From clean walls to clinical care: The next phase of Indian healthcare reform

Hospitals, by design, are meant to be sanctuaries — places where pain is met with care, and confusion with clarity. Yet, within the evolving fabric of India’s public health system, many healthcare professionals and observers are increasingly pointing to a more profound concern: that visual improvement alone cannot substitute for clinical readiness or institutional accountability.

It is into this landscape that the Kayakalp initiative, launched in 2015 by the Ministry of Health and Family Welfare, Government of India, made a remarkable entry. Aimed at incentivising hygiene, cleanliness, and aesthetic transformation in public health facilities, Kayakalp has visibly transformed many hospitals. From freshly painted walls and clean toilets to pest control systems, herbal gardens, and well-organised bio-waste segregation — the difference is real, and it is appreciated.

However, as many professionals working within the system now recognise, Kayakalp’s focus on visual and environmental quality is only one part of the healthcare experience. The next phase of reform must consider what happens beyond the visual — inside the consultation room, the emergency bay, the operating theatre, and the documentation register.

There is growing consensus that a hospital could, in theory, score well under Kayakalp while still being under-equipped in areas that define the clinical core of a modern healthcare facility. If a hospital cannot stabilise a patient in respiratory or circulatory shock, or if it cannot perform routine laparoscopic procedures due to equipment gaps, then visual excellence alone cannot fulfil its duty to patients.

The limits of current measurement

It is possible today for a hospital to meet the visible standards of care — clean corridors, properly labelled bins, and structured outpatient flow — while lacking:

  • Resuscitation capacity in casualty
  • Consistent access to advanced diagnostics
  • Structured staff appraisal systems
  • Or real-time patient feedback mechanisms

This does not diminish the achievements of Kayakalp. It highlights the need to expand its criteria to capture both clinical functionality and patient experience.

Many healthcare workers report that while their hospitals have become more welcoming in appearance, challenges remain in the day-to-day functioning of departments under high pressure — especially emergency and surgical services.

Referral remains the default response in some critical cases, not due to unwillingness, but rather due to infrastructure limitations, workforce burnout, and outdated equipment.

This creates a gap between expectation and capacity — a gap that can only be closed through expanded metrics of quality.

Toward a more comprehensive reform model

If Kayakalp is to remain the flagship standard for government hospital excellence, it could consider incorporating six new pillars into its evolving framework:

1. Periodic professional appraisal

Doctors and nurses form the core of service delivery, yet most enter government service through a merit-based process and remain unassessed for years. A non-punitive appraisal system, focusing on documentation, ethical conduct, communication, and adherence to protocols, can help maintain professional standards and provide feedback for development.

2. Structured patient feedback

Anonymous and recurring patient feedback could offer valuable insight into how care is received. This helps identify areas for improvement in dignity, responsiveness, and interpersonal conduct, which are often not visible in administrative reviews.

3. Peer review and clinical audits

Departments could benefit from regular case discussions, documentation reviews, and internal audits — not to assign blame, but to foster reflection and learning. National accreditation frameworks, such as NABH and NQAS, already recommend this, and it could be brought into alignment with Kayakalp scoring.

4. Support-oriented accountability

In cases of recurring performance challenges, institutions should be equipped to offer retraining, mentorship, or reassignments. The goal is not discipline, but stewardship — to ensure that healthcare workers are supported in improving their practice.

5. Modernisation of medical technology

While private hospitals routinely use laparoscopic, endoscopic, and advanced imaging tools, many government hospitals are constrained by older equipment. Addressing this gap — especially in high-load departments — will ensure both patient safety and professional parity.

6. Strengthened emergency infrastructure

Every major government hospital should be equipped to stabilise patients in shock, manage airway compromise, ventilate critically ill individuals, and initiate ICU referral with continuity of care. These are foundational services in emergency medicine and deserve structured investment.

These suggestions are not critiques of Kayakalp, but natural extensions. The initiative has already proven that large-scale transformation is possible in public healthcare. The next step is to align these aesthetic and hygienic gains with clinical robustness and ethical accountability.

The direction is also legally and ethically aligned:

  • In Paschim Banga Khet Mazdoor Samity v. State of West Bengal (1996), the Supreme Court interpreted Article 21 of the Constitution to include the right to timely and effective healthcare.
  • The Consumer Protection Act (2019) has strengthened patients’ ability to seek recourse in cases of medical negligence, emphasising the need for internal quality control.
  • The National Medical Commission’s Code of Ethics mandates respectful, updated, and diligent medical practice.
  • National quality frameworks (NABH, NQAS) already call for many of the additions suggested here.

In this context, expanding Kayakalp’s focus can strengthen public trust, improve clinical outcomes, and reduce both medico-legal vulnerability and systemic stress.

Some concerns may arise about whether such reforms could overburden already stretched institutions. But many within the system believe that measuring performance in a balanced, transparent, and supportive way will uplift morale, not diminish it. When quality is defined clearly and pursued collectively, accountability becomes fairer, and systems become stronger.

Ultimately, the goal is simple: to ensure that public hospitals not only look better, but also perform better — for the patient, for the professional, and in support of the principle of equitable public healthcare.

Let the hospitals remain beautiful — but let them also become functionally equipped, ethically grounded, and clinically prepared.

Let every hospital not only appear to be a sanctuary but truly become one.

Dr Anoop Prathapan is a general practitioner from Thiruvananthapuram, Kerala. He is a published translator and writes on healthcare reforms.

The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK.

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