Photo: unicefecu/Flickr, CC BY 2.0.
On a Friday evening in November 2019, I was at one of Tamil Nadu’s largest public tertiary-care hospitals, the 3,500-bed Rajiv Gandhi General Hospital in Chennai. At first look, the hospital seemed clean. There was little litter in the spacious corridors. Cleaning staff could be seen intermittently sweeping the floors. A few patient relatives, camped in the corridors, told me they were happy with the hygiene and the facility’s upkeep.
But my impression of a well-maintained hospital collapsed when I entered the toilets. Several patient and staff toilets lacked soap, including one next to an intensive care unit (ICU), where critically ill patients are treated. How do healthcare workers and patients clean their hands, then?
This situation is not unusual for many Indian hospitals, especially overburdened public ones. But poor hygiene in this environment has today become a bigger threat than before. The world is fast approaching a post-antibiotic era, in which pathogens that cause healthcare-associated infections (HAIs) are becoming better at resisting antibiotic and antifungal substances that were once quite effective. (See explainer: What is a healthcare-associated infection?). Patients infected with pathogens that are resistant to more than three drugs – dubbed multidrug-resistant (MDR) – often die or spend heavily on prolonged hospitalisation. (See explainer: Why are drug-resistant infections a problem?)
This is why hospitals today must work extra hard to keep drug-resistant HAIs from spreading from one patient to another. This is a huge and complicated task at the heart of which is improving hygiene. Perhaps the most critical infection-control measure known to medical professionals today is the discipline of washing hands, sometimes up to 20-30 times a day. In addition, there are hundreds of other practices that have been shown to cut HAI rates.
However, the high prevalence of infections in Indian hospitals indicates they aren’t enforcing these practices. For example, Indian patients on central lines – a tube placed in a large vein, like a jugular, to deliver drugs or to perform medical tests – are at high risk of contracting infections from the lines themselves. A surveillance network of ICUs at 35 Indian hospitals reported that for every 1,000 days that patients were hooked to central lines in 2017-18, they contracted 8.77 bloodstream infections. To compare, a network of 3,586 American acute-care hospitals reported only 0.77 bloodstream infections per 1,000 days in 2018.
One reason so many Indian hospitals are bad at tackling HAIs is that it isn’t legally mandatory for hospitals to maintain a minimum standard of infection control. Even though multiple health agencies have published infection-control recommendations – such as the Indian Council of Medical Research guidelines, the Indian Public Health Standards and the Kayakalp guidelines – neither private nor government hospitals are obliged to follow any of these.
The Clinical Establishments (Registration and Regulation) Act 2010 did include a provision allowing state governments to enforce their own infection-control standards. However, only a handful of Indian states have implemented this Act.
Against this background, several public health experts are calling for mandatory quality accreditation as a way out of India’s HAIs problem. Quality accreditation requires an independent body, like the National Accreditation Board for Hospitals and Healthcare Providers (NABH), to inspect hospitals and ensure they have the minimum safeguards against HAIs.
Accredited hospitals tend to be better at infection control than their counterparts. “Accreditation is how you build quality in a country,” Ramanan Laxminarayan, who studies antimicrobial resistance at Washington’s Center for Disease Dynamics, Economics and Policy, said.
According to Laxminarayan and others, India must follow in the footsteps of other countries that have forced high accreditation rates among hospitals through various mechanisms. For example, insurance programmes like Medicare and Medicaid in the US don’t pay hospitals unless they are accredited.
But widespread accreditation in India might be a long way off. Indian hospitals have abysmally low rates of accreditation today even though the NABH program has been around for 14 years. Government-run hospitals have been particularly reluctant to sign up. Consider this: of an estimated 80,000 facilities in India, a piddly 662 are NABH accredited. Among them, only 20 are government facilities, according to Giridhar Gyani, who helped found NABH and is its former CEO.
A smattering of accredited hospitals
The resistance to accreditation among government hospitals is due largely to how overstretched they already are. Several government hospital officials I spoke to said it would be hard for them to be accredited given they’d have to upgrade their infrastructure, ensure an adequate nurse-patient ratio and manage patient numbers, among other things.
“It is next to impossible here,” Nitin Karnik, an infectious-disease specialist at Mumbai’s 1,400-bed Lokmanya Tilak Municipal General Hospital, said. Frequently, he added, the hospital’s general wards accommodate two people per bed – a strict no-no for accredited hospitals given the possibility of infections spreading.
Many public hospitals also don’t have adequate isolation facilities, another key requirement. At Microcon, a conference for microbiologists in Mumbai in December 2019, microbiologist Arunaloke Chakraborty spoke about the challenges of isolation at Chandigarh’s Postgraduate Institute of Medical Education and Research (PGIMER), which recently treated a case of a deadly fungal superbug called Candida auris. American guidelines from the Centres for Disease Control and Prevention recommend that all patients with Candida auris be isolated in a single room so the fungus cannot spread.
“Do you think it is possible in India?” Chakraborty asked.
India does have an accreditation scheme for government hospitals alone: the National Quality Accreditation Scheme (NQAS), which the health ministry launched in 2014. However, NQAS is focused only on primary health centres, community health centres and district hospitals. Larger hospitals, like the Lokmanya Tilak Municipal General Hospital, Chennai’s Rajiv Gandhi and PGIMER Chandigarh, cannot be accredited under it.
Penetration is low under NQAS as well: only 536 of the 37,725 eligible hospitals in the country have been accredited as of December 2019, according to J.N. Srivastav, a quality expert who helped develop these standards.
The low rates of accreditation all around are worrying, Laxminarayan said, because it means most Indian hospitals needn’t meet any minimum quality bar. “Today, if you open a pharmacy in India, you have to have some license. But nothing stops you from opening a hospital.”
A drain on resources
India started its accreditation journey in 2006, when the Quality Council of India (QCI), a non-profit that develops quality standards for the Indian industry, established the NABH. The QCI’s impetus was to boost medical tourism, and hospitals saw accreditation as a way to signal quality to international patients.
Since then, the number of accredited hospitals hasn’t grown as originally planned, Gyani said. One reason is that the Indian healthcare sector has never been governed by any countrywide law, at least until the Clinical Establishments Act was passed in 2010. This means thousands of hospitals have sprung up without having to satisfy any regulatory code. For them, making the leap to full accreditation is hard.
NABH standards, for example, require a hospital to tick some 650 checkboxes, including fire safety, laboratory quality control and patient rights. Fifty-four of these requirements pertain to infection control alone. Compared to general wards, NABH standards for ICUs are even more exacting. Among other things, they require one nurse to cater to each mechanically ventilated patient, Lallu Joseph, a principal assessor for NABH, said. Such 1:1 nursing may be unachievable in most public hospitals where nurses are already overworked for want of more people.
“Infection control is a resource draining initiative. Imagine, for example, that you have a patient in isolation. You need many resources like gloves, aprons and N95 masks, to cater to one patient,” Joseph said. She argued that for many Indian hospitals to undergo this transformation overnight would be “logically impossible”.
Getting more public hospitals to improve infection control will require India to ease some of the burden on existing ones. This may be easier said than done. Many government hospitals today, like New Delhi’s Safdarjung, have a ‘no refusal policy’: they can’t turn away patients, rendering the load unmanageable during, say, an infectious disease epidemic.
Part of the reason this policy exists is because India is short of hospital beds: around 1.3 for every 1,000 people, instead of the WHO’s standard of 3.5. So a patient turned away by a public hospital may have nowhere else to go.
“Sion hospital [footnote]A.k.a. Lokmanya Tilak Municipal General Hospital[/footnote] has one of the biggest slums of Asia – Dharavi – located behind it. Plus, the [residents of the] entire slum of Govandi Mankhurd come here for treatment. We have some of the poorest people coming here. I can’t send them away,” Karnik said.
Still, some hospitals are pushing back. In August 2019, Delhi’s Safdarjung hospital – whose 2,800 beds sometimes accommodate 7,000 patients – asked the Union health ministry to rethink the no-refusal policy. Sunil Gupta, Safdarjung’s medical superintendent until December 2019, told me it was time for Indian healthcare to start triaging patients[footnote] Merriam-Webster: “the sorting of patients (as in an emergency room) according to the urgency of their need for care”[/footnote].
Even though Safdarjung Hospital is a tertiary-care hospital – whose patients have been referred there by primary- and secondary-care facilities – many people approach Safdarjung for basic illnesses on their own. “For a simple sore throat, simple fever and simple diarrhoea, why should they come here? They should go to a primary centre,” Gupta said. “If you see their profile, such patients account for more than 50% of Safdarjung’s patients.”
The roots of the no-refusal policy aren’t clear, although a landmark Supreme Court judgement in 1996 may have played a part. In the judgement, the court ruled that it was the state’s constitutional duty to treat every seriously ill patient even if government hospitals ran out of beds. “If feasible, such patients should be accommodated in trolley beds and even on the floor when it is absolutely necessary,” Justice S.C. Agrawal pronounced.
The policy ensured every patient had somewhere to be treated but made infection control that much harder.
A stepping stone
India’s low accreditation rates and poor infection-control practices are slowly changing, however. Faced with the low uptake, the NABH tried to widen its net in 2014 by creating a stepping stone for hospitals that weren’t ready for full accreditation. Called the Pre-Accreditation Entry-Level standards, they allow hospitals to be certified if they fulfil a select subset of all the requirements. The idea is that it’s easier for a hospital to go from the halfway mark to being fully accredited instead of going all the way from 0 to 1.
In 2016, the Insurance Regulatory and Development Authority of India gave this idea a further fillip: it required all hospitals empanelled under Indian government insurance schemes to opt for NABH’s entry-level certification. “This, as a move, is fantastic,” Sanjeev Singh, an NABH assessor and an infection-control expert, said. “It initiates a movement at a time when nothing exists.”
The problem is that entry-level certification may be too little to tackle India’s HAI problem. Compared to full accreditation, entry-level standards for infection control are “very very minimal,” according to B.K. Rana, who headed NABH between 2016 and 2017. Of the 54 infection-control requirements for fully accredited hospitals, entry-level hospitals need to meet only around 13.
So entry-level hospitals will need to improve hand-hygiene and set up infrastructure to manage biomedical waste – both critical measures that many hospitals don’t implement today. However, they won’t need to track rates of antimicrobial resistance or HAIs, which are equally important interventions. “If you are looking for good infection-control practices, you may not find them in [entry-level] hospitals,” Singh said.
The plan has been controversial for other reasons as well. Some believe it dilutes the accreditation process by giving large hospitals that really ought to go for full-accreditation an easy way out. Gyani told me that the purpose of entry-level certification was to encourage small hospitals and nursing homes, which lacked the resources for a full accreditation, to start their quality improvement journey.
“Hospitals with over 100 beds shouldn’t have been allowed to go for entry-level,” he said. “Today, many 1,200-bed hospitals have gone for it. It is a joke.”
Another bone of contention is that the NABH doesn’t limit the time within which a facility must go from being entry-level to fully accredited. This wasn’t the original plan; hospitals were meant to stay at the entry-level for only two years, after which they were to climb to the next level, called ‘progressive’, followed by full-accreditation. But because it has been so hard to get hospitals to sign up for the entry-levels, the NABH waived these deadlines, Singh said. It’s not an ideal situation because it means hospitals can indefinitely linger at a dilute standard.
But for all these shortcomings, Laxminarayan thinks accreditation is still a force for good. He doesn’t agree that being overstretched or having to invest in infrastructure is a good reason for public hospitals to skirt the process. And if forcing higher accreditation rates would mean that the government would be forced to build more hospitals, “that’s one way to solve this problem,” he says.
In the end, quality standards are a must-have – an assurance that a hospital is doing everything it can to prevent avoidable deaths. “All such regulations add to costs. But we as a society pay for those, because we say it’s worth it,” Laxminarayan said. “Should you be allowed to freely kill people just because it’s expensive to prove that you are not?”
Featured image: A bottle of alcoholic hand-rub rests on a reception desk the Amrita Institute of Medical Sciences, Kochi. Widespread availability of alcoholic hand-rub and soap in hospitals helps healthcare workers maintain high rates of hand-hygiene. Photo: Mansi Thapliyal.
Reporting for this article was funded by the European Journalism Center (EJC) through its Global Health Fellowship Program.
Priyanka Pulla is a science writer.