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Review: What does NITI Aayog’s report on the performance of District Hospitals say?

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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. 

  • On average, there are 24 beds for 1 lakh persons in a district hospital. Based on IPHS guidelines, a hospital should have 22 beds for those many people and the national average has exceeded this number. A total of 217 district hospitals were found to have at least 22 beds for every 1 lakh population. District hospitals in India have from one to 408 beds per 1 lakh population.  However, the WHO recommends five hospital beds for every 1,000 people. According to the assessment, Puducherry had the highest average beds (222) in the country while Bihar had the lowest average of just 6 beds per 1 lakh persons, in the district hospitals. 
  • Overall, 189 of 707 district hospitals were found to meet the doctor to bed ratio as per IPHS norms and a total of 399 hospitals were found to have a ratio of paramedical staff in position as per the IPHS norms. As per the IPHS norms, the total medical and paramedical manpower requirements vary depending on the number of beds. With respect to the number of doctors, Uttar Pradesh had the highest proportion (12.7%) of district hospitals that meet the IPHS norms for doctors in position, followed by Karnataka (9.5%) and Delhi (8.5%) and Haryana (8.5%). In terms of the number of hospitals meeting IPHS norms with respect to paramedical staff numbers, Madhya Pradesh had the highest proportion (14.8%) of such hospitals, followed by Delhi (12.5%) and UP (11.4%). 
  • On average, every district hospital in India had 11 support services, compared to the required 14. Only 89 hospitals had all support services which are crucial for day-to-day clinical services.  Tamil Nadu had the highest proportion (20.2%) of district hospitals with all the support services, followed by Rajasthan (11.2%), Uttar Pradesh (10.1%), and Karnataka (10.1%). 
  • Likewise, only about 1 in 7 hospitals fulfilled the criteria of having all 14 functional specialties such as General Medicine, General Surgery, Emergency, Obstetrics & Gynaecology, Paediatrics, etc. Even here, Tamil Nadu had the highest proportion (16.8%) of hospitals with all functional specialties, followed by Karnataka (13.9%), and West Bengal (10.9%)
  • With respect to the requirement of having 14 diagnostic testing services available including urine analysis, endoscopy, etc. in each hospital, only 21 hospitals had fulfilled the criteria of having all diagnostic testing services available. Karnataka had the highest proportion (28.6%) of such hospitals with all support services, followed by Telangana (19%), and Andhra Pradesh (14%). 
  • A high bed occupancy rate is an indication of the good quality of services being provided by the medical facility in addition to the infrastructure, trained staff, patient care, and satisfaction. Only 182 hospitals out of the 707 had bed occupancy of 90% and more while occupancy of 80-85% is considered ideal. Uttar Pradesh (14.8%) had the highest proportion of district hospitals with bed occupancy rate greater than or equal to 90 percent, followed by Madhya Pradesh (10.9%), Maharashtra (8.2%) and Odisha (8.2%).
  • On average, a doctor in a district hospital attends to 27 OPD patients. In small hospitals, a doctor has to attend to 28 OPD patients on average while in mid-sized hospitals, a doctor has to attend an average of 27 patients. In large hospitals, a doctor attends to an average of 26 OPD patients in a day. Uttar Pradesh (49.2%) had the highest proportion of districts hospitals with at least 34 OPD patients per doctor, followed by Tamil Nadu (12.4%), and Bihar (7.3%).

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. 

  • Establishment of an institutional mechanism to build capacity and enhance the quality of data reporting to help improve the quality of HMIS data. The HMIS system should be strengthened through clarification of definitions, periodic inspections, and ensuring better data management at the hospital level. 
  • Resources must be provided to district hospitals to encourage digitization. 
  • Availability of the support services, diagnostic testing facilities, and medical & paramedical staff must be ensured. This will help boost the bed occupancy rate and in general improvement of public health. 

Featured Image: Performance of District Hospitals in India

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