COVID-19 has put the spotlight back on Bengaluru’s government hospitals. When COVID-19 cases started to be reported in the city, authorities rushed to ensure that these hospitals were cleaned up and prepared to deal with the situation.

But on an average day, how well-maintained is an average government hospital in the city? These hospitals are all spruced up now, but how do we ensure this becomes the norm?

First, let’s see how hospitals are supposed to be maintained. The Centre’s Ministry of Health and Family Welfare (MoHFW) has issued several guidelines on this. Most recently, this January, the National Centre for Disease Control (NCDC) under MoHFW issued the National Guidelines for Infection Prevention and Control in Healthcare Facilities, primarily to prevent healthcare-associated infections (HAIs).

HAIs are infections that patients contract at hospitals or other healthcare settings while being treated for another illness. It can endanger the lives of patients who are already in critical condition, and also increase the time and money spent on recovery. But HAIs are largely preventable with good Infection Prevention and Control (IPC) measures.

According to the NCDC guidelines, several factors like ventilation, cleaning and sanitation, safe water and food, and handling and disposal of biomedical waste are critical to this. The guidelines state, “Hospitals need to practice and maintain the highest standards of hygiene and an environment conducive for speedy patient recovery.”

Following are some protocols on cleaning and sanitation in hospitals, extracted from the document:

• Cleaning staff should be properly trained on the practices of cleaning and decontamination of hospital surfaces.
• They should wear appropriate PPE (Personal Protective Equipment) – gloves, aprons and gowns, facial protection, footwear, and hair cover/cap. A log of all cleaning procedures must be maintained.
• Housekeeping surfaces can be divided into two groups – those with minimal hand-contact (e.g. floors, and ceilings), and those with frequent hand-contact or ‘high touch surfaces’ (e.g. doorknobs, bed rails, wall areas around the toilet in the patient’s room). The document specifies separate protocols for floor cleaning, and so on.
• All housekeeping surfaces (floors/tabletops/counters) should be cleaned on a regular basis, and also when visibly soiled and when spills occur. Hot water, a neutral detergent, or a detergent/disinfectant may be used.
• All horizontal surfaces, and all toilet areas including washbasins and commodes should be cleaned daily.
• Fresh detergent/disinfectant solutions must be prepared every day according to manufacturers’ instructions. These solutions must be replaced with fresh ones frequently.
• Floors should be cleaned by methods like wet mopping, and vacuum cleaning with filters attached. Avoid dry mopping with brooms, as this generates dust aerosols.

The guidelines also mention that the cleaning staff should be trained on safe work practice, and on relevant IPC policies and procedures including those on biomedical waste management. The staff deployed by contractors should comply with these protocols too.

There are also several other guidelines on hospital maintenance. For example, the Indian Public Health Standards (IPHS), developed by the National Health Mission (NHM), are used as the framework for maintenance and upgradation of public health infrastructure in all states. In fact, the IPHS has separate criteria for different categories of hospitals based on their size/number of beds.

How well do Bengaluru hospitals follow these protocols? While referral hospitals like RGICD (Rajiv Gandhi Institute of Chest Diseases) are often well-maintained, this isn’t the case with many average government hospitals.

In early March, just as the city was gearing up to fight COVID-19,  citizen journalist and civic activist Mukund Gowda visited two government hospitals in the city.

Below is a video of Mukund’s visit on March 5 to Epidemic Diseases Hospital (previously Isolation Hospital), near Swami Vivekananda Road Metro Station on Old Madras Road:

Isolation Hospital was built about a century ago to treat those with infectious diseases. This hospital still exclusively treats cases of infectious diseases like rabies, chicken pox and cholera; several patients of the recent cholera episode in the city had been admitted to this hospital.

As shown in the video, Mukund found that the road leading from the main gate to the hospital building was lined with dry leaves, plastic covers, bottles, etc. The compound also had many tender coconut shells that hadn’t been cleared for long. The toilets were dirty and didn’t have running water. The log outside the toilets was last updated in November.

Mukund also spotted discarded gloves, empty bottles and food packaging in the ward.

All these conditions certainly create breeding grounds for HAIs, but low-income groups who go to the hospital often have no choice. But it seems the hospital was cleaned up in the wake of COVID-19. As per a report in the Deccan Herald on April 3, a couple (one of whom is a doctor) quarantined in this hospital vouched for the cleanliness, food quality and facilities there.

On March 13-14, Mukund visited another hospital nearby – Sir CV Raman General Hospital, Indiranagar. This facility was built in 2012 as a referral hospital, to cater to the needs of people in this part of the city as well as areas like Hosakote and Mahadevapura. The hospital now has 300 beds, and over the years, government has procured new and costly equipment. But Mukund found that here too, the toilets, floors, beds and equipment in the ward were not clean; patients too complained about the same.

When Mukund discussed this issue with the hospital’s Superintendent Radhakrishna, he was told that only 30 out of 56 allotted Group-D staff were available for cleaning work. Some of the staff had gone on leave, fearing for their health following COVID-19 outbreak. Radhakrishna said the contractor wasn’t supportive and wasn’t providing enough manpower, and hence he was forced to bring in people from other agencies for help.

However, a few days later, by March 16, the hospital conditions seemed to have improved. By then, the city and state authorities were also ensuring that government hospitals were prepared to deal with COVID-19.

Senior BBMP health officers and Zonal Joint Commissioners today visited several #BBMP & Govt hospitals to check on hygiene & preparedness of staff in the light of reports of communicable diseases in some parts of the city. #Bengaluru #Cholera #GE #Gastroenteritis #COIVD19 pic.twitter.com/oSxnh4xr6e

— Tushar Giri Nath IAS (@BBMPCOMM) March 18, 2020

Speaking to me, Bengaluru Urban District Health Officer (DHO), Dr G Srinivas, says that in early March, the hospitals were “not up to the mark, but now they have maintained everything, and you can visit now to see it for yourself.” He says that CV Raman General Hospital is now being maintained as per COVID-19 protocol, including in the management of biomedical waste.

But the challenge is to ensure that these hospitals are well-maintained routinely. Shreelata Rao Seshadri, professor of health and nutrition at Azim Premji University, says hospital maintenance requires some basics – adequate staff, well-planned infrastructure, water supply and electricity, cleaning materials/consumables, and so on. And this requires funds and resources.

She says, “Very little money is allocated towards maintenance. Under the National Health Mission (NHM), each hospital is given an untied fund which can be used towards hospital maintenance, ranging from Rs 25,000 for a PHC to Rs 5 lakh for a District Hospital every year. However, given the huge need at each level, this amount of money is inadequate. There are also issues of understaffing – a lot of the hospital worker positions are vacant or have contractual staff. Plus the doctor is usually overworked and does not have the time to undertake proper supervision and oversight.”

What could be the solution?

Shreelata says, “Under NHM there is a provision for a hospital manager – recruiting them would ensure that basic maintenance and logistics in hospitals are taken care of. It would also reduce stress on the doctors. Also Hospital-based Quality Circles should be established under the State Quality Assurance Cell, which would involve all hospital staff as well as civil society members in setting standards and ensuring basic quality of services.” (Hospital-based Quality Circles are supposed to be set up as per the National Quality Assurance Standards, but rarely are.)

Shreelata points to the example of Jayanagar General Hospital, where a systematic attempt to improve quality turned out to be successful. “Such efforts should be expanded. Since Bengaluru has many large private companies, partnerships with them could bring in CSR funds for maintenance.”

On his part, Dr Srinivas says that action would be taken against hospitals that don’t follow guidelines. “The hospital superintendents are in charge of maintaining hospitals, and the Deputy Director and Divisional Joint Director of the Health Department conduct inspections from time to time. When hospitals are not maintained well, doctors and workers are at risk, and patients without infections have a high chance of being infected. If hospitals don’t follow guidelines, state government will take action against those responsible.”