Why is this so? It is so because health is a state subject and New Delhi can only do so much. Most states in India don’t have a law which requires hospitals and nursing homes to register themselves.
“A doctor has to register with the Medical Council of India or state medical councils. Otherwise, he cannot practice. So we have figures for the number of doctors in the country. But except in a handful of states, there is no legal requirement for hospitals and nursing homes to register with a regulatory body. States which have the law do not often monitor compliance with quality guidelines”, says Dr B.K. Rana, deputy director of NABH, an agency set up by the Quality Council of India (QCI) four years ago.
Though the requirements of NABH accreditation have motivated some hospitals to pull up their socks, most care little because accreditation is not mandatory.
From a consumer or patient’s perspective, all this is disturbing. We not only lack information about the number of hospitals and nursing homes in the country, we also don’t know what goes on inside our hospitals. Most hospitals either do not have, or make public, any data on percentage of medication errors, incidence of needle-stick injuries, bed sores after admission, infection rate in surgical sites and so on. Most official accounts of India’s healthcare sector gloss over these lapses.
Healthcare is touted as the “next big thing” after information technology. Those in the business of forecasts say it will be worth $280 billion by 2020. The hospital industry is expected to be worth $54.7 billion by 2012, representing more than 70 per cent of healthcare sector revenues. The rising Indian middle class along with its increasing purchasing power and willingness to pay for quality healthcare has been a prime driver for the emergence of high quality health facilities. Indeed, metropolitan India has some of the finest doctors and a growing number of multi-speciality hospitals. The harsh truth, however, is that the vast majority of hospitals in the country are sole proprietorships, have somewhere between 30 to 70 beds and are run much like provision stores.
Medical tourism and spread of health insurance have brought home the importance and benefits of quality adherence through mechanisms such as NABH. Healthcare providers have begun to recognise that improving quality helps patient safety as well as the bottomline. Accredited hospitals report significant improvements in leadership, medical records management, infection control, reduction in medication errors, staff training and quality monitoring, points out Dr Sanjeev Singh, associate professor and medical superintendent of the Kochi-based Amrita Institute of Medical Sciences and a member of NABH’s technical committee.
If, over the past year, many hospitals have applied for NABH accreditation, part of the reason is a ministry of health directive that made qualification for CGHS (Central Government Health Scheme) empanelment contingent on accreditation. This has spurred hospitals to upgrade their facilities and quality norms in order to meet NABH’s standards. Hospitals which do not take quality issues seriously run the risk of losing business to hospitals empanelled by the CGHS. Gujarat, for instance, which is chasing economic growth, is also taking the lead in hospital and health centre accreditation.
The recent passage of the Clinical Establishments (Registration & Regulation) Bill, 2010, in Parliament could give a big push to the quality movement in the health sector. The main objective of the new statute, which covers government-run clinical establishments as well as all “systems of medicine”, is to bring some sort of uniformity in healthcare delivery in the country by making registration of all clinical establishments mandatory and prescribing increased penalty for defaulters. The new law will initially be applicable in Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim and all the Union Territories. Subsequently, other states can adopt it after going through due procedure. Delhi, Maharashtra, Karnataka and Madhya Pradesh already have their own clinical establishment acts.
An emerging economic power like India should make a big deal about quality and patient safety norms in hospitals and nursing homes. Many of our Asian neighbours like Malaysia and Taiwan have already done so.

n Patralekha Chatterjee writes on development issues in India and emerging economies and can be reached at patralekha.chatterjee@gmail.com [2]