Primary care has been dramatically improved by the State involving the local governments which take the lead in infrastructure development of PHCs and sub-centers, purchase of medical equipment and drugs, filling up of vacancies on contract, and also supplementing the honorarium of ASHA (Accredited Social Health Activist) workers (14) .
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Currently, according to the NABH website, Kerala has 34 private hospitals and five public hospitals accredited by NABH and 3 JCI accredited hospitals when compared with 2005 when there was no single hospital accredited. Being a newly introduced state-level accreditation program in 2012, KASH aims to uplift the quality standards and services given by the government hospitals in all care settings with a modest investment. After the achievement of KASH, the individual hospitals may opt for higher standards viz. NABH, which requires more investment and effort(12,21).
It is important to advance the knowledge on accreditation impact in hospital settings, especially on the structural, procedural, and outcome levels, when considering the financial investment, effort, and time to attain quality assurance certifications.
Assessment of impact is important since it has become a common platform of quality transformation for primary, secondary, and tertiary care systems(6). Many conceptual and empirical studies focused on the theme of accreditation in varied settings and space. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted June 3, 2020. Considering the previous studies and their inconsistent results, there is a need to assess the overall effectiveness of accreditation on quality. Further, there is a dearth of studies assessing the impact of accreditation while having a comparison group and from the patients' perspective. Most importantly, the impact of accreditation programs in secondary healthcare care settings lacks evidence in the literature. In this backdrop, this study aimed to fill these gaps by assessing the impacts of accreditation implementation in primary and secondary public healthcare settings of Kerala while having a comparison group, from the patients' perspective. The study results will have implications at the policy level and service provider level to restructure the implementation process of accreditation. To this end, this study sets the following objectives:
To measure the level of patient satisfaction in accredited and non-accredited primary and secondary public healthcare facilities in Kerala . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
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To analyze the structural and procedural dimensions of healthcare delivery in accredited and non-accredited primary and secondary public healthcare facilities in Kerala
A cross-sectional study drawn on a positivist approach was conducted from July 2017 to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
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The questionnaire included 60 items in two sections. The first section sought demographic information on age, gender, educational level, marital status, employment status, and the reason for hospital selection. The second section measured patient's views on healthcare received by them on a 5-point scale (1=Strongly Agree to 5=Strongly Disagree) using ten constructs adapting previous critical studies and models in the The questionnaire was initially developed in the English language and subsequently translated into Malayalam. Based on the result from the pilot test, few questions were omitted from the questionnaire, in which respondents generally did not respond. The validity of the questionnaire was evaluated based on content validity and experts' opinion.
Cronbach's Alpha value was higher than the guideline value of 0.6. Simple statistical . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
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The measures to study the quality healthcare dimensions were Physical Facilities (PF), and Diagnostic Services (DS).
The outcome of healthcare delivery is measured by the Patient Satisfaction construct. As seen in Table. 3, accreditation impacted in-patient satisfaction in accredited primary care facilities (CHCs ( = 4.6 ± 0.41154) and THQH/TH category ( = 4.14 ± 0.90281) under the secondary healthcare facility. While in other secondary facilities (GH and W&C), the non-accredited category gets higher scores (W&C Hospitals ( = 4.43 ± 0.52094) and GH ( = 4.34 ± 1.2963). It shows that accreditation has a positive impact on patient satisfaction in primary healthcare facilities but not in secondary care facilities.
Structure domain includes Physical Facility, Financial Factors, Staff Services, and Diagnostic Services.
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The copyright holder for this preprint this version posted June 3, 2020. and W&C hospitals receive a lesser score than the accredited. It shows that accreditation has impacted only at the lowest level in the secondary care facilities, in the structure domain, but not in the district level and specialty level hospitals.
The process domain includes Admission Services, Patient centeredness, Accessibility of Medical Care, Professionalism, and Medical Quality. 
As seen in Table. 7, accreditation has impacted in THQH/TH marginally as two constructs out of four receive higher care in accredited facilities (AS, M=4.72; PC, M=4.26; AM, M=3.32;
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This study was conducted to examine the impact of accreditation in primary and . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted June 3, 2020. perceptions'(36). Facilities intended to deliver more specialized services have not been impacted by accreditation, which contradicts the finding of Shaw(4), who found accreditation had benefitted larger hospitals in improving the quality of care. Reasons may be a limited supply of workforce, equipment and medicines, limited drug supplies and faulty equipment, high staff turnover, and workload, and the absence of a referral system makes the situation more challenging (54) .
Despite the mixed response on the impact of accreditation in primary and secondary healthcare facilities, it is in line with the finding of El Jardali et al. (54) , who noted that accreditation impacted hospitals with significant differences across hospital size. It can be assumed that accreditation is a step towards quality enhancement, especially in tangible terms(36); it is not necessarily a predictor of quality(40). This may be due to the misconception of the implementing agency that the patients will be content if the physical infrastructure is made appealing. The service characteristics of the healthcare aspect are . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted June 3, 2020. . https://doi.org/10.1101/2020.05.30.20117432 doi: medRxiv preprint often misconstrued, and consequently, the accreditation effort will be concentrated in improving tangible dimensions.
The results demonstrate four aspects. First, the success story of primary healthcare accreditation in the State and the other successful models (for instance, Jordanian, Egyptian, and Saudi Arabian) may be pursued before implementing accreditation at specialty and referral secondary care centers. Second, the Indian private healthcare sector has evolved mainly because of the incompetence of the government to provide basic services to its population(1). Therefore, financial botherations of the vulnerable population must be considered seriously as Maya (55) in the public sector. Third, the leading health care transformation elements trust in 'improved integration of care' between the primary and secondary sectors (56) . A 'rebalancing of combined activity' between primary and secondary (hospital) care, (57), requires a benchmarked indicator in quality dimensions. Kerala needs to equalize the two-tier systems in terms of quality and be integrated as another model for providing access to quality healthcare for all. Finally, Rahat (52) suggested that the hospitals must be empowered with more resources and knowledge "along with development and growth in determinants of quality in terms of structure, process, and outcome of the service' before stepping into the accreditation process. If to receive the expected outcome from the accreditation process, there is a need for a rhetoric activity to transform the structural and procedural aspects of healthcare delivery.
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The copyright holder for this preprint this version posted June 3, 2020. . https://doi.org/10.1101/2020.05.30.20117432 doi: medRxiv preprint Findings from this research may provide important insights for redefining priorities while implementing or planning to implement accreditation in Kerala or elsewhere. This study has implications for the entire healthcare industry, both public and private, and the policymakers in terms of providing visions in the strategic implementation of accreditation programs.
The data collection period witnessed the outbreak of Nipah fever in Kerala, and that affected the accessibility of data sources from the medical wards. Further, there was only one GH accredited hospital in Kerala, which might have affected the result. To honestly assess the impact of accreditation, the study requires more data from the same strata making the comparisons more valid, and hence the future research may include more data for the study to confirm these initial findings.
Accreditation can produce a positive repercussion in the hospital as a whole.
Nonetheless, if to guarantee an expected outcome from this long and expensive process, the authorities must consider accreditation as a means of holistic and continuous transformation from conventional healthcare delivery. Hence, adequate human resource training must be imparted to deliver empathetic, patient-centered healthcare. Structure and process domains are the two sides of a coin and equally contribute to patient satisfaction. It has been suggested that the authorities have to intensify their monitoring and supervisory roles with an unwavering urge for excellence in the implementation process, to create an increased public acknowledgment.
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