Principles of Hospital Administration & Planning BM Sakharkar
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1The Hospital2

Role of Hospitals in Health CareCHAPTER 1

Medical care is a programme of services that should make available to the individual, and thereby to the community, all facilities of medical and allied services necessary to promote and maintain health of mind and body. This programme should take into account the physical, social and family environment, with a view to the prevention of disease, the restoration of health and the alleviation of disability.
—WHO, 1959
A Hospital is an integral part of a Social and Medical organisation, the function of which is to provide for the population complete health care, both curative and preventive, and whose outpatient services reach out to the family and its home environment; the hospital is also a centre for the training of health workers and biosocial research.
—WHO definition of Hospital
 
HEALTH AND MEDICAL CARE
Individual as well as group health has evolved as a product of human biology, environment, ways of living, economic status, and health services. The physical and mental traits of a person are also determined among others, by his or her genetic endowment, as evidenced by the discovery of many disorders being of genetic origin. The health status and disease status are, thus, a result of the process of a continuous adjustment between the internal and external environment.
Internal environment within the human being pertains to every tissue and organ system. Man is also exposed to external environment. Thus, whileas the external environment air, water and food, and his personal environment relating to his work, eating, drinking, smoking, etc., i.e. his way of living, all have a bearingon his health. Health habits, personal hygiene, health knowledge, and mental attitude to life also influence health.
Economic growth has had a positive bearing on improving the health indicators such as life expectancy at birth, morbidity and mortality rates, and in improving the quality of life. Poverty is the most common cause of disease and death in emerging countries through deprivation of adequate nutrition, lowered natural resistance and exposure to insanitary environment. On the other hand, economic affluence has been blamed for rising cardiovascular disorders, mental diseases, diabetes, cancer and the so-called life-style disease.
The society's health is influenced by the accessibility, affordability, quality, availability and utilisation of health services. The best health services are those that are easily accessible, both time-wise and distance-wise to all classes of society, those that can be afforded by the society and 4government which provides them and affordable by people who utilise them, of a minimum acceptable standard in keeping with the need of the users at each level, available to all classes of society who need them, and which range in their coverage from womb-to-tomb, with effective deployment of available resources.
Some people feel that health defined as a state of complete physical, mental and social wellbeing and not merely the absence of disease is an unattainable ideal, at best it can be a desirable objective, a comprehensive concept. Some approach it from a different angle which considers health to be a state of “optimal physical, mental and social adaptation to one's environment”. For example, an individual with a chronic disease condition, e.g. chronic heart disease can never return to complete wellbeing, but can adjust and adopt quite adequately. On the other hand, for the patients with terminal illness, facilitating adaptation would mean helping to prepare for and adjust to the realities of life.
Cynics may say that anything done in the name of health care including prayer, talisman, copper bracelet, magnet, vibhuti, naturopathy, special foods, prescription drugs-any thing at all-will be successful most of the time, because no matter what is done most patients get well most of the time. Therefore, many question the difference that a purely hospital-based, disease-oriented medical care approach alone can make to mortality and morbidity.1
Outcome of community development programmes in India during the successive five-year plans have indicated that health cannot be isolated from other socioeconomic factors in a developmental process. Social, cultural and psychological factors influence health and disease and are responsible for the response of individuals, families and communities towards measures for promotion and restoration of health. These factors also influence the attitude of the community towards utilisation of facilities provided by health and hospital organisations.
 
Environmental Health Services
Environmental health services are considered as a component of public health, with overlaps. It covers the following:
  1. Water supply
  2. Pollution control
  3. Sewage disposal
  4. Food hygiene
  5. Ecology and environmental pollution.
 
Public Health Services
Public health services are concerned with the following.
  1. Control of communicable diseases
  2. Sanitation
  3. Maternal and child health
  4. Public health education
  5. Vital statistics
  6. Health planning
  7. Occupational health and reduction of health hazards.
As has been evident from the examples of developed countries, which were at the same state of development as we are now, that public health measures such as sanitation have a greater impact on improving health than personal health care services alone.
 
Personal Health Services
Personal health services are the services provided by hospitals, health centres and nursing homes, apart from privately practising physicians.
The care provided has been traditionally classified into:
  1. promotion of health,
  2. prevention of disease,
  3. early diagnosis and treatment, and
  4. rehabilitation.
 
Promotion of Health
Promotion of health is not directed at any particular disease and is generally considered the responsibility of the individual. Good health practices promote health through adequate nutrition, exercise, rest, personal hygiene, health screening and health education. Although the primary responsibility is that of the individual, others outside the health system are also concerned with health promotion. Health promotion programmes aim at physical and mental fitness, diet, alcohol and drug abuse, recreation and genetic counselling. However, by itself, improved health is an insufficient incentive for many individuals to adapt good personal health practices. As a society we are concerned about placing incentives on members of the health team, but do little to place incentives on the individual. To cut down costs on hospital-based care, plans are now being proposed in many countries to provide financial incentives and disincentives through health insurance plans to individuals to promote their own health and avoid using health care services. Healthful behaviour tends to promote more healthful behaviour.
All concerned with medical care, i.e. doctors, nurses and auxillary medical staff are among the pepole actively concerned with the promotion of health. We need to find ways for the health team and the individual to work together more effectively in health promotion as well as illness care.5
 
Prevention of Disease
Primary prevention is a service designed to protect against specific diseases through immunisation, use of specific nutrients and protection against occupational hazards and accidents. All diagnostic and therapeutic activity has a preventive component in that it seeks to prevent further deterioration of a man's health. In this context, early detection of disease through mass screening services among vulnerable population helps in prevention of disease, although this approach is questioned by many from economic point of view. The cost of mass multiphasic screening can be high.
Multiphasic health screening, annual medical examinations and surveillance of individuals and groups with susceptibility to certain diseases falls under secondary prevention. Prevention of disease and accidents, e.g. refraining from smoking and alcohol, wearing appropriate protective clothing at work and wearing helmets while driving are matters of personal habits. Sports are needed to inculcate habits of healthful living among the people. Appropriate employee health programmes by employers and advice by physicians, and health education of patients while in hospital do contribute to prevention of diseases.
It is reasonable to expect that by preventing disease to the extent possible, the number of patients seeking medical care can be reduced and thus control overall health care costs. However, prevention of disease is dependent on many other factors, not the least of which is medical. This multiple causality calls for a many-pronged approach with emphasis on secondary prevention, screening, recognition and avoidance of risk factors and harmful life-styles, and attention to housing and sanitation.
 
Early Diagnosis and Treatment
The earlier a disease is diagnosed and treated, the better it is from the point of view of prognosis and for preventing secondary cases in the community. The principle of early detection and treatment of cases in the general population is the basis on which disease control is built. A good deal of early diagnosis now comes through hospital-based screening for disease programmes and periodical medical checkups among the apparently healthy people.
Diagnostic and treatment services can be made available both through ambulatory outpatient care or inpatient hospital care. Outpatient care is also provided in the general physician's clinics, although over the last two decades or so it is the hospital-based outpatient services which are increasingly in demand. Inpatient services by hospitals are also in increasing demand, but the provision of hospital beds alone is no substitute for effective environmental and preventive health services, which itself can lead to a reduction in the number of hospital beds required.
The all encompassing concept of treatment of all ailments in hospitals has also undergone change over the last two decades. Whereas in the past every patient irrespective of the type and duration of the disease was considered fit to be admitted to a hospital on humanitarian grounds if not on others, hospitals now are not considered as the sole repository of sick and dying patients. The concept of a place for medical treatment now incorporates health centres, health maintenance organisations, home care services, day care centres and night hospitals.
Primary, Secondary and Tertiary care: Treatment services are categorised as primary, secondary and tertiary care. Primary care is the entry point into the health system and usually obtained through family physicians and through the hospital-based ambulatory outpatients services—besides the community health workers and multipurpose workers at the grass-roots level. WHO defined primary health care as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families. It is the first level of contact of individuals, the family and the community.… and constitutes the first element of a continuing health process.”2 Secondary care services are at an intermediate level in the chain of hospitals. The services of smaller peripheral hospitals and general hospitals would fit in this category. Tertiary care refers to highly specialised care in specialist hospitals and speciality services provided in superspeciality centres and research centres.
 
Rehabilitation
WHO defines rehabilitation as “the combined and coordinated use of medical, social, educational and vocational measures for training or retraining the individual to the highest possible level of functional ability”. Apart from restoration of function (medical), rehabilitation medicine involves disciplines such as physical medicine, occupational therapy, speech therapy, education, vocational guidance. Rehabilitation is thus not an end-activity of the hospital, but must start early in the process of medical treatment.
 
Health Team
No single agency can deliver the entire range of medical and health care. Achievement of health and medical care 6can best be a joint function of many professional groups of workers like physicians, nurses, paramedical workers, health educators, health visitors, public health engineers and many others who share a common, unifying goal. This joint effort materialises through teamwork. The functional classification of the teams concerned with group health and personal health is as follows.
The health care team which consists of all those who are involved in improving health in a community setting, without necessarily being in active contact with patients.
The medical care team which consists of those professionals and paraprofessionals who provide service for the patient generally in a hospital setting, but without any direct or personal contact with the patient.
The patient care team which comprises any group of professionals and semiprofessionals in a hospital setting who jointly provide service that brings them into direct contact with the patient.
Comprehensively speaking, therefore, health and medical services cannot be delivered through any one agency. As earlier discussed, all the responsibility devolves on three health sectors, viz. environmental health, public health and personal health sector. Additionally, the two other service systems indirectly connected with health are the social welfare services and educational services.
 
HOSPITALS
 
History of Hospitals
 
Medieval Period
The word “hospital” originates from the Latin ‘hospice.’ In fact the word hospital, hostel and hotel all derive from the common Latin root hospice. The place or establishment where a guest is received was called the hospitium or hospitale. The term hospital has at different times been used to refer to an institution for the aged and infirm, a place of rest, a hostel where people lived as a small community, and an institution for the care of the sick and wounded. Lodging for the pilgrim and the wayfarer was also one of the primary functions of the early hospital. In its earliest form, the hospital was aimed at the care of the poor and the destitute, giving the aura of a “almshouse”.
In the early Greek and Roman civilisations, the temples of the gods were used as hospitals. These hospitals were not separate entities but formed an integral part of the temples. Little distinction was made between the disease and the supernatural powers that caused diseases, where mysticism and superstition saddled medical practice, and where more soul healing than physical healing was practised. The Greeks and Romans considered the temples of gods and their priests responsible for providing shelter and sustenance to the sick. Charity was the principal source for defraying illness costs of the poor. It was in Greece that Hippocrates—universally acknowledged as the father of western medicine—was born, in 460 BC (see Appendix 1 for the significance of the rod of Aesculapaeus and the snakes in medical emblems).
With the birth and spread of Christianity there was an impetus to hospitals which became an integral part of the Church and its monasteries. Medicine was reverted to religion, the nuns and monks practising it. Gradually, these Christian hospitals replaced those of Greece and Rome. During the crusades. (Christian expeditions to recover the Holy land from Mohammedans, 1100–1300 AD) over 19,000 hospitals were founded in Europe to cater for those suffering from war injuries and diseases. The order of St. John was one such sect, responsible for creating chains of hospitals. This order has survived all these centuries and still functions as St. John Ambulance Corps in England with its branches all over the world, including India.
Subsequently, certain decrees issued by the Church for divesting religion from medical succour had the effect of lowering the status of the entire medical profession and stopping the monks from practising medicine. In 1163 AD, the Church formally restricted the clergy from working as physicians, and this restriction heralded the beginning of the end of hospitals towards the end of the Crusades (around 1300 AD). During early nineteenth century, nurses of religious orders were replaced by lay people who treated patients badly. Patiens were crowded together in common bed, and infection and gangrene were commonplace all over the hospitals.
Some of the notable hospitals established in the Western world date back to the ancient times. In 542 AD the earliest hospital was founded at Hotel Dieu in Paris. St. Bartholomew's hospital in London dates from the year 1123 AD. In keeping with the hospital philosophy then prevalent, there was a general tendency to lump togther the sick, the physically handicapped, the socially unwanted and the pauper all together. The Spanish built the first hospital in Mexico city in 1524 and the French in Canada. In North America, the first general hospital, Pennsylvania Hospital, opened in 1751, Bellevue hospital in New York in 1736 and Massachusetts hospital in 1811 AD. This was followed by establishment of hospitals in quick succession in many other places in USA.7
 
Nineteenth Century
The middle of the nineteenth century saw the arrival of Florence Nightingale on the hospital scene. It fell upon Florence Nightingale to revolutionise nursing by supplementing good intentions and humane concern with scientific approach to nursing through training. The working of hospitals underwent a sea change as a result of her efforts when she was sent to attend to the sick and wounded at the Crimean War (1853–1856 between the joint forces of Britain and France with Russia. Total casualties: Allies—2,52,000, Russian—2,56,00) in 1854. This was the turning point in the history of hospitals in the Western World.
Various developments in medical sciences gave impetus to further progress in the hospital field. Discovery of anaesthesia and the principles of antisepsis (asepsis was to follow later) were two most important influences in the development of hospitals. Discovery of steam sterilisation in 1886, X-ray in 1895 and rubber gloves in 1890 revolutionised surgical treatment and gave further philip to hospital development. Great progress was being made in cellular pathology, clinical microscopy, bacteriology and so on during the period from 1850 to 1900, and each one of these had a definite impact on hospital progress.
Besides the scientific advances during this period, rapid industrialisation during the last quarter of 19th century generated enormous funds in the Western World. Hospital development in the 20th century has, therefore, been explosive, especially in the USA and Europe. A hospital was no longer a place where people went to die. The advances in medical science brought about by antibiotics, radiation, blood transfusion, improvement in anaesthetic techniques and the spectacular advances in surgical techniques and medical electronics have all brought about tremendous growth and improvement in hospital services.
 
Hospitals in India
Early indian rulers considered the provision of institutional care to the sick as their spiritual and temporal responsibility. The forerunners of the present hospitals can be traced to the times of Buddha, followed by Ashoka. India could boast of a very well-organised hospital and medical care system even in the ancient times. The writings of Sushruta (6th century BC) and Charaka (200 AD) the famous surgeon and physician respectively were considered standard works for many centuries with instructions (in Charaka Samhita) for creation of hospitals, for provisions of lying-in and children rooms, maintenance and sterilisation of bed linen with steam and fumigation, and use of syringes and other medical appliances. Medicine based on the Indian system was taught in the ancient university of Taxila. Charaka Samhita, a treatise on medicine based on the teaching of Charaka was written around 600 AD and Sushruta Samhita, a treatise of surgical knowledge, was compiled during 400 AD.
The most notable of the early hospitals were those built by King Ashok (273–232 BC). There were rituals laid down for the attendants and physicians who were enjoined to wear white clothes and promise to keep the confidence of the patients.
However, the age of Indian medicine started its decline from the Mohammedan invasions in the tenth century. The Mohammedans brought with them their Hakims who followed the Greek system of medicine which came to be known as “Yunani”. This system and its physicians started to prosper at the expense of Ayurveda and its Vaidyas. However, the influence of Ayurveda continued in the South.
The Modern system of medicine in India was introduced in the 17th century with the arrival of European Christian missionaries in South India. In the 17th century, the East India Company—the forerunner of the British empire in India—established its first hospital in 1664 at Chennai for its soldiers and in 1668 for civilian population. European doctors started getting popular and during the later part of 18th and early 19th century, there was a steady growth of modern system of medical practice and hospitals, pushing the indigenous system to the background. Organised medical training was started with the first medical college opening in Calcutta in 1835, two in Delhi in 1835 and 1836, followed by Mumbai in 1845 and Chennai in 1850.
As the British spread their political control over the country, many hospitals and dispensaries originally started to treat the army personnel were handed over to the civil administrative authorities for treating civil population. Local government and local self government bodies (municipalities, etc.) were encouraged to start dispensaries at tehsil and district level. In 1885 there were 1250 hospitals and dispensaries in British India. But the medical care scarcely reached 10 per cent of the population.
 
Emergence of Health Care Delivery System and Hospitals in Independent India
The health scenario when the country became independent in 1947 was, to say the least, unsatisfactory. The bed to population ratio was 1:4000, doctor to population ratio 1:6300 and nurse to population ratio 1:40,000. Although the population was distributed in urban and rural areas in the 8proportion of 20:80, a great disparity existed in the facilities available in urban and rural areas. The medical resources were polarised in the ratio of 80:20. The indicators of health spoke of a poor state of health of the people as indicated in the Table 1.1.
Table 1.1   Health indicators in India during 1947
1. Crude death rate
27.2 per 1000
2. Infant mortality rate
162 per 1000 live births
3. Death less than 10 years of age
48 per cent of total deaths
4. Expectancy of life at birth
30.9 years
5. Infectious disease accounted
Over 50 per cent of total deaths
On the eve of independence in 1947, there were 7,400 hospitals and despensaries in the country with 11,000 beds giving a bed to population ratio of 0.25 per 1000. There were 47,000 doctors, 7000 nurses, 19 medical schools and 19 medical colleges in the country.
Bhore Committee: The need to take stock of health care status of the country and plan appropriate measures was felt by the government in the early forties. Thus was born the “Health Survey and Planning Committee”, better known as Bhore Committee (by the name of its Chairman, Sir Joseph Bhore), in 1943. The committee was asked to survey the then existing health care organisation resources and to advice on the development of health care services in the country. The recommendations of the committee are considered the blueprint of health care delivery system in independent India which laid the foundations for the development of health care delivery system in development plans in independent India. The infrastructure for the delivery of medical and health care system was laid down on this committee's recommendations.3
The committee made extensive recommendations which can be classified into five broad headings as under–
  1. Provision of adequate preventive, promotive and curative services to all in the form of comprehensive health care (integration of services).
  2. Delivery of this comprehensive health care through an infrastructure of hospitals, dispensaries and by opening primary health care (PHC) centres at block level, and taluka level hospitals.
  3. Development of adequate communications in rural areas.
  4. Demarcation of health services into two groups, viz. personal and impersonal.
  5. Fitting the above concepts into a short-term plan and a long-term plan.
The short-term plan envisaged a province-wise organisation for the combined preventive and curative health work through establishment of a number of primary, secondary and district health units. The impersonal health services were to include town and village planning, housing, water supply, drainage and general sanitation. The bed:population ratio was planned to be raised from 0.2 in 1946 to 1.03 per 1000 population at the end of ten years, in 1956. The long-term plan envisaged a PHC for every 40,000 population with a 30 bedded rural hospital to serve four PHCs with a provision to double this number after ten years. Raising of hospital accommodation to 2 beds per 1000 population was also an important long-term goal, with creation of 12 more medical colleges in addition to 43 established during the first ten years. The committee recommended high priority to be given in the health development programme to reduction of sickness and mortality among mothers and children, with emphasis on nutrition, health education, school health services, housing, water supply, industrial health and legislation for environmental health.
Mudaliar committee: To provide guidelines for further national health planning in the context of the five-year plan, a fresh look at the health structure and resources was called for by the year 1959 to survey the progress made since the implementation of Bhore Committee report and to make recommendation for the future development. The Health Survey and Development Committee (also known as Mudaliar Committee for the name of its chairman) thus come into being in 1959. It was found by this committee that the implementation of the Bhore Committee recommendations was slow and the progress not as expected. Among others, it recommended consolidating the gains rather than going in for more services, the District hospital envisaged to play keyrole in the referral services from PHCs and taluka hospitals, mobile service teams, suggestion for a small fee for service in public hospitals, practical bed:population ratio of 1:1000, 50 bed Taluka hospitals, and district hospital with 300 beds, and long-range health insurance policy for all citizens.4
Other committees: There were many committees and study groups appointed from time-to-time. The following two were notable among them for the conceptual changes in the hospital services.
  1. The Hospital Review Committee (Dr KN Rao Committee) 1968 while reviewing Delhi Hospitals made the following general recommendations.
    1. That the hospital should function as an integral part of the comprehensive health service, both curative and preventive.
    2. That the office of the medical superintendent should be a full-time appointment with administratively qualified doctor with no clinical responsibilities.9
    3. That the administrative structure should be tripartite:
      1. clinical,
      2. nursing, and
      3. business administration.
  2. The Study Group on Hospital (1968) appointed by Central Government had recommended the following.
    1. By 1971 the following bed capacity should be attained:
      Teaching hospitals
      — At least 500
      District hospitals
      — At least 200
      Tehsil/Taluka hospitals
      — At least 50
    2. The projected bed capacity of 4.2 lakh beds in 1976 should be raised to 6.3 lakhs bringing the bed: population ratio to one bed per thousand population by 1976.
    3. A regular system of giving liberal grants-in-aid to voluntary organisations to open institutions for giving medical care on nonrestrictive basis.
    4. In difficult areas and in areas where distances are long and communications difficult, such as hilly districts, certain tehsil/taluka hospitals should be developed as full-fledged referral centres (Ref: Report of the study group on Hospitals [Jain Committee], 1968. Min. of Health Govt of India, New Delhi).
Military hospitals: In 1910 a committee appointed by the British Govt recommended the establishment of Station Hospitals for Indian troops of the British Army and the raising of an “Indian Army Hospital Corps” for the menial staff. These proposals were approved in 1918. All the 148 hospitals thus established were to be administered by Indian Medical Service (IMS) which had begun as a military service. A few years later the name was changed from station hospitals to military hospital, separately for British and Indian troops (BMH, IMH) and at some places combined (CMH). The advent of second World War (1939–45) saw some modifications. After the end of the War most of the hospitals created to cater for the needs of war casualties became surplus to the requirement and were disbanded in the two years following the end of the war, only some military hospitals were retained. Following the Chinese aggression in 1962, rapid expansion and modernisation of forces hospitals was initiated.5 The Army has now over 100 hospitals including a large research and referral hospital (Delhi), five command hospitals (CHs) and five base hospitals, the bed strength of MHs (excluding the research and referral hospitals and command hospitals) varying from 75 to 500. The navy and Air force have their own hospitals. As compared to national bed:population ratio, the bed: population ratio in armed forces is 18:1000 population.
 
Hospitals, Beds and Medical Manpower
There is an ongoing race between the medical resources and increasing population. Even though there has been a tremendous growth in the medical resources, they have not been able to cope up with increasing demand due to unchecked growth of population. What we have now in the form of hospitals, beds and medical manpower is as depicted in Tables 1.2 to 1.4.
Table 1.2   Hospitals and beds
1991
2003
No. of Hospitals
No. of Beds
No. of Hospitals
No. of Beds
States
1.
Andhra Pradesh
615
36,400
2,950
5,5524
2.
Arunachal Pradesh
18
1,091
262
3,246
3.
Assam
207
14,460
268
16,000
4.
Bihar
298
28,137
328
44,642
5.
Goa
108
3,383
114
4,232
6.
Gujarat
1,563
46,374
2,528
78,664
7.
Haryana
78
7,003
79
9,522
8.
Himachal Pradesh
65
4,274
57
7,679
9.
Jammu and Kashmir
67
8,202
67
9,000
10.
Karnataka
288
34,477
293
49,949
11.
Kerala
2,924
70,349
2,040
87,195
12.
Madhya Pradesh
362
22,103
363
28,724
13.
Maharashtra
2,104
1,11,420
3,115
1,26,528
14.
Manipur
25
1,460
30
2,059
15.
Meghalaya
15
1,754
15
2,915
16.
Mizoram
14
1,154
17
1,929
17.
Nagaland
31
1,114
31
1,549
18.
Orissa
287
13,988
371
16,642
19.
Punjab
230
15,018
245
24,892
20.
Rajasthan
267
21,815
278
35,142
21.
Sikkim
5
525
6
905
22.
Tamil Nadu
408
48,780
438
61,000
23.
Tripura
23
1,531
25
2,162
24.
Uttar Pardesh
735
47,278
745
74,450
25.
West Bengal
410
53,977
421
67,078
Union Territories
26.
Andaman and Nicobar
8
735
11
1,101
27.
Chandigarh
2
1,500
7
2,500
28.
Dadar and Nager-Haveli
2
62
3
112
29.
Daman and Diu
3
150
3
150
30.
Delhi
80
18,241
82
22,838
31.
Lakshadweep
2
70
2
110
32.
Pondicherry
10
2,608
10
3,211
Total
11,254
6,19,433
15,204
8,43,239
Source: Health Information of India: Directorate General of Health Services.6
10
In 1947, there were seventeen Medical Colleges with an intake of 1400 students. In 1995, the number of Colleges, rose to 146 with 15,000 seats. In 2007, there are 269 medical colleges with an annual intake of 30,000 students. Out of this, half are private Medical Colleges.
Table 1.3   Medical manpower
Population
1000 million (2001)
Hospitals
15,204
Urban : 4,903
Rural : 10,301
Dispensaries
28,279
Urban : 16,315
Rural : 11,964
Hospital beds
8,70,160
Bed : population ratio
0.84 per thousand
Doctors
5,03,947
Nurses
7,37,000
ANMs
3,01,691
Dental surgeons
28,705
Doctor:population ratio
1:1985
Urban : 1:500
Rural : 1:14,000 to 18,000
Nurse: population ratio
1:1649
Nurse: doctor ratio
1.0.83
Medical colleges
140
Source: Health Information of India: Directorate General of Health Services.6
Table 1.4   Hospitals and doctors of Indian System of Medicine (ISM)
No. of Hospitals
No. of Dispensaries
No. of Practitioners
Ayurveda
2,230
14,048
3,52,328
Unani
183
977
41,630
Siddha
122
335
12,528
Total
2,535
15,360
4,06,486
Source: Health Information of India : Directorate General of Health Services.6
 
THE CHANGING ROLE OF HOSPITALS
From its gradual evolution through the 18th and 19th centuries, the hospital both in the eastern and the western world—has come of age only recently during the past 50 years or so, the concept of todays hospital contrasting fundamentally from the old idea of a hospital as no more than a place for the treatment of the sick. With the wide coverage of every aspect of human welfare as part of health care—viz. physical, mental and social wellbeing, a reach-out to the community, training of health workers, biosocial research, etc.—the health care services have undergone a steady metamorphosis, and the role of hospital has changed, with the emphasis shifting from:
  1. acute to chronic illness
  2. curative to preventive medicine
  3. restorative to comprehensive medicine
  4. inpatient care to outpatient and home care
  5. individual orientation to community orientation
  6. isolated function to area-wise or regional function
  7. tertiary and secondary to primary health care
  8. episodic care to total care.
 
Impediments to Medical Care Delivery and Role Perception of Hospitals
In spite of the phenomenal growth in the number of hospitals and medical manpower, it is a paradox that medical services have remained inaccessible to many. Geographical barriers, climatic features, insufficiency of resources and inability to provide finances, the conditional nature of the right to services under social security institutions, poverty and illiteracy are some of the causes that make medical services inaccessible to a great proportion of the population.
In a society well-protected against epidemics, each individual seeks medical advice 3 to 4 times a year either for protection of his or her health or because of illness or injury. In the 50s and 60s, the frequency of hospital admissions in such a society was between 150 and 200 per 1000 population per year, with each admitted patient spending as an average of 1.5 to 2 days a year in the hospital. The cost of an average hospitalisation episode was about four to five times the average per capita daily income, the overall expenditure on hospitals being 2 to 3 per cent of the GNP. Although health promotion and disease prevention have the greatest impact on health, diagnostic and therapeutic factors, i.e. physician and hospital services receive primary attention only when health problems are encountered.
Many authorities point an accusing finger at the complacency of hospitals which have developed as highly sectionalised segments of medical care and which have drifted further away from their true role as community institutions that should assume a larger role than just “caring for the sick and relieving often.”
To fulfil its role a hospital need not be content with bidding goodbye to cured patients at its gates and expressing sympathies for the dead and noncured. It is useful only if it is in tune with the economic limits of the people it has to serve, and patients and family members coming to the hospitals should be able to go back home after being 11educated on the present disease, its prevention and their personal role in prevention of disease and promotion of health in general.
Informed nonmedical opinion considers that medical and hospital services are “crisis care”—concerned with illness, not health. Sociologists believe the reason for this is that it is concerned with personal attitudes—people respond only when they have to. A shift in the emphasis of medicine is therefore needed, that from “cure” to “care”. Although medicine can claim many effective cures, it must confront the task of caring for the sick with greater zeal and effectiveness. Caring necessitates concern with the quality of life of the ill and reduction in any handicap consequent to disease.
The important factors which have led to the changing role and functions of the hospital are as follows.
  1. Expansion of the clientele from the dying, the destitute, the poor and needy to all classes of people
  2. Improved economic and social status of the community
  3. Control of communicable disease and increase in chronic degenerative diseases
  4. Progress in the means of communications and transportation
  5. Political obligation of the government to provide comprehensive health care
  6. Increasing health awareness
  7. Rising standard of living (especially in urban areas) and sociopolitical awareness (especially in semiurban and rural areas) with the result that people expect better services and facilities in health care institutions
  8. Control and promotion of quality of care by statutory and professional associations
  9. Increase in specialisation where need for team approach to health and disease is now required
  10. Rapid advances in medical science and technology
  11. Increase in population requiring more number of hospital beds.
  12. Sophisticated instrumentation, equipment and better diagnostic and therapeutic tools.
  13. Advances in administrative procedures and management techniques.
  14. Reorientation of the health care delivery system with emphasis on delivery of primary health care.
  15. Awareness of the community.
If the task of the hospital is to restore health and not merely to cure a disease entity, the role and responsibility of hospitals assume great significance. It goes far beyond the diseased organ or individual. The modern hospital is a social universe with a multiplicity of goals, profusion of personnel and extremely fine division of labour.
 
HOSPITAL VIEWED AS A SYSTEM
A hospital can be variously described as a factory, an office building, a hotel, an eating establishment, a medical care agency, a social service institution and a business organisation. In fact, it is all of these in one, and more. Sometimes it is run by business means but not necessarily for business ends. This complex character of the hospital has fascinated social scientists as well as lay people.
Management science defines a system as “a collection of component subsystem which, operating together, perform a set of operations in accomplishment of defined objectives.” A system is viewed as anything formed of parts placed together or adjusted into a cohesive whole. Every system is therefore a part of a large system and has its own subsystem.7
A system is construed as having inputs which undergo certain processing and get transformed into output, the output itself in turn sending feeback to the input and the process, which can be altered to achieve still better output. A system is therefore a continuous and dynamic phenomenon (Fig. 1.1).
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Fig. 1.1: Conceptual representation of a system
Transformation of matter, energy or information produce the output by two processes, viz. decision process, i.e. the process of deciding what to do, how best to do it, when to do it and so on, and action process, i.e. the process of putting the above decisions in action.
 
Peculiarities of a Hospital System
In spite of the simple definition of a system, a hospital system is more than the sum of its parts. The peculiarities of a hospital system are as follows.
  1. A hospital is a open system which interacts with its environment.
  2. Although a system generally has boundary, the boundaries separating the hospital system from other social systems are not clear but rather fuzzy.
  3. A system must produce enough outputs through use of inputs. But the output of a hospital system is not clearly measurable.12
  4. A hospital system has to be in a dynamic equilibrium with the wider social system.
  5. A hospital system is not an end in itself. It must function, as a part of the larger health care system.
  6. A hospital system like other open social systems tends towards elaboration and differentiation, i.e. as it grows, the hospital system tends to become more specialised in its elements and elaborate in structure, manifesting in the creation of more and more specialised departments, acquisition of new technology, expansion of the “product lines” and scope of services.
In considering the hospital as a system for the delivery of personal services, which is the most important of its functions, Anand (1984) views the system from four different perspectives which are as follows.8
  1. Client-oriented perspective which is that of access to service, use of service, quality of care, maintenance of client autonomy and dignity, responsiveness to client needs, wishes and freedom of choice.
  2. Provider-oriented perspective that of the physician, nurses and other professionals working for the hospital, and include freedom of professional judgement and activities, maintenance of proficiency and quality of care, adequate compensation, control over traditions and terms of practice and maintenance of professional norms.
  3. Organisation-oriented perspective which covers cost control, control of quality, efficiency, ability to attract clients, ability to attract employee and staff, and mobilisation of community support.
  4. Collective orientation perspective which includes proper allocation of resources among competing needs, political representation, representation of interests affected by the organisation, and coordination with other agencies.
 
Hospital as a Social System
Sociologists have considered hospital as a social system based on bureaucracy, hierarchy and superordination-subordination. A hospital manifests characteristics of a bureaucratic organisation with dual lines of authority, viz. Administrative and Professional. In teaching hospitals and in some others, many professionals at the lower and middle level (interns, junior resident, senior residents, registrar) are transitory, whileas in others, all medical professionals are permanent with tenured positions and nontransferable jobs. In order to continue in a orderly fashion, every social system has to fulfil the functional needs of that system, viz. the need for pattern maintenance, the need for adaptation, for goal attainment and integration.
In a hospital system, the patients’ needs determine the interactions within the system. When a patient is cured and discharged, in his or her place a new patient is admitted. This new patient also demands all the attention and skills of doctors, nurses and others, thus, forcing the essential and separative components into immediate action, repeatedly as each patient is admitted. Free upward and lateral communication is an important characteristic of any system.
So far as communication within the hospital system is concerned, in fact there is considerable restriction in communication among people in the hospital. Doctors communicate freely with doctors, nurses with nurses and patients with each other (if not too ill) and with their relatives, but there is little communication between these groups at the nonformal level.
In the course of interaction among the various units of a hospital social system, tensions and conflicts emerge. These strains have to be dealt with effectively if the system is to function properly. The system has to develop mechanisms of tension management to cope with such strains.
Integration deals with the problem of morale and solidarity in the hospital social system. Morale is necessary both for integration as well as pattern maintenance. Integration has to be achieved at the microlevel. It involves the development of loyalty to the system, to its other members and the values for which the system stands.
Need for pattern maintenance acts as a barrier to upward or lateral mobility of the staff. One occupational group cannot be promoted to the other group, e.g. laboratory technician cannot become nurse and nurses cannot become doctors.
In general, there is a trend in bureaucratisation of hospitals, in which hospitals are seen to work towards achieving their goals through reliance upon such structural devices as systems of division of labour, an elaborate hierarchy of authority, formal channels of communication, and sets of policies, rules and regulations.
The two lines of authority (viz. administrative and professional) come into conflict, because each group has a different set of values. One is concerned with the maintenance of organisation and the other with providing medical expertise. This leads to interpersonal stress. A system that operates through multiple subordination subjects the subordinates to multiple orders which are often inconsistent with one another.
A hospital is more than the sum of its parts. The major components of a hospital system are depicted in Figure 1.2 and Table 1.5.13
Table 1.5   Hospital as a system
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Fig. 1.2: Components of a hospital system
As a component part of health system, the first task of the hospital is to reach people all the time at a cost the community can afford. The concept of hospital as the centreof preventive medicine has enlarged its role enormously. The primary task of the hospitals is the provision of medical care to a community. However, the hospital has two other important roles to fulfil—to be a centre for the education of all types of health workers, doctors, nurses, midwives and technicians and for the health education of the people.
The growing realisation of the thin line of distinction between health and disease, the important relationship between social and material environment, its effects on theindividual's physical and mental well-being, the increasing demands for a better standard of living and health awareness of the people have all had a significant effect on hospital system and the trend of services provided by hospitals.
 
INTRAMURAL AND EXTRAMURAL FUNCTIONS OF HOSPITAL
The activities of the present day hospital can be divided into two distinct types—intramural and extramural. Intramural activities are confined within the walls of the hospital, whereas extramural activities are the services which radiate outside the hospital and to the home environment and community. These functions are set out in Table 1.6.
 
HOSPITAL AND COMMUNITY
The ultimate purpose of the health services is to meet effectively the total health needs of the community.
There are a lot of factors which determine the health needs of community and solutions to them. Some of the important factors are listed in Table 1.7.
A good hospital would build its services on the knowledge and understanding of the community it is to serve, its success will depend upon the involvement of many groups, both professional and nonprofessional within and outside the hospital.14
Table 1.6   Intramural and extramural functions of a hospital
Intramural Functions of a Hospital
1. Restorative
a. Diagnostic
:
These comprise the inpatient service involving medical, surgical and other specialities, and special diagnostic procedures.
b. Curative
:
Treatment of all ailments
c. Rehabilitative
:
Physical, mental and social rehabilitation
d. Care of emergencies
:
Accidents as well as diseases
2. Preventive
  1. Supervision of normal pregnancies and childbirth
  2. Supervision of normal growth and development of children
  3. Control of communicable diseases
  4. Prevention of prolonged illness
  5. Health education
  6. Occupational health
3. Education
  1. Medical undergraduates
  2. Specialists and postgraduates
  3. Nurses and midwives
  4. Medical social workers
  5. Paramedical staff
  6. Community (health education)
4. Research
  1. Physical, psychological and social aspects of health and disease
  2. Clinical medicine
  3. Hospital practices and administration
Extramural Functions of a Hospital
1. Outpatient services
2. Home care services
3. Outreach services
4. Mobile clinics
5. Day care centre
6. Night hospital
7. Medical care camps
 
The Providers, Support Group and Community
The hospital being a distinct, albeit integral, part of the health service, is influenced by all the above mentioned factors and the health services in turn influence those factors. It has to deal with three different groups which from the larger community.
Table 1.7   Factors determining the health needs of community
1. Demographic Factors
  • Age
  • Sex
  • Marital status
  • Family composition
  • Education
2. Enabling Factors
  • Family financial resources
  • Family relationships in the household
  • Availability and accessibility of services
  • Health insurance (compensation for illness changes health behaviour)
  • Attitude to health and disease
3. Internal or Health System Factors
  • Manpower availability
  • Physical facilities
  • Organisation and structure
  • Interface with users
4. External Factors
  • Political
  • Social
  • Administrative
  1. The first group is the “providers” of medical care, viz. the doctors, nurses, technicians and paramedical personnel.
  2. The second group is management, administrative and support group comprising of personnel dealing with nonclinical functions of the hospitals, such as diet, supplies, maintenance, accounts, housekeeping, watch and ward, etc.
  3. The third group and the most important one for whose benefit the first two groups exist in the first place, is that of the patients who seek hospital service and their attendants, relatives and associates who, along with patient come in close contact of the hospital. This group is broadly termed as the “community.”
 
Hospital-Community Relationship
In a complex juxtaposition between the providers of care and intermediate support group on the one hand and the patient and the community on the other, it will not be unusual to expect conflicts between the two groups. The nature of relationship between the two groups influences community relationship, and on this relationship depends the image of the hospital. To better this image, hospitals have to reorientate themselves to the expectations of the community (Fig. 1.3).15
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Fig. 1.3: Hospital community relationship
Relevant communication and information must reach the user community in order to promote their participation and involvement. A community that is well-informed and aware of its social responsibilities can become an effective instrument of cooperation and support.
However, the unpleasant fact that this community participation can be distorted by sectional interests trying to use the community as a pressure group (to attain specific objectives which are not always compatible with the paramount aims of the hospital programmes) need also to be remembered.
People go to the hospital with high expectations believing that every disease is fully and quickly curable. The average health consumer regards contemporary hospitals as the panacea to all his health problems. They cannot appreciate the limitations of the hospital. There is an increasing demand for better care and quick cure. Besides giving care to every patient public expects sympathetic understanding of the behaviour of the patient and his or her attendants and relatives. This shift has necessitated a new approach to doctor-patient and hospital-community relationship.
On the other hand, some questionable assumptions on which the value system in hospital is based are still prevalent among medical personnel. These are that cure is more important than the care of patients, that the staff assume power over the patients, that every problem has a solution, and that death is the worst thing that can happen to man.
Respect for the dignity of the patient is one of the most basic rights and needs of the patient. Concern for the care of the human being as a whole needs contribution from everyone working in the hospital. The hospital is like a federal system with several departments each enjoying considerable autonomy and discretion in its management of work. The great challenges is one of coordination.
Whether it wishes to stress its links with the community and its human and personal character, or its power and glory as a temple of healing will depend upon the hospital itself. From starting as a work of charity, hospital care has developed into a science with many specialisations, to a high perfection industry, but still a social institution which yet remains to be integrated with society. There has to be a growing interest in the importance of human well-being, in the integration of health services provided.
 
PRIMARY HEALTH CARE (PHC) AND HOSPITALS
Realisation of the importance of the role of hospitals in primary health care (PHC) was generated as a result of the International conference on Primary Health Care held at Alma Ata in the erstwhile USSR in 1978 jointly sponsored by WHO and UNICEF. PHC is a concept providing comprehensive health care, i.e. promotive, preventive, curative, and rehabilitative services covering the main health problems in the community. Hospitals have an important role in fostering and encouraging the growth of primary health care.
Health being dependent on economic conditions and correlated to social and cultural values of the society, the quality, quantity, nature and content of health services under this concept are bound to vary between different societies. The exercise of providing primary medical care (supported by other components of medical and health services) has evolved into certain concepts based on basic technical knowledge. “Health for all by 2000 AD” declared as a goal of all nations at Alma Ata and accepted by India needs to be supported by all components of medical and health care services.
 
Elements of Primary Health Care
Eight essential elements of PHC as described by the WHO are as follows.9
  1. Adequate nutrition
  2. Safe and adequate water supply
  3. Safe waste disposal
  4. Maternal and child health and family planning services
  5. Prevention and control of locally endemic diseases
  6. Diagnosis and treatment of common diseases and injuries
  7. Provision of adequate drugs and supplies
  8. Health education.16
 
Benefits to the Health Care System
Tremendous costs are incurred everytime a patient is treated in a hospital who could well be treated in an efficient PHC facility which is inexpensive, avoiding the overuse of the hospital by unnecessary patient self-referral.
However, there has been a traditional hospital disinterest in PHC activities. The interest of acute care hospitals has been centering around development of quality secondary and tertiary care facilities and programmes. Hospitals have viewed their role as delivery of curative services and not in early intervention, reduced mortality, prevention of disease or health education which are the basis of most PHL programmes. However, there is now a growing realisation of the role hospitals can play in PHC.10
 
PHC as Entry Point into Hospitals
In large cities there is marked tendency to bypass primary care facilities in preference for the teaching hospital resulting in primary and routine care workload on specialised services, defeating the special role of such hospitals. Opening PHC units within the premises as the first entry point to the hospital for such routine direct cases will reduce avoidable routine workload for specialised outpatient departments (OPD). Teaching hospitals, as a back-up support to PHC, can start screening units within their premises for patient's coming directly for routine medical care as part of PHC. These PHC units can also be utilised as laboratories for experimentation with different models of primary health care after epidemiological research, beside setting examples for hospitals at district level and others.
 
The Role of General Practitioners (GPs)
The position of GPs in providing primary health care and the potential for integrating their activities with other health personnel is being increasingly recognised. A community primary health care programme (CHP) started by a small urban hospital can establish a strong relationship between the CHP and the hospital, with GPs helping to run the primary health care centre. Coordination between these CHPs and the hospital at the appropriate level with open channels of communication can keep the programme going well. However, it is also feared that an excellent programme can fail if it lacks constant drive to maintain a certain level of standard and if consistent supervision is lacking. One of the difficult problems to solve is keeping the hospital focussed on primary care. It is natural for a small facility to want to keep growing bigger and more sophisticated.
 
Some PHC Related Experiences Abroad
In USA a changing relationship is emerging between hospitals and PHCs. A shift from cost reimbursement to hospitals to the fixed fee payment schedules for specific diagnostic related groups (DRGs) has forced hospitals in USA to cut costs and resulted in reduced length of stay, reduced admissions, reduced utilisation of ancillary services, and large increases in outpatient procedures. The decreasing demand for inpatient acute care has thus resulted in overcapacity of hospital beds. In some areas many hospitals are only 50 per cent occupied. Another factor that has focussed the attention of hospitals on PHC is the rapid popularity of health maintenance organisations (HMOs) in the USA. HMOs are interested in primary and not secondary health care. They are interested in health education, prevention, screening and immunisation programme, early detection and diagnosis, “wellness” and other primary care activities.” They (HMOs) carry out these programmes with a variety of health professionals including midwives, physician, assistants, nurse practitioners, registered nurses and other allied health professionals.11
Sweden, whose health care was based totally on hospitals, has realised the need for primary health care. The expansion of primary health care implied an increase in the number of general practitioners, district nurses and other types of staff to get over the necessity of too many patients being admitted for inpatient care just because the appropriate services were not available in day care or other institutions. The Swedish concept envisage that patient who need continuity in their relationship with doctors and those with multidimensional problems should be better of with well-functioning primary care services.12
Finland, one of the pioneers in primary health care implementation in Europe, presently spends about 55 per cent of its health expenditure on preventive and ambulatory services and 41 per cent hospitals. Sweden has adopted the “lowest level of care” concept.
 
Development of a PHC Policy by Each Hospital
To decide the scope and extent of the PHC to be provided by it, every hospital will have first to prepare a PHC policy and strategy. The policy statement should outline the essential points to be included and then list the actions needed ensure putting the policy into effect.
The hospital's effective involvement in PHC would require a much broader vision than cure alone, and therefore, a broader range of action. What restricts the effective 17involvement of hospitals is that few hospital professionals are trained and inclined to think in this communitywide context, so that a substantial change of attitude is needed to accept the centrality of PHC as the basis of hospital involvement.
The hospital may either assume a lead role in organising PHC for its population or play a purely supportive role. With its concentration of health professionals, a hospital is in a position to effectively supervise and monitor PHC work, in addition to providing primary care through the hospital-staffed mobile and outreach clinics. The secondary care role of the hospital would support PHC by providing referral from primary health services, technical and logistic support and acting as a centre for education and training of PHC-oriented manpower.
 
Referral Function
  1. Organising a two way referral system from mobile and outreach clinics to the hospital and referral back with reports for follow-up
  2. Backing up the referral system with medical records
  3. Organising visits of hospital specialists to outreach clinics
  4. Carry out training and reinforcing skills at PHC workers by visiting specialists
  5. Giving preferences to patients referred from PHC centres for specialist clinics and for admissions.
 
Support Function
  1. Providing logistics support in respect of equipment, materials, drugs and other supplies
  2. Reinforcing diagnostic capabilities of PHC workers and outreach clinics
  3. Providing transport for referrals and outreach services
  4. Making hospitals facilities available for training and retraining of PHC workers.
 
THE CHANGING SCENE IN THE HOSPITAL FIELD
Our technical abilities have outstripped our social, economic and political policies. The technological advances in the field of medical sciences have provided clinicians with more esoteric aids to diagnose and treat illnesses. Clinics and communities will continue to pressure hospital management to provide such advances even though they will be very costly. Not only pressures will increase for providing newer technological capabilities, but there will be growing demands for such care. There are growing indications that this has started happening in our Indian situation.
Since treatment is provided free of charge in government hospitals, it has in many cases resulted in abuse, particularly in the outpatient department. This has led to the patient being made to pay a small charge, varying between 10 to 20 per cent of the cost of medical attention, which, though modest is a useful contribution to hospital running costs.
The model of the nationalised health system that took shape in Great Britain and some other countries has not found true acceptance in India, because health and medical care is not a central but state subject. Allocation of funds for the health sector both in the central and state budgets has also declined gradually. Perhaps this is the reason, among others, that private institutions, commercial firms and corporate bodies are jumping into the medical care field to form investor-owned, for-profit hospitals.
One-third of the last decade's increase in medical costs is attributed to increase use of high technology medicine, particularly surgical and diagnostic procedures. Even then, successful launching of state-of-the-art investor owned hospitals has proved that hospitals can benefit from corporate management principles and can function profitably and efficiently without sacrificing quality and affordability.
At the turn of the century most people died at home cheaply. Today, more than 20 per cent die in expensively equipped hospitals, and it is estimated that up to half of an average person's lifetime medical expenses will occur during his last six months.
The changing trends are indicating the following–
  • In determining the extent and coverage, there will be more and more dominance by consumers rather than providers or producers.
  • Hospitals and health care institutions will become akin to industries.
  • Not all services under one roof. Hospitals will be catering more and more to the needs of patients in fragments, which:
    1. will lead to more and more specialised hospitals in place of general hospitals which provided medical, surgical, obstetric and gynaecological, ENT, paedia-trics, etc. under one roof
    2. people will medical care
    3. hospitals will require more and more management skills as administrators at each level
    4. will lead to growth of corporate hospitals and modern management concepts
    5. will be capital intensive
    6. will be technology intensive
    7. ascendancy of technical expectations over human values.18
 
Urban Hospital Concentration
More and more doctors are concentrating in larger cities, as a result the quality of service which the outlying communities get has remained mediocre. The government and health care services are increasingly dependant upon young doctors to provide medical care services through measures promoting two or three year's rural service in peripheral hospitals and primary health care centres. This is not a pleasing arrangement for rural people who have constant changes of their doctor, and the latter regards his or her stay as a temporary one with no future to it in the rural health centre/hospital.
The teaching of medicine and medical research play a decisive role and have therefore a great influnence on hospital planning. Today, specialised training comprises a very large part of medical curriculum, and a student spends more and more time in the specialist departments. The peoples preception of teaching hospitals as centres for highly specialised treatments and excellence has tended patients to concentrate in urban centres with medical colleges.
 
Sickness Insurance
The charitable nature of hospital of the past has given way to the principle of the universality where every social class is admitted. The introduction of sickness-insurance and social security schemes, although not on a universal scale has contributed to this. The economic structure in India has not yet permitted large scale application of this principle, but the hospital system has to take stock of this emerging development.
 
Preventive Medicine, Health Promotion and Hospitals
The scope of medical examination and treatment is being extended gradually to take care of the post-sickness conditions and the importance of rehabilitation of sick and disabled people is being emphasised. The scope of medicine is also expanding to include “pre-sick” conditions of human beings. In this context, the example of the so-called “ningen dock” in Japan, which performs complete physical check-up of apparently healthy people is illustrative. The term “ningen dock” is a colloquial Japanese term meaning examination in dock, comparing to a ship's dock wherein a ship is thoroughly inspected on completion of long voyage. Ordinary people can undergo a complete physical check-up at such facilities during a period of three to seven days once every year or two, be hospitalised and receive early treatment if any disease condition is discovered, and can receive proper guidance and instruction on their physical condition. Most general hospitals in Japan have beds specially reserved for this “ningen dock” programme.
Priorities in the developing countries should be of preventive nature, whereas modern medical technology strives to lessen the effects of disease, to defer incapacity or death. The organisation of preventive medicine and the hospital system have developed independently along dual lines. The fusion of preventive medicine activities and the hospital has not yet emerged. But as medicine has both a preventive and curative purpose, ideally hospital facilities should meet both these ends. In making available the resources of specialised establishments for prevention on one hand and inpatient care and treatment on the other, the multipurpose centre, combined and coordinated with other health activities, represent the best service available. The future hospitals will have to develop on these lines.
 
Rising Mental Illness, Heart Disease and Cancer
The myth that underdeveloped or developing countries are not as much susceptible to degenerative, mental or cardiovascular disorders and cancer has been recently exploded. India now faces the unenviable task of not only curbing the high incidence of communicable diseases but also checking the rapid rise of noncommunicable diseases like mental illness, heart disease and cancer.
 
Geriatric Care
Even as we have not eradicated the scourge of communi-cable diseases, we are experiencing a rise in the incidence of health problems associated with old age. A national Sample Survey had revealed that 45 per cent of the elderly population (viz. about 27 million) sufferes from chronic diseases. Old age is associated with growing incidence of heart disease, high blood pressure, osteoarthrosis, cognitive disorders, prostate enlargement and cancer and urinary tract infections.
The growing elderly population will throw a public health challenge, including institutional care. In future, our hospitals will be compelled to remodel their resources to face this challenge.
 
Building New Hospitals and Establishing Linkages
During the fifth and sixth five year plan, one in every four primary health centres upgraded to a 30-beded rural hospital were expected to provide general service in medicine, surgery and obstetrics, with emergency and acutely ill cases referred to them from neighbouring primary health centres. This 19was expected to result in relieving overcrowding in district and other hospitals, and bring expert medical care within easy reach of outlying communities. However, for various reasons this has not happened the way it was visualised.
A large majority of our hospitals fall in the category of small hospitals with obvious limitation in the scope of their services. These are not able to provide a complete service to the patient even though it is obvious that more small hospitals are needed. Unless their services are supplemented by knowledge, skills and resources from the larger hospitals, and unless they are linked with larger hospitals, patients would increasingly get disillusioned with them, continue to trickle to large city hospitals for all services, and the services of the small hospitals would go waste.
Correcting this will require building up a relationship among hospitals whereby the larger and better staffed and equipped hospitals will support smaller hospitals with the skills and resources which the smaller hospitals do not have. In essence, it requires coordinating among hospitals on a regional basis. The practice of supporting a few peripheral hospitals by certain medical college hospitals are steps in this direction. These steps have to turn into standard practices with honest involvement of all concerned and active material support from government agencies.
 
Development of New Management Practices
Exchange of knowledge pertaining to hospital practices by consultation and coordination among hospitals, and on the same lines consultation and guidance in administrative matters including costs, purchasing, personnel and other phases of hospital administration would promote efficient utilisation of personnel and finances. Hospitals in a defined area can accomplish better standards of patient care and promotion of efficiency through cooperation among participating hospitals.
 
MARKETING OF HOSPITALS
Health care industry in India seems to have arrived at a turning point. As in some other service industries, viz. banking and the hospitality (hotels, restaurants, travel, tourism) industry, health care industry is going through a marketing revolution.
During the 1980s in USA hospital trustee boards and hospital administrators realised that because institutional strategic planning is an essential management task—
  1. Marketing can be a useful function that should not be rejected summarily because of the sanctimony attached to health care activities.
  2. Promotion, including advertising is not inherently bad but is an important communication activity.
  3. The word “customer” is not a dirty word.
 
Strategic Planning
Diligent promotion of the marketing concept is changing professional attitudes as it challenges the institution to provide services that consumers want and will pay for.
Strategic planning is that set of decisions and actions which lead to the development of an effective strategy to achieve the basic objectives of the hospitals, viz. quality patient care at a reasonable cost and achieving excess revenue over costs. Strategic planning is gaining importance in advanced countries, because the health care needs and technology is changing so fast that it is the only way to anticipate future threats and opportunities. Strategic planning is the need of the “market place”—which the health care industry resembles in some respects.
 
Marketing of Medical Services
India now does not lack the infrastructure to attract overseas patients in substantial numbers. We do not have a lobby to sell medical services to the West. Yet, among the services that India can sell to the West, health care could be one of the easiest. And the pickings promise to be plentiful in foreign currency.
When the UK's National Health Service found hospital beds going empty at home, it began to sell health care services to the US. India needs to market its medical services abroad aggresively if it is to win a share of the global health care market.
India can now offer world-class facilities and services, with its growing number of well-equipped corporate hospitals at costs far below the international rates. The cost of a major surgical procedure, e.g. open heart surgery is still about one-third to half of that which would cost in UK or US.
Hospitals will have to be more receptive to marketing management philosophy which involves many conceptually new approaches within the framework of strategic planning. With increasing health insurance coverage, price competition becomes an appealing marketing tool. We can anticipate competitive pricing schemes, use of incentive premiums, new attitude towards admissions, discharge, food service, “package pricing” obstetrical family participation pro-grammes, and similar other changes designed to attract and service patients and his or her family members.
A competitive health care industry, with carefully devised marketing strategies for market product combinations is an emerging alternative to a heavily regulated and socialised system.20
zoom view
Fig. 1.4: Proliferation of specialty hospitals
Strategic planning and marketing are associated with the challenge to do better in the health care market place, and to provide new dimensions to hospital management. The subject is dealt with in more detail in a later chapter.
 
Specialty Hospitals
Medical science has expanded laterally to include the conditions surrounding sick people. Specialised hospitals are coming up in many places in recent years, e.g. those for cancer and cardiovascular diseases, geriatric hospitals, paediatric hospitals and perinatal hospitals.
Health maintenance organisations are institutions that are concentrating on preventive aspects of medicine, emphasising on diet, exercise, antismoking and antialcohol programmes, meditations and the like, with provision of only primary medical care. The scope of conventional preventive medicine is being expanded by the health check-up centres. And the time may not be far when health promotion centres be in vogue as extensions of hospitals (Fig. 1.4).
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  1. Report of the health survey and planning committee: Govt of India,  New Delhi,  1946.
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