Dr. Sudhir Singh
Senior Consultant and Head,
Department of Ophthalmology,
JW Global Hospital and Research Centre,
Mount Abu, India
NABH accreditation is becoming mandatory for all hospitals and while most authorities welcome this step, there are certain issues when it comes to smaller health care facilities. The process of getting accredited is not easy and often costs fair amount of time and resources. Dr Sudhir Singh senior consultant and head of department of Dept. of Ophthalmology, JW Global Hospital Research Centre, Mount Abu, India talks about why we should say No to NABH.
Do you think healthcare accreditation should be mandated?
No, we do not think present health care accreditation should be mandatory.
The currently prevailing health care accreditations in India are based on developed countries health care practices. These health care accreditations are very expensive and complicate to implement. They are not suitable for our 1.3 billion populations as they make affordable health care to unaffordable to healthcare seekers as well as providers.
The NABH standards are also based on the European standards and are not suitable private clinics, small and medium hospitals as they raise establishment and recurrent costs of private clinics, small and medium hospitals many times. Eventually forcing hospitals to pass it on to consumer and making affordable health care to non affordable to majority non insured population.
I would like to mention famous dengue death case in the Fortis hospital Delhi in 2017 in this context. She was a young girl who died due to dengue and she was charged 1.70 million rupees. This is the perfect example of accreditation and affordability in Indian scenario. This case was highlighted in Indian media for wrong reasons and doctors were painted as greedy, looters by the society and media. There were hundreds of deaths due dengue in government hospitals and private hospital in same period in Delhi region but not became news. It was 1.70 millions rupees bill that leads this case in media lime light. The lesson we all healthcare professions and health providers can learn form this case is that we should work to find out ways and means of the affordable and quality health care.
If the NABH standards are so good and essential then the government should first implemented in all government hospitals. Private small/medium hospitals are much better in every respect like quality, accessibility and accountability.
What is the basis of the say no to NABH campaign?
“Say No To NABH” is a pan India campaign of small and medium hospitals and health care providers from small towns to metro cities. We are providing affordable health care to the majority of our population. Most of these hospitals are run by solo doctors with limited resources. This movement was started in response to IRDAI decision to link cashless medical insurance and national accreditation board for hospitals (NABH) accredited hospitals. We feel that NABH standards are based on western work culture and they are serious threat to affordable and accessible health care for following reasons:
1. The NABH accreditation needs licenses/no objection certificates from various agencies: The NABH requires so many licenses from various agencies like pollution control board, fire department, drug licenses, PCNDT, gases storage licenses are few examples which are mandatory for even the smallest hospital. Procurement/renewal of these licenses are very difficult and associated with bribe at every level. This will lead to an inspector raj and corruption in healthcare. The employee’s state insurance (ESI) and employees provident fund (EPF) facilities need to be given to employees of the small hospitals. The small hospital cannot afford to provide the ESI and EPF facilities to their staff.
2. The land or space requirement for the setup of a new NABH accredited small hospital/
medium hospitals: As per norms of the NABH the land/space requirement is much more. The more land/space requirement would have more cost. The cost of the land in the big and medium cities is sky high. This cost is out of the reach of the most of doctors in big and medium cities.
3. The operation theater norms for the NABH accredited hospitals: The operation theater should have laminar flow or it should be a modular operation theater. The operation theaters with laminar flow/modular operation require more space than normal operation theater. So it will increase the establishment cost steeply. The running cost of the laminar flow/modular OT is also very high. If we look at ophthalmology in last two decades in India, the infection rate was not high despite the fact that the most of the operation theaters were not have laminar flow or modular concept. If we review the cluster endophthalmitis incidences, the main culprits were contaminated irrigation fluid and viscoelastics. The reautoclaving irrigation fluids and viscoelastics were found to be effective in endophthalmitis prevention in high volume cataract surgery centers with non laminar flow/ modular operation theaters. Dr David Chang a famous ophthalmologist from United States of America after visiting the Aravind Eye Hospital Madurai. He wrote many operating room regulations may unnecessarily increase costs without proven benefit. In other words, the developed countries want to learn from us but irony is that we Indians are following blindly their expensive practices without proven efficacy over our decades old practices. The NABH guidelines for operation theaters are perfect examples blindly copying of western world.
4. The NABH requires documentation of each and every process/procedure:
The most of these process and procedure are copied from western countries and are not suitable for Indian scenario. The documentations of the process/procedures need extra time and manpower. These unnecessary documentations consume so much skilled medical manpower in unnecessary clerical work. I feel that the skilled medical manpower should be judiciously utilized for clinical purposes, where it requires the most. Our country is already facing shortage of the skilled medical manpower like doctors and paramedical staff, so we need a health system which requires less documentation and more clinical output.
5. Human resource related issues of the NABH accredited hospitals: All employees should be enrolled for employees provident fund (EPF) and employees state insurance (ESI). The Internal Complaints Committee for prevention of sexual harassment of women at workplace should be constituted. These human resources requirements are not feasible for most of the solo doctor, small and medium hospitals and pose extra burden of the responsibility and expenditure.
6. The cost and benefit of the NABH accreditation implementation: The NABH accreditation raises establishment costs, recurrent costs and operational cost of the private clinics, small and medium hospitals many times. Eventually forcing hospitals to pass it on to consumer and making affordable health care to non affordable to majority of uninsured population. The hospital can not charge more from insured and empanelment patient due to capping of the charges by insurance and empanelment companies.
would like to conclude by saying that the small and medium hospital are playing vital role and providing affordable and accessible health care to the majority of the Indian population. The enforcement of the NABH standards will be setback to affordable health care being provided by non NABH accreditation small and medium hospitals to 1.3 billion fellow Indians.