NABH and Other Standards that are Possible in Rural Areas


The Public Perception and sometimes the perception of the Medical community is that rural hospitals do not need to have standards of care and it might not be possible to do so in rural areas. However many of the areas of patient safety and interventions are relevant to all types of Hospitals [1]. However most of the standards are based on research conducted in urban hospitals and it is not a good idea to generalize them to the rural hospitals.

The National Accreditation Board for Hospitals and health care Providers [NABH] [2], has carried out extensive studies and have come up with standards relevant to India and recently introduced the Entry Level standards that are relevant to rural hospitals.


In a study of hospitals in rural and remote areas in 8 high income countries by Bernd Rechel and others they found that only 4% met the required standards [3]. In a similar study in Australia only 30% understood the standards and less than 10% of those who understood followed the standards. Hence it is not a good idea to directly apply the standards developed in the urban areas to the rural areas. This is true even in well developed countries. The Association of Rural Surgeons of India [5], attempted some standards for rural surgery without any success [6].


The Cochrane Library published a review that showed improvement from 48 to 78% of good practice in a compilation of 12 studies. There was about 2.4% improvement in significant outcome measures like mortality. Although some researchers feel that there is no proved causal relationship of improved process care and better outcome [8], for specific ones like WHO surgical safety check list there is significant difference before and after use [9]. However, the general feeling is that data from meta-analysis show significant improvement in outcome measures [10].


The Appendix A gives the list of standards chosen primarily from the NABH standards [2] that could be followed in rural and remote hospitals. The rural hospitals willing to try out these standards are requested to do so and give the feedback to the Association of Rural Surgeons of India [5]. The association can then work on these standards and make recommendations to the NABH to consider having separate standards that are applicable to rural and remote hospitals.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

  1. Coburn AF1, Wakefield M, Casey M, Moscovice I, Payne S, Loux S. Assuring rural hospital patient safety. What should be the priorities J Rural Health. 2004 Fall;20(4):314-26.
  3. Bernd Rechel, Alexsandar Dzakula, Antonio Duran, et. al. Hospitals in rural or remote areas: An exploratory review of policies in 8 high income countries. Health Policy. Vol. 120 issue 7 July 2016 p758-769
  4. Available from:
  6. Gnanaraj J. Rating of Rural Surgical Centers by Association of Rural Surgeons of India: A proposal and advantages. Rural Surgery Vol. 4, No. 2, April 2008 p 8 -12
  7. Available from:
  8. Health Services Research Group. Outcomes and the management of health care. Can Med Assoc J 1992;147:1775-1780.
  9. Available from:
  10. Abbot TEF, Ahmad T, Phull MK, Fowler AJ et. al. The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis. Br J Anaesth. 2018 Jan;120(1):146-155.


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