Review: What does NITI Aayog’s report on the performance of District Hospitals say?
Sai Krishna Muthyanolla
October 7, 2021
NITI Aayog, recently released a performance assessment report of district hospitals in India in collaboration with the Ministry of Health and Family Welfare and WHO India. This is the first time that the performance assessment of district hospitals across the country has been conducted. Here is a review.
NITI Aayog, the think tank of the Government of India recently released a performance assessment report of district hospitals in India, titled ‘Best Practices in the Performance of District Hospitals’, in collaboration with the Ministry of Health and Family Welfare and WHO India. The National Accreditation Board for Hospitals and Healthcare Providers, a constituent board of the Quality Council of India, conducted the on-ground data validation. This is the first time that the performance assessment of district hospitals across the country has been conducted. It captures the infrastructure and service outputs of the district hospitals to understand their performance.
According to the CEO of NITI Aayog, “the report marks a major shift in the health care delivery system towards data-driven governance and takes us even closer to communities and people availing health services. The entire objective of the exercise is to pave the way for a more informed understanding of health care services available in different regions and flag gaps if any”.
District hospitals in India serve at the secondary referral level
In India, healthcare services in public health facilities are extended through a 3-tier structure. These are primary, secondary, and tertiary healthcare. District Hospitals serve at the secondary referral level. Comprehensive secondary health care services are provided to the people in the district in the district hospitals. Each district hospital is linked with public hospitals/health centres such as the community health centre (CHC), the primary health centre (PHC), and the sub-centre (SC). The hospitals have been categorized into 3 groups, small (up to 200 beds), mid-sized (201-300 beds) and large hospitals (more than 300 beds). About 62% of the hospitals were small, as per this categorization. Large hospitals constituted 21%, and mid-sized hospitals constituted the remaining 17%.
707 hospitals of the 810 district hospitals in the country have been included in the assessment
Currently, there are over 810 district hospitals across India. Of these, a total of 707 district hospitals across 36 States and Union Territories, including medical colleges from some States, as shared by the Union Ministry of Health, participated in the performance assessment conducted in 2018–19. The Health Management Information System (HMIS) data for the year 2017-18 has been used as a baseline for this exercise. The data was validated against the physical records maintained by the hospitals. It was found that there was a 75% match between the data in the physical records and that entered on HMIS.
Structure-based and output based indicators have been evaluated
A wide array of health indicators such as the number of beds, number of doctors and paramedical staff, bed occupancy rates, availability of diagnostic and health care specialties, C- Section rate, Surgical Productivity Index, among others have been taken into consideration for the assessment. A total of ten indicators that have been broadly classified under the domains of structure and output have been considered for the report. These have been calculated using data from HMIS, Medical Superintendents, Census, and the Indian Public Health Standards guidelines. The ten indicators and source of information for each indicator are provided below.
Best and least performing district hospitals have been identified for each indicator
Furthermore, the top and least performing district hospitals in each indicator have been identified by assigning scores. Such a scoring system is to enable healthy competition among the hospitals to perform better. Additionally, some of the best practices of the top-performing district hospitals in each of the hospital categories across the 10 indicators have been documented in the report.
The government believes that this report can serve as a foundation for a roadmap of action for upgrading and improving district hospitals in the country. It is to serve the district and state officials in taking informed and evidence-based decisions and in improving service delivery.
District hospitals lack adequate facilities
Some of the key findings of the assessment are the following.
There are limitations to this assessment
While the assessment is a very important step in the right direction, there are a few limitations with respect to the calculation of KPIs and the scoring process. Firstly, the HMIS definitions are based on IPHS 2007 and so the data was collected based on IPHS 2007 guidelines, and not the updated IPHS 2012 guidelines. This has resulted in discrepancies. For instance, IPHS 2007 includes non-technical posts such as plumber under the category of paramedical staff. Another limitation is the different interpretations and non-uniform reporting of KPI components which are not captured in HMIS. The study recorded annual scores for numeric indicators and so, was required to take an aggregate score of 12 months for the reference period from the HMIS.
Furthermore, a proper data recording and reporting system have also been considered in the scoring exercise in addition to the other quality services offered. Suppose the hospital was unable to provide relevant data, the missing value is assigned the worst possible indicator score (=0). The framework of the performance assessment exercise can be further improved in the future by including more indicators such as child and maternal health, communicable diseases, and NCDs.
The assessment suggests the way forward
The findings suggest that there is a lot to improve with respect to the quality and quantity of resources available in most district hospitals as noted below.
Featured Image: Performance of District Hospitals in India