ASSESSING THE NEED FOR AND DESIGNING AN ACCREDITATION SYSTEM
Suituation in India
Sunil Nandraj
Health services in India is a multi-provider system comprising of public, private and non-government organisations. Considering the size of India's population and its distribution, one can easily conclude that public sector alone cannot provide the health care services, particularly the curative care. It is, therefore, necessary to continue the present policy of having a multi – provider system comprising of public as well as private and NGO sectors. The basic question in such multi-provider system is how to define the quality of service and construct standards applicable to local situation. Such appraisal should ultimately provide an opportunity for the customer to make and intelligent assessment of the relative quality of the service offered by different health care facilities.
There is no doubt that private sector makes a significant contribution to health care delivery in India. The database available with HIS which is being updated by filed visits indicates that in the State of Andhra Pradesh the private and voluntary sector together provide about 42,00 beds which is more or less equivalent to the total beds in different categories of public sector hospitals. The NSSO 42nd round indicates that, among the households samples, more than three fourths of the non-hospitalised cases and about a third of all hospitalised cases preferred private sector.
The private sector in India offers a wide range of facilities and services. There is also wide varieties in the quality of care provide by the private sector. To provide reliable information on quality of care, there should be an appropriate mechanism. One certified, the system should also ensure that the quality standards are being maintained. Any talks of quality assurance have been met with resistance from the medical profession and /or hospital owner manager. Even if hospitals were to accept accreditation, there is hardly any capacity operates an accreditation service. One of the fundamental requirements for accreditation is a set of agreed standards. India has hardly any standard in the area if hospital procedures, facilities etc. Recently the Bureau of Indian Standards (BIS) has developed important standards for hospitals, IS I2377/1988 is the standards for classification and matrix for various categories of hospitals IS 12433/1988 is the standards on basic requirements for 30 bedded hospitals. Both the standards aim to provoke a broad framework at the national level. The AP Vaidya Vidhana Parishad has developed some standards at the state level (Mahapatra 1988)
In India health care services are provided by many entities, who use various forms of organisations and practice different systems of medicine. The provision is mainly through the public and private sectors. The public sector health services are primarily provided by the State Government and to some extent Central Government, municipal corporations and other local bodies. In additions to the health ministries, Government health services are provide by ministries and departments of the health ministries., government and through Employee's State Insurance Scheme (ESIS) for the organised sector employees. The private health sector consists f the 'not-for-profit' and the 'for-profit' health sectors. The not-for profit health sector includes various health services provided by Non Government Organisations (NGO's), charitable institutions, missions, trusts etc. health care in the for- profit health sector is provided by various types of practitioners and institutions. These practitioners range from General Practitioners (GPs) to the super specialists, various types of consultants, nurses and paramedics, licentiates, Registered/Rural Medical Practitioners (RMPs) and a variety of unqualified persons (quacks). The practitioners not having any formal qualifications constitute the 'informal' sector and it contains of tantrika, faith healers, bhagats, hakims, vaidyas and priests who also provide health care. The institutions falling in the private health sector range from single bedded nursing homes to large corporate hospitals and medical centres, medical colleges, training centres, dispensaries, clinics polyclinics, physiotherapy and diagnostic centres, blood banks, etc.
The NSSO's 42nd round finding show that for impatient care nearly 60 percent approach public hospitals among both rural and urban population. But for routine medical care (out patient care) 60 to 70 percent is provided but the private health sector (NSSO 1989, this is substantiated by other studies conducted in the country Duggal andAmin 1989, Kannan et.al. 1991, George A et.al 1994, NCAER 1992). The findings also make it evident that a substantial financial burden of the household is borne for meeting health care need. Compared to the state expenditure on health the private household expenditure is nearly four to five times more than that of the state (Duggal R. Amin S. 1989.p94). In India, the private sector has grown to be the most dominant one in the Health care sector. The share of private health care sector is between 5-6 percent of the Gross Domestic Product. This share at today's prices work out to between Rs. 20,000 and Rs. 24,000 crores a year. India probably has the largest private health sector in the world (Duggal R. 1992)
The National sample survey 42nd round conducted between July 1986 and June 1987 showed that for ambulatory are 53.01% in rural areas and 51.83% in urban areas were using the private health sector. The corresponding rural –urban figures for private sector utilisation with respect to indoor care was comparatively much less at 36.85% and 36.59% respectively. (NSSO 1989 Tables 2R, 2U, 13R and 13U). Most of the other macro and micro studies conducted in recent years have not gone into a break up of utilisation data by impatient and out patient care and hence show a relatively high utilisation of the private health sector. The two large studies done by the NCAER and the Kerala Sasthra Sahitya Parishad (KSSP), therefore showed a private health care utilisation of around 65% (NCAER 1992 p39 and Kannan KP et.al 1991 p127). Two micro studies carried out on substantial samples in Maharashtra and Madhya Pradesh indicated 83.45% and 69.05% utilisation if private health facilities for acute episodes. (George A(ed.) 1994 pp118-119). The findings of these studies also made it evident that a substantial financial burden of the household expenditure is nearly four to five times more than that of the state (Duggal R, Amin S, 1989 p94). The share of the private health sector is between 4 to 5 percent of the Gross Domestic Product. This share at today's prices works out to between Rs. 16,000 crores to Rs. 20,000 crores per year. (Duggal R, Nandraj S., 1991 p5)
Review of Private Hospitals and Nursing Homes
In India the contrasts with regard to private hospitals is vast. On one extreme there are the hi-technology, five star corporate hospitals and at the other end there are small nursing homes with 1 or 2 beds functioning from residential places and sheds. During the last one and half decades the growth of corporate hospitals has been at a very fast pace. Many corporate houses and non-resident Indians have recently entered this enterprise. Several large business houses in addition to their regular business have diversified into the field of health. During 1974, 16% of the hospitals and 21.50% of the hospital beds in India were in the private sector and the rest in the public sector. This proportion increased in 1990 to 57.95% of the hospitals and 29.12% hospital beds in the private sector. (CBHI, GOI, various years). There are reasons to believe that the number of hospitals in the private sector is much larger than the available data suggests. A survey undertaken by Andhra Pradesh Government found the existence of 2,802 private hospitals and 42,192 private hospitals beds in Andhra Pradesh Government found the existence of 2,802 private hospitals ad 42,192 private hospitals were located in urban areas (which were the States capital, District HQ, Divisional HQ and Taluk HQ). The bed population ratio in private hospitals was 6.37 beds per 10,000 population as compared to public hospital which was 5.12 (AP Govt .1993). The above data suggests that the sizes of private hospitals are mainly concentrated in the urban areas. In many of the metropolitan cities, district head quarters and semi-urban places the majority of the hospitals/ nursing homes have a bed size of 15 to 25. There has been very little information forthcoming and documented on the structure, functioning role and quality of care provided by Private Hospitals and Nursing Homes (PH and NH) in the country. Very often information that is available is thorough media reports and studies, which are far too few.
Of late many facts are coming out due to judicial orders. In Calcutta a petition was filed by an advocate in the Calcutta High Court regarding the conditions of private hospitals and nursing homes. In response to this a committee was appointed by the speaker of West Bengal Legislative Assembly in 1985 to prepare a report. This report found that the nursing homes lacked adequate floor space, ventilation, lighting, water, bathroom facilities and qualified doctors and nursing staff. (The Telegraph, 2nd July). In 1991 the Chief Justice of the Bombay High Court directed the Bombay Municipal Corporation (BMC), to set up a permanent committee to oversee and supervise the implementation of the Bombay Nursing Home Registration Act (BNHRA), 1949, and make recommendations.
The committee as one of its tasks decided to look at the functioning of existing private hospitals and nursing homes in the city of Bombay. The committee studies 24 hospitals and nursing homes in the eastern zone of Bombay, (Nandraj S, 1992). The major findings of the study were that a seventh of them were functioning from sheds or lofts in slums and more than half were located in residential premises. More than sixty percent of the hospitals and nursing homes did not have a minimum of 50 sq.ft. space for each bed. Most of them were congested, lacked adequate space, passages were congested, entrances narrow and crowded and there was inadequate space for movement of either of trolley or stretcher.
Out of the 22 who were supposed to have an Operation theatre (OT), only 15 of them had one while in seven the OT also served as a labour room. It was observed that in some the OTs and labour room were in rooms originally designed as kitchen. Some had OT's that were pathetically as small as 48 sq.ft and leakages were to be found in the OT and labour room. Seventy seven percent did not have a scrubbing room. Many of the hospitals and nursing homes were ill equipped, especially those providing maternal health services. For instance many of them did not have resuscitation acts in the labour room for newborn babies. The availability of supportive services like ambulance services, blood, oxygen cylinders, generators etc was insufficient. Majority of them employ unqualified staff. Out of 24 hospitals and nursing homes only 1 hospital had employed a post graduate doctor, whereas 10 of them had doctors trained in other systems who were providing treatment in allopathic. Few hospitals had provision for the doctors to be present round the clock. Majority of the nursing homes utilised the services of visiting consultants. Less than a third have qualified nurses and most of them had employed unqualified nurses.
The sanitary condition of private hospitals and nursing homes leaves a lot to be desired. It was found that in 37.50% of cases, the hospital premises and beds in general ward were dirty. The number of toilets and bathrooms were not in proportion to the number of beds provided in the hospital. It was quite shocking to note that many of the hospitals did not have continuous supply of water and in some of them it was being provided from outside through tankers and other means. With regard to waste disposal none incinerates infectious waste material, but instead, all dump it in municipal bins. While these facts relate to Bombay, it should be apparent that the situation in the private health sector in other cities is likely to be similar, or perhaps even worse. (The Hindu 12th August 1992).
Among the major complaints against private PH/NHs are those of overcharging, not providing the personalised care they claim to provide, subjecting patients to unnecessary tests, consultations and surgery, defunct equipment, not providing information about diagnosis and treatment, absence of doctors for long periods even in the ICU, general disregard for patients and their highly commercial nature of operation. (Times of India 4th March 1991). It is also alleged that referrals are often made to specialists and laboratories for a kickback.
The dismal conditions of hospitals and nursing homes functioning can be attributed to there is practically no monitoring and accountability to the people or the authorities concerned. In fact there is hardly any authority concerned to deal with this sector. In most of the states in India there are no legislation's, regulations for PH/NH. An enquiry undertaken by the Medico Friends Circle (Bombay group) on regulatory and monitoring mechanisms existing in several states of India, found that the States of Tamil Nadu, Punjab, Andhra Pradesh, Kerala, Goa Daman and Diu, Mizoram, Gujarat, Orissa, Sikkim and Manipur do not have any rules, laws, regulations even data of PH/NHs. Added to these states are Madhya Pradesh and Rajasthan. This was found out through visits and discussions with government officials of the respective state governments. To our knowledge Maharashtra, Union territory of Delhi and Karnataka have a legislation for private hospitals/nursing homes. In Delhi there is the Delhi Nursing Home Registration Act (DNHRA), 1953, Bombay Nursing Homes Registration Act (BNHRA) 1949 is applicable for Maharashtra (Nandraj.S.1994). In Karnataka there is the Karnataka Private Nursing Homes Act, 1976.
Over the last two years there were many questions raised by members in the Andhra Pradesh assembly, regarding the regulations, functioning, norms, fees charged, exploitation of the patients, low wages paid to the employees, free treatment to poor patients etc. The Health minister's replies have been that there are no rules and regulations for PH/NH/ in the state, and the matter would be considered. (AP, assembly questions, 1992-94).
In Bombay the Bombay Municipal Corporation (BMC) was not enforcing the BNHR Act. The judges in their order observed that "The Writ petition has served the purpose of activising the concerned authorities, who seem to have woken up and taken certain steps in the direction of implementation of the various provision of the law." The corporation during the hearings admitted that the officials had not visited nor taken action against any hospital or nursing home. In fact, one out of four hospitals were functioning without registration. Though the Act was applicable to entire Maharashtra, its implementation was found to be restricted to the cities of Bombay, Pune, Nagpur and Solapur. In Delhi, the administration admitted that only 134 out of 545 nursing homes were registered. There is hardly any regulatory intervention or interference of the government in the private sector and on the health care market. (Jesani A and Nandraj S 1994). Nor is there any significant attempt so far towards developing an accreditation system though this issue is catching attention recently.
Analysis of effects made for evolving standards and developing an accreditation system.
The awareness of need for standardisation has been a recent phenomenon in the Indian health delivery system, more specifically for private hospitals. The need and development of standards for hospitals could be broadly viewed from the role-played by the government, consumer organisations and health organisations and the various organisations of hospital owners and other professional bodies. In the past one-decade there have been debates and discussions on issues of functioning, quality, finance, monitoring, accountability and standards of private hospitals and nursing homes in the country. These have taken place between hospital owners, health professionals, researchers, activists, consumer groups and government functionaries. One of the major concerns has been the issue of standards for hospitals and nursing homes taking into consideration their location, size and type of services provided. These efforts were mainly in two directions, one was to evolve minimum standards and the other to develop an accreditation system.
Government's Role: As seen earlier the government role in monitoring the private hospitals has been minimal. In Bombay and Delhi where there is legislation on minimum requirement and guidelines have been laid down in the Act regarding space, sanitary conditions, personnel, equipment, fees to be charged etc to be followed by the hospital and nursing home activities. Very surprisingly in Bombay the public health department o BMC which grades restaurants in the city on the basis of hygiene and facilities is also responsible for PH/NH. Only recently the Delhi administration has started evolving certain minimum standards for private hospitals. These are that the doctor- patient ratio should be 1:10, the nurse-patient ratio should be 1:5 in a general ward, and 1:1 in intensive care units. The doctor holding a recognised degree should be present round the clock. A separate labour room and OT, each having minimum floor space of 180 sq.ft should also be there. The new rules also make it obligatory for the nursing home to display the charges to be levied for various services available at a prominent place.
There has been little or no effort to evolve any kind of guidelines, minimum standards for hospitals and nursing homes in the private sector. The government's efforts have largely been concerned with guidelines and standards for their own institutions. There are guidelines for running of government hospitals and institutions. Maharashtra and Andhra Pradesh have guidelines for running of government hospitals. In Maharashtra there are Hospital Administration Manuals Vol. 1 & 2 and in Andhra Pradesh there are the Hospital Standing Orders. (Govt of Maharashtra, Govt of Andhra Pradesh 1967). These manuals/orders contain detailed instructions on the management of hospitals for the various services, in terms of duties, norms, instructions etc. In all probability other state governments too have similar guidelines. The government periodically has appointed committees to evolve and upgrade standards and specifications for its own hospitals and institutions. The various committees that made specific recommendations in this regard were the Mudaliar, Ayar, Rao and Bajaj committees.
In the recent past a study was conducted by the National Institute of Health and Family Welfare (NIHFW), New Delhi for the purpose of drawing up of norms for equipment for hospitals. It undertook a review of literature on the various standards existing for hospitals. The study mainly concentrated on government hospitals. It came up with guidelines on norms for essential and major equipment for 50, 100 and 500-750 bedded hospitals. These were for basic diagnostic, therapeutic, supportive, other important service areas of the hospital and various departments of medical and surgical services of the hospitals. The norms laid down covered specifications of the equipment, their quantity and approximate price. (Anand T R, Agarwal A.K, 1992)
The Bureau of Indian Standards (BIS) has developed standards for basic requirement for hospitals up to 30 beds (IS: 12433 (part 1)-1988) and standard on the classification and matrix for various categories of hospitals (IS 12377). The standards covers basic requirement for planning a 30 bedded general hospital in respect of functional programme, functional and space requirements, manpower requirements, instruments and equipment and essential requirements for building services and environment. The classification and matrix for 5 categories of hospitals (30, 100, 250, 500, and 750 bedded) and according to the functions (BIS(a), (b) 1988)
Role of consumer and Non-government health organisations.
The credit of focusing attention of the people regarding standards for private hospitals and nursing homes largely goes to the consumer groups. This was due to the fact that these groups were working on various aspects of the private health sector for quite some time. Along with the consumer bodies, groups of health professionals and hospital organisations were also involved for drawing up standards and to develop accreditation system. These efforts though at infant stage show a potential for developing in the near future. These were undertaken primarily by consumer and non-governmental organizations based in the cities of Bombay, Pune and Hyderabad.
MFC along with other like minded organisations has been in the forefront on the campaign of accountability of private hospitals to the people and authorities. In this connection it filed Public Interest Litigation in the High Court of Bombay. As an outcome of the case the a committee if experts was appointed by the Bombay High Court to oversee the implementation of the BNHR Act and to make guidelines for the functioning of PH/NH in the city of Bombay. The committee could not complete the tasks due to the bureaucratic composition of the committee. As part of its campaign the group organised seminars, workshops and public meetings. One of the seminars was to suggest minimum guidelines for PH/NH. The speakers at the seminar spelled out what they considered the minimum basic requirement for a 10-20 bedded hospital. Among the minimum requirements emphasized by the speakers was an adequate supply of essential drugs, enough space, separate room to carry out medical procedures, arrangements for blood free from AIDS and hepatitis, 24 hour water supply with built-in sterilising equipment, portable x-ray machine, four to six oxygen cylinders, a safe wiring system. They also stressed the importance of availability of trained personnel round the clock. One of the speakers pointed out that standards had to be drawn up keeping in mind conditions in India and not necessarily as per British or American norms. Another speaker wanted the doctors to set the ideal standards first and then reach a compromise on attaining them over a period of time. Many of the speakers felt that the hospitals should be categorized according to the level of care they offer. (Times of India, 9th April 1992).
Meanwhile in Pune the Health Committee of the Lok Vihnyana Sanghatana (People's science organisation in Maharashtra) took the initiative in preparing minimum standards. After intensive discussions by the committee for check up for anaesthesia before surgery it came up with 'Routine Preoperative investigations for 'Minor Surgery' in A.S.A. Grade 1 patients'.
In Hyderabad the Institute of Health Systems (IHS) is working on evolving an accreditation system for private hospitals in Andhra Pradesh. As a first step it has collected and maintains a database on PH/NH in the state. Along with this it conducted an exit poll of patients treated in private hospitals in the city of Hyderabad. The study found that majority of the respondents were in favour of an accreditation system and felt the need for a third party inspection for compliance of standards.
Hospital owners and other professional bodies:
There have been efforts from within the PH/NH owners associated and the medical procession also to promote an accreditation system by the Indian Hospital Association (IHA) both at Bombay and Delhi. In Bombay the IHA along with the Bombay Management Association joined hands to promote the scheme in the city. The scheme visualised that PH/NH would be given accreditation according to the degree to which they conformed to the minimum standards laid down by an accreditation committee comprising prominent members of the medical and legal fraternity. The accreditation fees varied from Rs. 2000 for a 15-bedded hospital to Rs. 15,000 for one with more than 300 beds. The accreditation given would be valid for two years. The organisers reason that they would depend on persuasion and the doctors self scrutiny and not have a policing role. The scheme was envisaged with the idea that the PH/NH would get accredited voluntarily (The Independent, 24th February 1993). The response to the scheme has been very luke warm. To the best of our knowledge the organisers did not lay down the basis for gradation and only three hospitals had come forward. Many of the private hospital and nursing home owners felt that the move was in the right direction but at the same time regarded it with scepticism and suspicion. It was felt that the committee should tone down the minimum requirements for areas such as space allotted per bed and the number of trained nurses.
The responses of Private hospitals and nursing homes for having minimum standards and to participate in an accreditation scheme has not been encouraging. Among the problems put forward are that the proposed standards were unreasonable and impractical for them to follow. Nurses were not available since majority of them joined the Government service and many went to the Middle East. A vocal and powerful section of health care professionals assert that the medical profession is only accountable itself and not to society. Even in the U.S.A, which has a prominent private health sector, there is an established system of accreditation and various rules governing the functioning of private hospital and nursing homes. India lags behind in these respects and this call for the need of an accreditation system. Towards this end the I.H.S. Hyderabad is making a small step in evolving an accreditation system for Andhra Pradesh (A.P).
References:
Andhra Pradesh Assembly Questions, Q. no. 5556, Dr. Geeta Reddy, 26/8/92, Q. No 9069, Shri M Kodanada Reddy 17/2/94 – 21/2/94
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