Adherence to Quality in District Hospitals of Haryana: A Recent Assessment as per Indian Public Health Standards (IPHS)

Abstract

The article assesses the quality standards of available health care services as per the Indian Public Health Standards (IPHS) at all the 22 District Hospitals (DHs) in Haryana and also brings out a ranking of districts within the State based on these parameters. A structured schedule was prepared using IPHS norms and guidelines, and data was collected from all the DHs in the State on required components of quality standards. The article uses different statistical tools such as mean, standard deviation, coefficient of variation (CV) for analysis and attempts preparing a composite IPHS Index based on the type and number of services available. It found that the overall mean percentage score of observed quality standards was 66.5% across 22 DHs in Haryana (8 DHs>70%, 11 DHs between 60% and 70% and 3 DHs < 60%). Further, ranking across the State shows DH Panchkula on top with rank one whereas DH Charkhi Dadri appears at last with rank 22 based on the laid IPHS parameters. The article asserts that the observed quality standards are not fully matched with expected quality standards at DHs in Haryana and recommends the need for periodic reviews, perpetual monitoring of these standards and functioning, and emphasises on systemic management of the required IPHS parameters to ensure provisioning of optimal healthcare services at these hospitals.

Keywords

Quality standards Indian Public Health Standards (IPHS)the Composite IPHS Index (CII)district hospitals Haryana

Introduction

Quality is a crucial and all-pervasive component in the provisioning of any health care services irrespective of the type of health care facility, that is, primary, secondary or tertiary. The quality inter-alia depends on adherence to various laid down parameters and standards. After the 1990s, it was overwhelming felt that there are enough health institutions in the country but they are grossly inadequate in terms of manpower and other equipment. Aggarwal and Parthi (2002) stated that a distinct vision of health aspires for a generally healthy population, free from the impact of communicable and non-communicable diseases with client-friendly manpower in health and family welfare centres. Besides the continuation of the usual preventive health care measures, the state must ensure provisions for the availability of quality health care services (including secondary and tertiary health care services) to everyone, including the underprivileged. The health care system of the future should be based on scientific evidence and be more technologically advanced. It was also realised that there was a disparity in the available health care system of India by type of area (rural and urban areas), type of institution (public and private health care institutions) and among different tiers of public health institutions (primary, secondary and tertiary).

In this context, a set of uniform standards known as the Indian Public Health Standards (IPHS) were framed in 2007 (which were later revised in 2012) for public health institutions in India. These standards were defined according to the type of health care facility and designated bed-strength and envisaged to improve the quality of health care delivery across different institutions throughout the country. IPHS document provides services that a District Hospital (DH) is expected to provide. These standards are the benchmarks for quality expected from various components of public health care organisations and may be used for assessing the performance of the health care delivery system. These have been grouped as Essential (Minimum Assured Services) and Desirable (which are aspired to be achieved). IPHS, besides the basic specialty services, gives due importance to newborn care, psychiatric services, physical medicine and rehabilitation services, accident and trauma services, dialysis services, anti-retroviral therapy & patient safety, and infection control norms (MoHFW, 2012).

The DH is an essential component of the district health system and functions as a secondary level of health care that provides curative, preventive and promotive healthcare services to the people in the district. Every district is expected to have a DH (MoHFW, 2012). This article attempts to assess the level of available quality standards in DHs of Haryana, namely, expected level of quality standards through IPHS, as these hospitals serve as a major and critical provider of health services in the State. The review of the literature did not point out any substantial input on assessing the implementation of these standards in the DHs of Haryana. Thus, it became imperative to assess the implementation of these laid down quality standards in the DHs of Haryana.

Rationale

The service quality components (performance drivers) can be helpful as they can be used as managerial control tools which may pressurise the organisers to improve the overall health management system. Similarly, such assessment becomes more important as causative determinants may point out the reasons for low use of public hospitals in Haryana for treatment of ailment in comparison to other States in India. NSSO 71st Round points out that only 18% of the hospitalised patients received treatment at public hospitals in Haryana as compared with 82% at private hospitals in 2014 (GoI, 2014) which improved only marginally (20%) in 2018 as per the NSSO 75th round (GoI, 2018). Hence, it is pertinent to assess different dimensions of these DHs in terms of IPHS standards. The article aims at helping the policy makers/regulators to remove the anomalies, optimise and make efficient utilisation of resources which in turn will result in better service provisioning.

Objectives of the Study

The article aims:

To assess the currently prevalent quality standards of health care services at different DHs in Haryana as per laid down IPHS and find out district-level variations, if any.

To rank the DHs in Haryana as per the composite IPHS index (CII).

Review of Literature

Zaman and Laskar (2010) conducted a study in 2008 to compare the quality of health services provided by Primary Health Services (PHCs) in terms of IPHS guidelines by selecting 10 PHCs from Assam Empowered Action Group (EAG) and five PHCs from non EAG state of Karnataka and found substantial gaps between the existing infrastructure and IPHS norms. The study found that all the PHCs under consideration were providing OPD, outdoor emergency and referral services, whereas the provision of 24*7 delivery services was only in 80% of the PHCs. The availability of laboratory services at PHC level was substantially high (80%) in Karnataka compared to very low (20%) in Assam. Sodani and Sharma (2012) assessed in their study the availability of assured services, surgeries, maternal and newborn health care services, and child health care services at PHCs in five districts of Rajasthan in reference to the IPHS for the year 2006. The study exhibited that about 90% of the PHCs under consideration showed the availability of services such as outpatient department, antenatal & postnatal check-up, immunisation, and treatment of diarrhoea. However, emergency services and other services related to fractures, pregnancies, surgery of cataract, lower weight babies and gynaecological cases were not up to the mark at these PHCs. Srinath and Veena (2012) assessed the compliance of the IPHS with respect to manpower, services, equipment and drugs & supplies in PHCs of Bangalore urban district with a sample size of five PHCs selected randomly. The study found higher variations in terms of manpower and lesser variations in terms of drugs and supplies at these PHCs. Medical staff was not much aware about the IPHS guidelines. Some of the equipment were not found in working condition. Ninama et al. (2014) assessed the quality standards of healthcare services available at PHCs of Rajkot (Gujarat) according to the IPHS in 2010–2011 choosing 14 randomly selected PHCs. The results were positive in terms of availability of high percentage of doctors (92%), nurses (57%), lab-technician (100%) and pharmacist (100%). However, residences/staff quarters were available only at 21% of the Centres. All PHCs were providing OPD services with availability of essential drugs and emergency services were also available at 92% PHCs. However, bio-medical waste management norms were followed by only 71% of the PHCs. Chauhan et al. (2016) assessed the availability of medical staff, services and infrastructure through the IPHS guidelines by selecting seven community health centres (CHCs) and 12 PHCs from Shimla District during 2011–2012 and found non-adherence to IPHS protocols. They found 100% availability of OPD and referral services. Moreover, separate labour rooms and laboratories were available in 86% and 100% of the CHCs, respectively. However, no specialist doctor was available at any of the CHC, no pharmacist was available in 43% and 75% of the CHCs and PHCs, respectively. Likewise, three-fourth of the selected PHCs were without any staff nurse and laboratory technician was not available at 43% CHCs and 83% PHCs. Patil and Shivaswamy (2016) conducted a cross sectional study to assess the quality standards of CHCs of Belagavi district of Karnataka in terms of IPHS in 2014. They visited a total of 10 randomly selected CHCs. Their findings stated that about 40% of the CHCs were covering larger populations than stipulated norms. General duty officers, nursing staff, pharmacist and laboratory technician were available in all the CHCs but the availability of specialised doctors was only limited to 30% of the facilities. Availability of equipment and drugs ranged from 50% to 75%. Dolma (2018) conducted a study to assess the quality standards of various components of services provided in sub-divisional hospital (SDH) situated at Khaltsi block of Leh district of Kashmir during the month of June 2014 as per the IPHS guidelines 2012. They found shortage of medical services like surgery, paediatrics, radiology, ENT, ultrasonography, etc., and non-availability of General Duty Medical Officers and surgeons at these hospitals though most of the ancillary services, except bio-waste management, were found in accordance with the IPHS guidelines. The review of literature did not come across any study attempt to assess the quality standards compared to IPHS in DHs in Haryana.

Null Hypothesis

H₀: There is no statistically significant difference between observed quality standards and expected quality standards with respect to medical services, medical &surgical procedures, physical infrastructure, manpower, investigative & laboratory services, equipment and essential drugs, as per revised IPHS guidelines at DHs in Haryana.

Theoretical and Conceptual Framework

An assessment of quality standards of health care of DHs has its theoretical roots to the Donabedian Model (1966) of healthcare, which is a model for assessing the health care services and quality of care. This model categorises the system of health care into three components namely structure, processes and outcome. ‘Structure’ of any health care system includes buildings, staff, sources of financing, types of equipment, etc. ‘Processes’ consist of both technical excellence and interpersonal excellence and personal characteristics. An ‘outcome’, the third dimension of health care, refers to the impact of the health care services on the patients’ perceived health status. In order to have a full assessment of the healthcare performance, Donabedian suggested measuring the performance of each component.

With the help of the Donabedian model and our null hypothesis, a conceptual framework was conceived (Figure 1) to assess the availability of all quality standards of health care under seven categories (medical services, medical and surgical procedures, physical infrastructure, manpower, investigation and laboratory services, equipment and essential drugs) at DHs in Haryana.

Figure 1.

Conceptual Framework.

Data and Methods

The present study is cross-sectional in nature which was carried out in all the DHs of Haryana through primary data collection and field survey conducted during September 2019 to February 2020. There are 22 DHs in Haryana and all of them were included in the study as one of the main objectives was to rank them on the basis of availability quality standards of health care services as per IPHS. Structured schedules were prepared as per the standards mentioned in the revised IPHS guidelines 2012 for DHs according to their bed strength, that is, for 100-, 200- and 300-bedded hospitals separately. In Haryana, out of a total of 22 DHs, 11 DHs were classified as 100 bedded, nine as 200 bedded and two as 300 bedded. It is pertinent to mention here that some of the DHs (Ambala, Panchkula, Mewat, Palwal, Charkhi Dadri, Sirsa and Yamuna Nagar) were using extra beds in day-to-day practice. However, for our analysis, we treated all of them as per their official sanctioned bed strength.

Expected Quality Standards at DHs

The article identifies seven components to assess the quality standards of health care services at DHs in Haryana as per the laid down IPHS guidelines for DHs. Presuming that every reader may not be aware about all these components, they have been elaborated in brief in the following paragraph.

The expected ‘Medical Services’ include specialist services, para-clinic services, support services and administrative services which are 55 in number for 100- and 200-bedded hospitals but 64 in case of 300-bedded hospitals. The second component ‘Medical and Surgical Procedures’ is extremely important as this component includes service mix of procedures by the specialist doctors at DHs. Higher the adoption/application of these procedures, higher will be the ranking of the hospital in terms of satisfaction of the patients and will also result in higher patient visitation rate for outpatient and inpatient services. However, the adoption of these procedures depends upon the availability of all other components like doctors, technicians, departments/rooms and more important the functional instruments/equipment in these hospitals. All these expected listed procedures are 459 in number. The third component namely ‘Physical Infrastructure’ includes number of buildings, number of departments (including diagnostic, clinical laboratory, blood bank critical care area, intensive care unit, number of ICU beds, operation theatres, and physiotherapy) besides hospitals services (like central sterile and supply department (CSSD), easily accessibility of CSSD to operation theatre, hot water facilities, dietary service, hospital laundry, medical & general stores and mortuary) and engineering services (like electric sub-station, generator room, emergency lighting services, call bells and natural & mechanical system of ventilation, AC and room heating in OT and neo-natal units, air coolers or hot air convectors, water coolers and refrigerators) adding to a total of 126 expected services irrespective of DH’s bed-strength. The fourth component ‘Manpower’ includes medical staff, nurses, paramedical staff and administrative staff. Total expected number of required staff is 123, 185 and 273 for a 100-, 200- and 300-bedded DH, respectively. The fifth component ‘Investigative and Laboratory Services’ expects all DHs with fully equipped laboratory in general with separate rooms for doctors, as well as for sample collection, and fully equipped laboratory separate for blood bank. A total of 96 such services are expected at each DH. The sixth component ‘Equipment’ expects availability of 329 essential equipment for 100- and 200-bedded DH and 368 equipment for 300-bedded DH. The seventh component ‘Essential Drugs’ expects availability of a total number of 462 essential drugs. Table 1 lists the expected number of identified quality standards with respect to the above mentioned seven components.

Table 1.

Number of Items in Identified Quality Standards Expected at DHs as per IPHS.

S. No.	Name of the Expected Quality Standards	Label	Total Number of Expected Quality Standards
S. No.	Name of the Expected Quality Standards	Label	100 Bedded Hospitals	200 Bedded Hospitals	300 Bedded Hospitals
1	Medical services	QS-1	55	55	64
2	Medical & surgical procedures	QS-2	459	459	459
3	Physical infrastructure	QS-3	126	126	126
4	Manpower	QS-4	123	185	273
5	Investigative & laboratory services	QS-5	96	96	96
6	Equipment	QS-6	329	329	368
7	Essential drugs	QS-7	462	462	462
	Total		1,650	1,712	1,848

Source: IPHS Guidelines for District Hospitals.

To assess the availability of quality standards in DHs, the Percentage of Observed Quality Standards (POQS) for ‘individual’ as well as for ‘the composite’ IPHS score was calculated as

P O Q S = \frac{O b s e r v e d Q u a l i t y S t a n d a r d}{E x p e c t e d Q u a l i t y S t a n d a r d} \times 100

(1)

To calculate the composite IPHS score, all the individual components were added up in absolute form then the percentage of total observed quality standards was calculated with respect to the total expected number of quality standards according to bed strength of the hospitals, using Equation (1) and labelled as Composite IPHS Score.

To find the existence of inter-hospital disparities regarding the availability of the IPHS quality standards, the coefficient of variation (CV) was calculated as

C V = \frac{S D}{Mean} \times 100

(2)

where SD is standard deviation and mean is arithmetic mean.

To rank the DHs on the basis of available quality standards, a CII was constructed for all the DHs in Haryana through the deficiency index (di) (Sheet & Roy, 2013) by following the below procedure.

First, the levels of deficiency for a specified DH, for selected quality standards, were measured through the mathematical formula of di as shown in equation(3):

d i_{i j} = \frac{(M a V_{i} - X_{i j})}{(M a V_{i} - M i V_{i})}

(3)

where, di_ij denotes deficiency index of the ith quality standard at jth DH, MaV_i and MiV_i denotes the maximum and minimum values of ith quality standard, respectively, and Xij denotes original value of ith quality standard at jth DH.

Second, the average deficiency index (di_j) for the jth DH was calculated by taking arithmetic mean of deficiency indices (di_ij) of all the quality standards for the jth DH using Equation (4) as given below;

d i_{j} = \frac{Σ_{i = 1}^{n} d i_{i j}}{n}

(4)

where di_j denotes the average deficiency index of jth DH. Here ‘n’ denotes number of quality standards.

Finally, the CII_j for jth DH was constructed on the basis of the average deficiency index (di_j) using the following equation:

C I I_{j} = (1 - d i_{j})

(5)

where CII_j denotes the Composite IPHS Index.

Here, in this article, only the average deficiency index (di) and the CII are shown to rank the DHs.

One unique features of this article is the construction of a separate IPHS index, for observed quality standards at DHs, according to their ‘sanctioned bed-strength’ besides the usual ‘overall CII,’ irrespective of sanctioned bed-strength.

Results and Findings

Gap Between Expected and Observed Quality

Table 2 shows that DHs in Haryana are classified in three categories on the basis of their bed strength, that is, 100 bedded (11 hospitals), 200 bedded (9 hospitals) and 300 bedded (2 hospitals). It shows the component wise availability of these services as against the expected services besides showing the mean values at State level, standard deviations and coefficient of variations for each component. Observed Quality Standards have been calculated in two ways; ‘individual DH quality standards’ and ‘overall observed quality standards of all the 22 DHs.’ The percentage of observed quality standards has been calculated on the basis of Equation (1) whereas the existence of variations in the availability of observed quality standards was calculated on the basis of Equation (2).

Table 2.

District-wise and Bed-strength Wise Observed Quality Standards against Expected at DHs in Haryana.

Name of DH/Bed-strength		Observed Quality Standards as % to the Expected							Composite IPHS Score
Name of DH/Bed-strength		QS-1	QS-2	QS-3	QS-4	QS-5	QS-6	QS-7	Composite IPHS Score
S. No.	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)
100 Bedded
1	Charkhi Dadri	74.5	11.3	55.6	38.1	50.0	41.6	62.6	41.5
2	Fatehabad	89.1	59.7	66.7	73.8	58.3	62.9	69.7	65.8
3	Gurugram	98.2	54.9	73.8	96.8	75.0	83.9	58.9	69.2
4	Jhajjar	94.5	37.9	63.5	67.5	71.9	85.7	58.0	61.2
5	Kurukshetra	94.5	54.2	84.1	92.1	56.3	74.5	72.5	70.1
6	Mewat	76.4	38.3	67.5	87.3	57.3	62.9	74.0	61.6
7	Narnaul	74.5	37.3	65.9	62.7	42.7	66.3	59.7	55.1
8	Palwal	89.1	65.8	67.5	83.3	52.1	65.3	47.2	62.1
9	Rohtak	98.2	60.1	91.3	112.7	70.8	86.9	59.1	73.6
10	Sirsa	94.5	60.6	81.7	96.8	58.3	88.8	68.4	73.9
11	Yamuna Nagar	89.1	57.5	65.1	76.2	58.3	81.8	61.5	66.7
Mean (100 Bedded)		88.4	48.9	71.2	80.7	59.2	72.8	62.9	63.7
200 Bedded
12	Ambala	98.2	64.7	64.3	63.2	70.8	83.0	71.2	71.2
13	Faridabad	90.9	71.2	74.6	44.3	67.7	80.9	52.4	65.8
14	Hisar	94.5	69.7	71.4	96.8	56.3	80.2	75.5	76.4
15	Jind	87.3	56.6	64.3	63.8	53.1	84.5	59.1	64.8
16	Kaithal	96.4	68.4	52.4	65.9	57.3	86.9	60.8	68.8
17	Karnal	96.4	62.7	72.2	65.9	61.5	77.8	60.6	67.1
18	Panipat	94.5	50.5	71.4	60.0	66.7	84.5	63.9	65.5
19	Rewari	96.4	64.7	81.7	84.3	70.8	80.2	58.4	70.7
20	Sonipat	100.0	54.2	84.9	90.3	60.4	84.5	85.5	76.5
Mean (200 Bedded)		95.0	62.5	70.8	70.5	62.7	82.5	65.3	69.6
300 Bedded
21	Bhiwani	82.8	44.4	61.9	48.4	63.5	79.1	52.4	57.4
22	Panchkula	92.2	74.1	98.4	80.2	78.1	94.3	61.0	78.2
Mean (300 Bedded)		87.5	59.3	80.2	64.3	70.8	86.7	56.7	67.8
HARYANA
	Mean	91.0	55.4	71.8	75.0	61.7	78.0	63.3	66.5
	SD	7.7	14.5	11.3	19.0	8.9	11.8	8.8	8.2
	CV	8.4	26.1	15.7	25.3	14.4	15.1	13.8	12.3

Source: Own calculations based on primary data.

Note: Labels of quality standards (QS-1 to QS-7) defined in Table 1.

Bold values indicate maximum and minimum values.

‘Overall assessment of observed quality standards’ was made to rank the DHs on the basis of these standards. Table 2 shows that the observed scores are 63.7%, 69.6%, and 67.8% for a 100-, 200- and 300-bedded DH, respectively. Table 2 points out that eight DHs are having IPHS quality standard score of more than 70%, 11 DHs between 60% and 70%, and three DHs less than 60%. The table indicates that mean composite IPHS score was 66.5% (minimal (41%) for DH Charkhi Dadri as against maximum (78%) for DH Panchkula. The lowest and the highest values itself confirms the variation in observed quality standards across DHs and the same is revealed by the value of CV which is 12.3% for the State.

QS-1 for ‘Medical Services’ was observed at 91% (minimum at 74% for DHs Charkhi Dadri and Narnaul, and maximum at 100% for DH Sonipat) with calculated CV at 8.4%. QS-2 for ‘Medical & Surgical Procedures’ was observed at 55% (lowest (11) for DH Charkhi Dadri and highest (94%) for DH Panchkula and CV at 26.1% which reveals a high degree of variation in observed quality standards on this parameter for DHs across Haryana. QS-3 for ‘Physical Infrastructure’ was observed at 72% (minimum (52%) availability at DH Kaithal and maximum (98%) availability at DH Panchkula with CV at 15.7%. QS-4 for ‘Manpower’ shows availability at 74% (lowest (38%) at Charkhi Dadri and highest (113%) at DH Rohtak (115.4%) with a high degree of CV (25.3%). QS-5 for ‘Investigative & Laboratory Services’ had a mean value of 63% (minimum (43%) at DH Narnaul and maximum (78%) at DH Panchkula) with CV at 14.4%. QS-6 for ‘Equipment’ availability was observed at 79% (lowest (42%) at DH Charkhi Dadri and highest (94%) at DH Panchkula CV at 15.1%. QS-7 for availability of ‘Essential Drugs’ shows mean availability of 63% drugs (minimum (47%) at DH Palwal and maximum (85%) at DH Sonipat with degree of CV at 13.8%. From this important table, it can be easily drawn that in implementation of IPHS norms, Haryana lacked more in terms of medical and surgical procedures, investigative and laboratory services, medicines and physical infrastructure as compared to medical services, equipment and manpower. Moreover, a high degree of coefficient of variation was observed in case of availability of medical and surgical procedures and manpower which indicates larger disparities in availability of these components at the district level hospitals.

Ranking of DH Based on the CII

As stated earlier, a CII was constructed as shown in Equation (5) to rank all the DHs in Haryana. The ranks have been calculated ‘according to sanctioned bed-strength’ besides ‘overall ranking in the state’. Table 3 ranks all these hospitals.

Table 3.

The Composite IPHS Index (CII) and Ranks of DHs (According to Sanctioned Bed-strength and Overall Within Haryana).

Name of DH/Bed-strength		Composite IPHS Index (CII)	Rank of DH
Name of DH/Bed-strength		Composite IPHS Index (CII)	According to sanctioned bed-strength	Overall rank within Haryana
S. No.	(1)	(2)	(3)	(4)
100 Bedded
1	Charkhi Dadri	0.126	11	22
2	Fatehabad	0.509	7	16
3	Gurugram	0.699	2	4
4	Jhajjar	0.541	5	12
5	Kurukshetra	0.650	4	9
6	Mewat	0.430	9	19
7	Narnaul	0.262	10	21
8	Palwal	0.441	8	18
9	Rohtak	0.788	1	2
10	Sirsa	0.698	3	5
11	Yamuna Nagar	0.525	6	15
200 Bedded
12	Ambala	0.654	4	8
13	Faridabad	0.536	8	14
14	Hisar	0.681	3	7
15	Jind	0.464	9	17
16	Kaithal	0.538	7	13
17	Karnal	0.578	5	10
18	Panipat	0.578	6	11
19	Rewari	0.683	2	6
20	Sonipat	0.772	1	3
300 Bedded
21	Bhiwani	0.376	2	20
22	Panchkula	0.803	1	1

Source: Own calculations based on primary data.

Column 2 of Table 3 exhibits the CII which is constructed on the basis of the average deficiency index. Further, obtained CII score was used to rank all the DHs according to ‘their sanctioned bed strength’ and ‘overall’, respectively, as shown in columns 3 and 4, respectively. In the category of 100-bedded hospitals, DH Rohtak was ranked first (CII Score 0.788) followed by DH Gurugram and DH Sirsa (CII Scores 0.699 and 0.698, respectively). While the fourth, fifth, sixth and seventh positions were held by DHs Kurukshetra, Jhajjar, Yamuna Nagar and Fatehabad (CII scores 0.650, 0.541, 0.525 and 0.509, respectively), the DHs at Palwal, Mewat, Narnaul and Charkhi Dadri were assigned eighth to eleventh ranks, respectively, with abysmally low CII scores. Likewise, in the category of nine 200-bedded hospitals, DH Sonipat was assigned rank one (CII Score 0.772) followed by DHs Rewari and Hisar at ranks 2 and 3 (CII scores 0.683 and 0.681, respectively). DHs Ambala, Karnal, Panipat Kaithal, Faridabad, and Jind were assigned rank 4 to rank 9, respectively (with lot of disparities in obtained CII scores which ranged 0.464–0.654). In the category of 300-bedded hospitals, DH Panchkula ranked one (with a high CII score 0.803) followed by DH Bhiwani (with very low CII score of 0.376). The obtained CII score clearly indicates that quality of health services in Haryana varies a lot among different districts, and all DHs require lot of over-hauling to match them at par with laid down IPHS standards.

In overall ranking, irrespective of sanctioned bed-strength (column (4) Table 3), DH Panchkula ranked one (CII Score 0.803) closely followed by DHs Rohtak and Sonipat (CII scores 0.778 and 0.772, respectively). DH Charkhi Dadri was ranked 22nd (with a CII score of 0.126) out of all the 22 DHs in Haryana. So, in both ways of ranking, DH Panchkula ranked first whereas DH Charkhi Dadri ranked last.

Results of Testing Hypothesis

The proposed hypothesis (H_o: There is no statistically significant difference between observed quality standards and expected quality standards with respect to medical services, medical & surgical procedures, physical infrastructure, manpower, investigative & laboratory services, equipment and essential drugs, as per revised IPHS guidelines at DHs in Haryana) was tested on the basis of expected and observed quality standards in DHs of Haryana. The value of t-statistic (16.24) was highly significant at 1% level of significance indicating that there was statistically significant difference between expected and observed quality standards at DHs in Haryana. So, our study rejected the null hypothesis and concluded that the observed quality standards are not fully matched with expected quality standards at the DHs in Haryana.

Discussion and Policy Implications

This is a pioneer study which examines component-wise quality standards at all DHs in Haryana, through its micro and macro analysis. The seven components of quality standards assessed at all the DHs in Haryana shows that the mean availability of observed quality standards (QS-1–QS-7) at all of these hospitals ranged between 55% and 91%, with composite IPHS score value of 66.5%. No single DH exhibited 100% availability of all laid down IPHS quality standards.

This article draws some important conclusions for policy makers. It found a clear mismatch between the expected and observed components of quality standards at DHs in Haryana. Similar results were also found in PHCs of Shimla district of Himachal Pradesh (Chauhan et al., 2016), DHs, sub-divisional hospitals, CHCs and primary health centres of Rajasthan (Bakhshi & Nair, 2014) and in sub-divisional hospitals of Leh district of Kashmir (Dolma, 2018). For instance, availability of ‘Medical & Surgical Procedures (QS-2)’ shows a high degree of disparity (11% at DH Charkhi Dadri to 74% at DH Panchkula with low mean availability at 55% for all DHs). Likewise, the percentage availability of ‘Essential drugs (QS-7) again showed lot of variations (from 47% at DH Palwal to 86% at DH Sonipat with mean availability at 63% for the State of Haryana). Such mismatch between observed and expected quality standards is a matter of serious concern and need to be rectified.

The article brings forth high degree of variations in the availability of some quality standards as shown by high value of CV across different DHs. This is quite strange given the fact that all DHs within the state are managed by same set of policymakers. It points out that there is a need to carry out rigorous planning and assessment exercises (systemic component-wise management, monitoring, and periodical review), before the next budgetary allocations are sanctioned and implemented in the State. One of the reasons for these variations is State’s excessive dependence on central government grants and funds. Health being a state subject, it is time that State of Haryana should set its own priorities, in their annual budgets, to provide equitable and uniform health care facilities to entire population within the State.

Field Discussions

The field discussions with senior officers working at these DHs clearly brings out the fact that non-adherence to quality standards, as laid down in IPHS, at these hospitals is partly a managerial problem but also an economic problem. The funds required to bring sufficient improvements in these components are often not available with state sanctioning and allocating a miniscule of funds in their annual budgets towards capital expenditure.

During the primary data collection, it was observed that the availability of health care services (medical, infrastructural, laboratory and medicine, etc.) were not satisfactory in at least half of the DHs in Haryana (Bhiwani, Charkhi Dadri, Faridabad, Fatehabad, Jind, Kurukshetra, Karnal, Mewat, Narnaul, Palwal and Yamuna Nagar). For instance, in Faridabad, the population has increased manifold but the health infrastructure has not kept pace with the changing time. Medical staff was regularly assigned assignments other than their prime job. Some of the problems reported by OPD and IPD patients include lack of basic infrastructural facilities such as availability of drinking water, availability of adequate number of beds, cleanliness of wards and toilets, availability of electricity points in wards, provision of security in wards, adequate ventilation, shortage of medicines, etc. It was also observed that a Quality Assurance Cell was functioning in every DH of the state to ensure and monitor the quality of services in different departments at these hospitals. But, often they function under very limited autonomy to introduce systematic improvements and bring about efficiency in the functioning of these DHs.

Conclusions and Recommendations

Better health is vital to human happiness and well-being because a healthy population lives longer. It proves more productive and hence makes an important contribution to economic progress (Singh & Aggarwal, 2021). Keeping this in mind, the present article attempts to assess the existing quality standards of health care services in terms of laid down IPHS standards besides ranking all DHs in Haryana based on their performance in terms of available IPHS standards. It found that the overall mean percentage score of observed quality standards was 66.5% across 22 DHs in Haryana (8 DHs>70%, 11 DHs between 60% and 70% and three DHs < 60%). The IPHS revised norms were applicable to be implemented from 2012. However, after almost a decade of implementation, we are lacking on many fronts so far as adherence to laid down quality standards are concerned. The existence of variability in the availability of these quality standards highlights the indifferent attitude of the policy makers in bringing about improvement on a uniform pattern, in these hospitals. Further, ranking through CII across the State shows DH Panchkula on top with rank one whereas DH Charkhi Dadri appears at last with rank 22. The study rejects the null hypothesis that there was no statistically significant difference between observed and expected quality standards as per revised IPHS guidelines at DHs in Haryana and concluded that the observed quality standards were not fully matched with expected quality standards at these hospitals.

This mismatch between observed and expected quality standards at different DHs is a matter of serious concern and need to be examined seriously at highest level of administration in the State. The gaps point out the requirement of not only enhanced infrastructure but also increase in manpower, equipment, drugs and provisioning of more medical, surgical and investigative facilities at all of these hospitals.

Limitation and Scope for Future Research

The primary data was collected for this study only for the DHs in the state. There are other types of referral health institutions in the State such as SDHs, CHCs and PHCs, for which a separate set of IPHS guidelines exist. We could have included them in our study to check the status of all referral institutions in Haryana but due to the limitation of time and associated data collection costs, it was avoided. However, it is pertinent to mention here that the methodology used in the article for component-wise analysis for observed and expected availability standards, is possible to be replicated for similar such research in future. Moreover, the ranks assigned in this article are dynamic and subject to change with improvement in different quality standards in future.

Footnotes

Acknowledgements

The present article is based on data collected for doctoral research work of Mr Dalbir Singh under the supervision of Dr Rajesh Kumar Aggarwal, Associate Professor at the Centre for Research in Rural and Industrial Development (CRRID), Chandigarh. Data were collected across all the 22 DHs in Haryana with due permission from Director General, Department of Health and Family Welfare, Government of Haryana vide letter number 8/65-1HE/2019/MH/1661-1683 dated 06-09-2019. The authors express gratitude to the Department of Health and Family Welfare, Government of Haryana and various officers and officials posted across the State for providing necessary support during the data collection.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval

The institutional ethical approval and permission was obtained from the Department of Health and Family Welfare, Panchkula, Haryana. Privacy and confidentiality was maintained at all levels, during and after the field survey.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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