The proper function ofteaching hospitals within health systems
Item
- Title
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The proper function ofteaching hospitals
within health systems
- extracted text
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WHO/SHS/DHS/96.1
Original: French
Distr.: Limited
I
IEPS REPORTS
INSTITUTE FOR HEALTH POLICY STUDIES (IEPS)
The proper function of teaching hospitals
within health systems
with the collaboration of
The World Health Organization
-?
I
September 1995
INSTITUTE FOR HEALTH POLICY STUDIES (IEPS)
Paris, 5-8 April 1994
The proper function of teaching hospitals
within health systems
Scientific coordinator and editor: Daniel PUZIN
4
I
- because it belonged to a teaching establishment (the definition given by the
representatives of Chile and the Netherlands);
because it provides a university training (the definition proposed in the seminar
source document);
- because it is officially recognized as such (as in France where a list of teaching
hospitals is drawn up by the supervision authorities concerned);
or because it provides tertiary care for a section of the population.
The participants finally opted for the last definition. They did, however, wish to add a
few supplementary points. The definition finally adopted during the seminar was as follows:
A Teaching Hospital is a centre for complex health care characterized by:
- the important role it plays in providing tertiary care;
- its involvement in teaching and research related to the type of care it dispenses;
the high concentration of resources it attracts.
Typically, these hospitals are costly and exercise important political influence.
In the remainder of this report, the use of capital letters in the term ’’Teaching Hospital"
implies that the above definition is being used.
Working methods adopted at the seminar
The participants had received the source document for the seminar several months
beforehand (Annex 5).
At the beginning of the document, each participating country described the social,
economic and cultural context of its own Teaching Hospitals. Some countries also supplied
examples of measures already implemented with a view to placing these hospitals back at the
heart of their health system.
The participants then split up into several working groups to describe the present role of
Teaching Hospitals in terms of their aims and the economic, legal and political issues they
raise.
In plenary session, they concluded by working together to formulate a strategy for
helping Teaching Hospitals carry out their proper function within health systems.
The first part of this report compares the present situation in Teaching Hospitals in the
different participating countries using general data, statistics and, finally, a more subtle
qualitative appraisal.
In the second part, the three traditional functions of the Teaching Hospital (health care,
training, research) are discussed, as is the question of whether it should perform a social
function in the future.
2
'T
The third part takes into account the economic, legal and political implications of
Teaching Hospitals’ activity.
The report's conclusion summarizes the work carried out during the seminar and
proposes a new strategy for ensuring that Teaching Hospitals function as they ought within the
system.
COMPARISON OF PARTICIPATING COUNTRIES
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1.
General considerations
The data supplied by the 22 countries participating in the seminar have revealed the
wide discrepancies between these countries' geographical, cultural and economic
environments.
Geography
The six geographical regions of WHO were represented at the seminar (Europe, Africa,
the Americas, South-East Asia, Western Pacific, Eastern Mediterranean).
Europe and the Western Pacific Region were over-represented (by six countries each),
the likely reason being that the first meeting of the network was held in South Korea and the
second occurred in Europe. The absence of representatives of North America ought also to
be noted.
The equatorial regions were represented by 10 countries, temperate regions by 13. This
near perfect balance of participating countries, climatically speaking, is interesting since it
makes the agreements reached during the seminar valid both for countries with tropical
disease patterns and for those with disease patterns characteristic rather of temperate climes.
Economy
The participating countries were classified with respect to their gross national product
(GNP) per capita and divided into three categories according to a differential criterion
adopted by the World Bank. Thus, high-income countries (GNP per capita over 8000 US
dollars) and "middle-income countries" were each seven in number, and "low- income
countries" (with a GNP per capita of less than 635 US dollars) numbered eight.
This type of classification is particularly apt since, as is well known, health variables are
closely linked to the level of economic development.
2.
Statistical comparisons
The data supplied by the participating countries have been collated in three tables in
Annex 1, classified according to their GNP per capita expressed in US dollars.
*
Even if it is not possible to infer general rules from the tables, considering the small
number of countries being compared, it is however possible to demonstrate that certain
accepted ideas do not hold true by showing the exceptions to these rules.
3
The box below contains some vital statistics.
cost of teaching hospitals in
%ofGNP
population
(millions)
GNP/capita
life expectancy
health expenditure
in%ofGNP
hospitals in % of
health expenditure
7
32 550
77
7.5
43
0.6
JAPAN
124
25 840
79
6.5
60
0.4
SWEDEN
9
23 780
77
8.8
55
1.0
FRANCE
57
19 590
76
8.9
57
1.0
NETHERLANDS
15
17 570
77
7.9
55
0.6
AUSTRALIA
17
16 560
76
7.7
50
UNITED KINGDOM
58
16 080
76
6.1
51
SOUTH KOREA
44
5 450
70
6.6
52
1.4
CHILE
13
1 950
72
4.7
JAMAICA
2
1 500
73
COLOMBIA
33
1 260
69
4.0
48
0.2
MOROCCO
26
970
62
2.6
PHILIPPINES
64
730
64
2.0
COUNTRY
SWITZERLAND
0.1
*
4
Jf
4
population
(millions)
GNP/capita
life expectancy
health expenditure
in % of GNP
ALBANIA
3
640
72
4.0
EGYPT
54
610
60
2.6
INDONESIA
188
560
61
2.0
PAKISTAN
122
400
58
3.4
CHINA
1 171
370
70
3.5
BENIN
5
360
47
4.3
NIGERIA
112
290
51
2.7
TANZANIA
27
110
54
4.7
VIET NAM
68
63
2.1
COUNTRY
hospitals in % of
health expenditure
cost of teaching hospitals in
% of GNP
58
0.3
55
0.6
(a)
Demographic data
Population and population growth rate
The population is that of 1991 and the growth rate is an average rate projected from 1991 to the
year 2000.
The population growth rate is less than 1% for all high-income countries, apart from Australia
whose growth rate is higher owing to its immigration policy.
The other countries all have a growth rate higher than 1%, except South Korea which will probably
join the group of high-income countries over the next decade.
Sub-Saharan Africa has recorded the highest growth rates (3% or more).
Population under 15 years
In high-income countries, less than 20% of the population is under 15 years (except in Australia),
whereas this age group constitutes between 31% and 47% of the population in other countries.
Population 65 years and over
This age group amounts to over 10% in high-income countries, but less than 10% in the other
countries.
(b)
Economic data
Human Development Index (HDI)
The United Nations Development Programme (UNDP) has created a Human Development Index
which combines indices relating to real purchasing power, the level of education and the health of a given
population.
The HDI classification does not, evidently, always correspond to the income-related groupings.
It should be noted that of the 10 countries at the top of the index classification, seven took part in
the seminar, namely Japan, Switzerland, Sweden, Australia, France, the Netherlands and the United
Kingdom.
Rural population
Teaching Hospitals are always located in large towns. This leads to a problem of hospital access in
countries with a large rural population (China, Indonesia, Viet Nam) and in countries which are highly
urbanized but where distances are great (Chile, Australia, Sweden).
Gross domestic product (GDP) per capita after adjustment
This is expressed in US dollars and the figures are from 1990.
This index enables disparities in purchasing power due to exchange rates to be taken into account
and its use considerably narrows the discrepancies between countries. After adjustment, the discrepancy
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between China and Switzerland, for example, is 1 to 10 with respect to the GDP per capita, whereas it is
of the order of 1 to 100 before adjustment.
GNP per capita and the growth rate of the economy
This is 1990 GNP before adjustment
The growth rate is the average growth rate of GNP between 1980 and 1990.
a
Note 1
The use of GNP in some instances and GDP in others may seem surprising. The choice of one
aggregate as opposed to the other was made by the information sources concerned (UNDP or World
Bank). GDP and GNP tend to be relatively close.
Note 2
Economic data on Albania for 1990 were not available at the seminar. A GNP per capita of 640 US
dollars had been suggested, based on Table la of the World Bank's World Development Report for 1993.
In this report, Albania is thought to lie in the lower bracket of middle-income economies.
Data collected since have revealed that Albania, with a GNP of approximately 360 US dollars per
capita, ought actually to figure amongst the low-income economies.
(c)
Health indicators
Life expectancy at birth
The year of reference is 1990.
The discrepancies are small in high-income countries where life expectancy is between 76 and 79
years. In low-income countries, the discrepancies are striking (from 47 years in Benin to 70 years in
China).
Infant mortality
The infant mortality rate is calculated from the number of deaths during the first year of life in 1000
new-bom babies.
In high-income countries, the infant mortality rate ranges from 4.8 per thousand in Japan to 8.7 per
thousand in Australia.
In low-income countries, this rate varies from 29 per thousand in China to 104 per thousand in
Tanzania.
The statistics correspond to the year 1988 for high-income countries, to 1991 for the others.
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(d)
Means and resources in health systems
Jobs in the health sector
There are large disparities here, not only between high-income countries (with more than 16 jobs
per thousand people) and low-income countries (with less than five jobs in the health sector per thousand
people), but also amongst developed countries themselves: 40.7 health sector jobs per thousand in
Sweden as compared with 16.7 in Japan.
A
It should be noted that there is some confusion between the notion of health sector jobs as opposed
to the more restrictive concept of health professionals.
Physicians and nurses
Data on numbers of physicians and nurses are hard to compare since job descriptions vary from
country to country. Should Japanese nursing auxiliaries with two years of specialized study be counted as
nurses? Should assistant physicians in certain Asian countries be considered physicians?
It is often maintained that developing countries have trained too many doctors. This popular belief
seems to be contradicted by the present statistics.
Differences between high-income countries may range up to a factor of two, as, for example,
between Japan (1.7 physicians per thousand people) and Sweden (3.0 physicians per thousand). The gaps
are much wider in the other countries.
Numbers of specialists
Discrepancies are wide even amongst the high-income group of countries (70% specialists in
Switzerland, but only 34% in Australia).
It is interesting to note that, contrary to popular belief, there does not seem to be a link between the
number of specialists and the volume of health expenditure, even though it tends to be assumed that the
greater the number of specialists, the higher the health expenditure, owing to the high cost of treatment
provided by specialists.
Health expenditure in terms of GDP
In high-income countries, health expenditure represents on average 7% of GDP, with small
variations, whereas it amounts to only 3.5% in other countries, with large variations from country to
country. It should not be forgotten, however, that definitions and calculation methods vary considerably
from country to country and make comparisons tenuous.
Public sector health expenditure alone
It is not so simple to arrive at a definition for "public sector". This can refer both to expenditure by
public institutions and to expenditures met by the State or by local communities, but which are actually
implemented by private institutions. Whatever the case might be, in high-income countries, the public
sector’s quota amounts on average to 70 or 80% of overall health expenditure. In contrast, the figure is
less than 50% in the majority of developing countries. This fact contradicts the generally accepted notion
that the State and public authorities in these countries play a dominant role in the health sector.
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Percentage of health expenditure funded by various sources
In countries where the GDP per capita is high, the percentage funded by the patient is much lower
and the percentage financed by the health insurance system (or taxation) much higher than in countries
where the GDP per capita is low. Regrettably, this is all the more true since in developing countries, the
patient's contribution (often unrecorded) is most likely to evade statistics...
(e)
Hospitals
Numbers of beds
High-income countnes (with approximately 8 beds per 1000 people) are much better equipped than
the others (with approximately 2 beds).
The surprising over-provision in Japan is worth noting (13.6 beds per 1000 people).
Percentage of health expenditure devoted to hospitalization
This figure is more or less constant (approximately 50%) whatever the country or economic level.
This leads us to take it as an unavoidable structural law and to wonder whether it would actually be
possible to significantly reduce the percentage of health expenditure devoted to hospitals.
Hospital personnel
In high-income countries, the number of hospital jobs in relation to beds varies considerably from
country to country. This makes up for the differences in numbers of beds. The abundance of hospital
beds in Japan, for example, is thus compensated by a low concentration of personnel in attendance at each
bed.
As regards the other countries, we can only bemoan the scarcity of statistical information provided.
Beds for the critically ill
The disparities between the various participating countries in the numbers of beds for the critically
ill per thousand people highlight the immense differences which exist: in Japan, for instance, there are 8.7
such beds for every' thousand people, whereas in Indonesia there are only 0.5 per thousand.
The explanation traditionally given for this discrepancy is that hospitalization is costly, probably not
so much in terms of personnel (even if the largest proportion of hospital expenditure everywhere is
devoted to personnel) but, rather, in terms of equipment and medical products.
We might also be tempted to look for an explanation in terms of population age. In developed
countries, there are three times more elderly people over 65 years than in developing countries. However,
there are on average six times more beds available for the critically ill.
(0
Medical training
To obtain a ratio of two physicians per 1000 inhabitants in an imaginary country with a stable
regime (assuming a professional life of 30 years), one would need to train 666 physicians for every million
inhabitants each year. This is the order of magnitude actually observed in developed countries. Countries
particularly well supplied with physicians continue to train large numbers (Switzerland, Sweden) or are
currently limiting training (France), whereas the least well provided countries are maintaining present
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policy (Japan, United Kingdom, Australia) or attempting to make up for shortages (Netherlands).
Developing countries are either training fewer physicians (Pakistan, China) or many fewer (Benin,
Tanzania, Indonesia) compared to developed countries.
A more detailed study, beyond the scope of the present seminar, would have to lake several factors
into account (the population age pyramid, demographic forecasts, morbidity, the age pyramid of practising
physicians, the role of assistant physicians, the training of foreign physicians and courses abroad, etc.).
The duration of medical studies leading to a full medical degree varies from 5 to 7 years. A simple
perusal of the table could be misleading, since in order to make true comparisons, the level at the
beginning of study would have to be taken into account, as would the trainee's ability to practise medicine
immediately after obtaining the doctorate or not. In the United Kingdom, for example, after the 5 years of
study necessary for the degree, the student must work in a hospital for a year and undergo 3 years of
practical training before becoming a general practitioner.
Similarly, the duration of specialized study must be examined very carefully. The figure is no more
than an average, and it must be remembered that those destined to become general practitioners must also
take an enhancement course after obtaining their doctorate.
(g)
Teaching Hospitals
The size of teaching hospitals is shown here by the number of beds. The numbers of beds given by
each participant do not necessarily correspond to the definition of the Teaching Hospital adopted at the
seminar.
Comparing industrialized countries alone, the differences between countries are probably more a
question of definition than real difference. A preliminary reading of the table suggests that there are three
times more teaching beds in France than in the Netherlands. However in France, Centres HospitaloUniversitaires (CHU) also serve as general hospitals in towns possessing a medical faculty, whereas in the
Netherlands clinical training is provided in large hospitals which are not, however, classified as "teaching"
hospitals.
The fact remains that in industrialized countries, the number of teaching hospital beds per million
inhabitants is around 1000, whereas this figure is less in other countries, sometimes as low as
approximately 100 (Colombia, Benin, Tanzania).
Staffing levels are relatively constant from country to country (0.5 physicians and 2 to 3 other staff
per bed), with some exceptions (5 times more non-physicians in Sweden tnan in Japan and a very low
staffing level in Benin).
In developed countries, the running cost of a bed ranges from $126 000 in France to $218 000 in the
Netherlands. This is explained by the more selective definition of teaching hospitals in the Netherlands.
The cost of running a bed drops considerably with the economic level. The proportion of these
costs in terms of GNP is more or less the same everywhere, with a maximum in South Korea (probably
due to an overly wide definition of teaching hospitals) and a minimum in Morocco and Benin.
3.
The situation in each country
There follows a brief overview, whose simplistic nature should not be overlooked.
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4
Developed countries
Switzerland
The Swiss health system is characterized by a high specialization of physicians and a considerable
proportion of private sector funding (32%).
There is a teaching hospital in each of its large towns (Basel, Bern, Geneva, Lausanne and Zurich).
Health policy is determined at a cantonal level, which can lead to great differences. Thus in Geneva, the
teaching hospital alone caters for all State hospitalization and private clinics are relatively underdeveloped,
whereas in Bern, the teaching hospital only caters for a quarter of all hospitalization.
Japan
The Japanese health system is characterized by excellent results at a relatively modest cost (6.5% of
GDP), and this despite an aging population. There are fewer physicians compared to the other developed
countries. Although the hospitals boast relatively few personnel, they attract 60% of expenditure on
health, a maximum amongst the countries participating at the seminar.
The classification of hospitals at tertiary level is determined by size, the specialized treatment on
offer and the percentage of patients referred from primary level or from other hospitals. Teaching
hospitals more or less correspond to hospitals classified as tertiary. The main dilemma for teaching
hospitals, then, is how to obtain or preserve a particular percentage of patients referred by the primary and
secondary levels in order to maintain their tertiary level status entitling them to charge higher rates.
Sweden
Sweden is characterized by an aged population, an abundance of health personnel and a high level
of specialization amongst its physicians. Health policy decisions are made at county level (whereas other
social issues tend to be regulated at municipal level). The public sector largely predominates. The
proportion funded privately is very low. Access to teaching hospitals (one in each region) is by referral or
through casualty.
France
France is characterized by a costly health system (surpassed only by the United States and Canada).
Primary health care is, for the most part, private and hospitals tend to be State funded (70%); however,
the part of the private sector approved by the Department of Health is financed by the welfare system in
the same way as the public sector.
There is no formal system for referring patients to a level of higher complexity of care. Teaching
hospitals also serve as general hospitals in towns which are host to medical faculties. They also therefore
treat very common cases which, strictly speaking, do not come under tertiary care. This partly explains
why the cost per teaching bed in France is the lowest of all participating industrialized countries, whereas
the running costs of French teaching hospitals are the highest in relation to GNP.
The Netherlands
The health system in the Netherlands occupies an average position amongst the industrialized
countries, whatever parameter is observed. Far-reaching reforms are in progress with a view to balancing
free market principles (choice of health insurance schemes) with equal access for all.
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There are six teaching hospitals (four public and two private). Each is affiliated to a faculty of
medicine. These hospitals tend to concentrate on the more specialized treatments, leaving more common
care and related clinical training to general hospitals. The problem over the next few years for these
hospitals will be to avoid overlap with the other hospitals in order to be able to justify the high cost of their
services to the insurance funds. With the introduction of free market principles they may also have a
problem in maintaining a common front, within the Association of Teaching Hospitals, towards the
insurance funds.
i
Australia
One specificity of Australia is the considerable influx of immigrant physicians (who, in some years,
outnumber those trained locally).
Hospitals are managed by the State. Hospitalization is free of charge, but patients can pay to select
their own physician and thus jump some queues. Extra-mural general practitioners and specialists practise
freely. Funding is predominantly federal.
Medical faculties are all funded with public money, as are the teaching hospitals attached to them.
Specialization is not arranged by universities, but by colleges of specialists (in the English tradition).
The clinical training of specialists occurs within hospitals, which are not necessarily all teaching hospitals.
United Kingdom
The establishment of a National Health Service after the Second World War enabled a high quality
medical service to be developed while maintaining control over cost. The drawback was the formation of
waiting lists. Reforms based on profit-sharing by GPs and the encouragement of competition between
hospitals has recently disrupted this system (it is the GP who now chooses the hospital offering the best
value for money).
Medical training is clearly divided between the universities, which cover the initial stages of training
(27 medical schools, 8 of them in London), and the colleges, all located in London, which train specialists.
Teaching hospitals have their own governing bodies which are independent from regional
authorities. For many years now, they have received a larger portion of the health budget than other
hospitals, without any real justification. Now that competition is in place, these hospitals will find
themselves up against serious funding difficulties.
Intermediate countries
South Korea
One of the "dragons” of Asia, South Korea is becoming economically similar to developing
countries and now devotes nearly 7% of its GDP to health.
Since 1989, the population has been completely covered by a health insurance system initially
established in 1977. Health care services profited by expanding rapidly, starting with hospitals which now
attract more than 50% of health expenditure. 85% of the hospitals are private and non-profit-making.
Restrictions had to be introduced to control the growth in expenditure, with a 3-level referral system
imposed since 1989.
12
Under this system, third-level hospitals are only responsible for 10% of beds, and benefit from
financial advantages.
Teaching hospitals, responsible for 24% of beds, are concerned to become classified as tertiary.
Their main dilemma is therefore how to find sufficiently pertinent, but nevertheless non-inflationary,
criteria.
Chile
Chile is a country of geographical contrasts (shape, influence of the capital) and social contrasts.
The diseases of rich countries (vascular diseases, cancer) are already present whereas diseases
characteristic of developing countries have not yet been
eradicated.
Up until the end of the 1970s, the health system was directly administered by the State. During the
1980s, a well-equipped private medical system was developed, thanks to the introduction of private health
insurance schemes just when the national health system was on the decline.
80% of the State-run medical schools make use of large hospitals within the national system for
clinical training, as well as the J. J. Aguirre Hospital of the University of Chile and the Catholic Teaching
Hospital.
Colombia
A country of extreme social inequalities with a dynamic economy, Colombia combines a
State-funded public health care sector geared towards the least privileged sector of society with a private
sector for wage-earners which is funded by the welfare system.
The eleven oldest medical schools (almost all public) each have their own affiliated hospital, always
tertiary.
During the 1980s, medical schools almost doubled in number. The new schools, all private, have
made agreements with tertiary7 and even general hospitals.
Morocco
Morocco's health results, albeit mediocre, are improving.
Health expenditure as a percentage of GDP is low and households and optional insurance policies
finance a large proportion of these costs (63%).
The public sector is directly managed by the State. A national social security system serves as
medical insurance for private sector workers and treats those who contribute to it in its own
establishments. Finally, there is also a profit-making private sector (with clinics and surgeries) for the
wealthier population.
Morocco's two teaching hospitals were set up at the same time as the medical faculties in Rabat and
Casablanca. They are at the top of the country's health pyramid. They provide a very small number of
beds per million inhabitants compared to other countries with a similar economic level and there is a huge
training requirement (there are still only 0.3 physicians for 1000 inhabitants despite a rapid rise in medical
school enrolment recently).
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The Philippines
Health expenditure in relation to GDP remains low and 50% funded by households.
The health care system comprises a variety of public services generally devolved to local
communities and private units.
There are 26 faculties of medicine (mostly private) and 40 affiliated teaching hospitals. The main
one, the Philippines General Hospital, has recently expanded dramatically.
Albania
Albania is a small, largely rural country which has long been isolated politically. In terms of
quantity, there is an adequate number of physicians and hospital beds, and new physicians appear to be
being trained in sufficient numbers. As regards quality, the opening up of the country should bring
improvements.
The health system is almost entirely public.
The main hospitals in Tirana, already united geographically, have recently been united by law to
create what is now the country's sole Teaching Hospital, affiliated to the one faculty of medicine.
Low-income countries
Egypt
This country is characterized by a high demographic growth rate and small area of
cultivable land.
The Ministry of Health directly manages 50% of health personnel. The State-employed physicians
often practise privately as well.
Medical costs are directly covered by the State or reimbursed by a national (but non-compulsory)
public health insurance system which still only covers 20% of the population.
The 110 000 hospital beds are run by the government (77%) or by semi-public organizations (13%,
including the Curative Care Organizations and the Teaching Hospitals Organization) and private
organizations (10%), the latter in rapid expansion.
The teaching hospitals are either directly dependent upon the Ministry of Education (15 400 beds)
or on the Teaching Hospitals Organization (with 4700 beds).
Indonesia
This subtropical archipelago stretches over 5000 km. It has the fifth largest population in the world.
The country's economic growth is strong and its demographic growth rate moderate.
However, resources allocated to health are still very slight (1 physician per 7000 inhabitants, 1
hospital bed for 1500 people), and very unequally distributed.
14
4
The State provides a well conceived but insufficient health system. Private medicine is developing.
30% of hospital beds are private (often entrusted to charitable organizations). The establishment of a
health insurance system is somewhat slow.
Clinical training is conducted in about twenty provincial hospitals, not usually the last referral level
(there are only 4 of these).
Unless the number of physicians trained by the system is increased, it will not be possible to make
up for lost time.
Pakistan
A country undergoing strong economic growth, but with a poorly controlled demography, Pakistan
is still lagging behind in health care despite significant efforts made with respect to medical training.
A highly original experiment was carried out by the Aga-Khan Teaching Hospital, where medical
students are put into contact with underprivileged communities at a very early stage in order to receive
clinical training combining primary, secondary and tertiary health care.
China
The most populated country in the world with a comparatively small cultivable area, China has
succeeded in controlling its birth rate and its health is the best of its group. Its economic growth is
extremely strong. In terms of quantity at least, there is an adequate number of health personnel and
hospital beds.
Guaranteeing health remains the duty of the State or local communities, but a mix of public and
private health activities is emerging spontaneously. The patients themselves make a considerable
contribution and, in the absence of a health insurance system, the appearance of a two-tier health system is
to be feared.
Medical schools usually possess their own hospitals.
Benin
This is a small country in sub-Saharan Africa emerging from an interventionist economy following
political upheaval in 1990.
Life expectancy is very low and the birth rate high. Benin's Human Development Index is one of the
lowest in the world.
The national health system, centred on primary health care, is being challenged by a private sector
which is developing rather chaotically.
Physicians are trained in the capital (in a still insufficient number) and receive their clinical training
at the Centre National Hospitalier Universitaire (CHNU) in Cotonou, an institution with 630 beds.
Nigeria
This is the most populated of the African countries. Characteristic of sub-Saharan Africa, its birth
rate is high, its output per capita low, with poor health indices, a shortage of physicians and health
15
personnel in general. As a result of the difficulties typical of oil producing countries, economic growth is
poor.
Tanzania
This country is also characteristic of sub-Saharan Africa (see above).
GDP per capita is particularly low (approximately 100 US dollars). The number of physicians is
particularly inadequate.
The Medical School provides training in association with the Muhimbili Consultant Hospital (1500
beds) and with the Muhimbili Medical Centre in Dar es Salaam, the country’s sole clinical training unit.
Viet Nam
A highly impoverished country but with economic transformation in full swing, Viet Nam can boast
adequate health cover (health personnel and hospital beds), at least as far as quantity is concerned.
The State and local communities remain the principal providers of health care. Theoretical training
is provided by medical faculties in Hanoi, Hue and Ho-Chi-Minh-City. Clinical training takes place in the
municipal hospitals within these towns.
FUNCTIONS OF TEACHING HOSPITALS
1.
Health care
All participants agreed that the primary function of the Teaching Hospital was to care for the sick.
This priority is furthermore reflected financially, since virtually all teaching hospital expenditure is devoted
to care, compared to a small fraction devoted to teaching or research.
The discussion of the health care provided by Teaching Hospitals thus centred on three issues:
What sort of care should Teaching Hospitals be providing?
preventive or curative?
- emergency or pre-programmed?
simple or complex?
extra-mural or confined to hospital premises?
Should the care be of a particular quality?
Who can and should have access to this care?
(a) Type of care
Teaching Hospitals dispense essentially curative treatment. Should they also concern themselves
with prevention? Participants thought they should.
16
In certain cases, this preventive role is surely a matter of course: if, during an examination for
curative treatment, the case history suggests the presence of another illness, it is the hospital’s duty to
diagnose this illness at an early stage. Similarly, educating the patient and family is an integral part of the
overall care provided for chronic illnesses (diabetes or cardiovascular disease, for example) which are
treated in Teaching Hospitals. These diseases are becoming increasingly widespread, particularly in
developed countries.
*
However, within the wider context of national health policy. Teaching Hospitals ought also to
participate in public health programmes geared towards the local community and primary health care
(home treatment, private practitioner networks, etc.), which would ensure that all involved would be
performing their assigned function. They could also play a special role in distributing information on
subjects as diverse as family planning, smoking, HIV infection, and infectious and parasitic diseases (in the
case of developing countries in particular).
Finally, the participants thought Teaching Hospitals had a special role to play in health education.
- Should Teaching Hospitals be providing secondary and primary health care?
If we adhere to the definition adopted at the beginning of the seminar, Teaching Hospitals exist first
and foremost to provide complex care (using advanced technology). In actual fact, however, they also
dispense more simple care as, for example, at the Assistance Publique-Hopitaux de Paris.
Some participants did not exclude the possibility that Teaching Hospitals might deliver various types
of care, ranging from the simplest to the most complex. After all, as the representative of Pakistan pointed
out, if Teaching Hospitals focus their activity exclusively on complex hospital treatment, they risk isolating
themselves from the other levels of care.
After lengthy discussion, the contrary opinion prevailed. The function of Teaching Hospitals was to
provide exclusively complex care since common treatments could and should be provided by the lower
levels of the health pyramid, namely the secondary and primary levels. Similarly, all health institutions,
whether they be health centres, district hospitals or regional hospitals, ought to provide care consistent
with their function and role within the health system.
This point of view was especially supported by the representative of South Korea; as far as the
South Korean government was concerned, all complex cases should be treated at tertiary level and an
effort should be made to ensure that more simple care is restricted to the secondary and primary levels.
The arguments generally focused on economic considerations (treating simple cases in an
environment designed for more complex conditions is a waste of money), but also on considerations of
quality (simple care is of a higher standard when provided in an environment tailored exclusively to that
type of care).
The participants thus shared the hope that their health systems, however diverse they might be,
should be properly effective at every level (local GP, community clinic, general hospital...) allowing
Teaching Hospitals to devote their resources to those needs which require more complex technology.
- Should Teaching Hospitals be providing extra-mural treatment?
Tertiary care increasingly requires less hospitalization. Teaching Hospitals must thus be in the
foreground of experimentation with the different types of treatments available. More often than not, it is
within Teaching Hospitals that new organizational structures and types of treatment are developed. This
17
applies particularly to alternatives to hospitalization, whether they be in-house (day, overnight or weekend
admissions, outpatient consultations) or extra-mural (home care, home hospitalization, the hospital-town
network). It also applies to palliative care units, parent boarding facilities in paediatric hospitals, voluntary
hospital help, etc.).
(b) Care quality
Is care of higher quality in Teaching Hospitals?
No participants at the seminar knew of any recent study demonstrating that there was a difference in
quality of identical treatments provided by Teaching Hospitals as compared to other hospitals. (Such
studies have been made in the past, for example: "Case-fatality in Teaching Hospitals and non-Teaching
Hospitals, 1956-1959" by Lipworth, Lee and Morris, Medical Care I: 71-76, 1963. J.B. Lippincott Co.,
1963.) The participants did agree, however, that Teaching Hospitals do not necessarily provide better
treatment than other health institutions. Nowadays, it is important not to assume that a dense
concentration of resources and highly trained personnel necessarily means high quality. Teaching
Hospitals ought indeed to provide the best quality care possible, whenever advanced technology and
specialized knowledge are called for. To this end, it is evident that the best equipment currently available
(compatible, however, with the country’s economic level) ought to be located in Teaching Hospitals;
however, the use of this equipment must be assessed on a systematic basis.
The participants were of the opinion that Teaching Hospitals have an important role to play in
setting standards of quality and drawing up protocols for treatment, not only with regard to resources and
procedures, but also in terms of results achieved. Regrettably, it is more convenient, and thus more usual,
to talk of controlling expenditure rather than of the need to ensure quality of health care.
(c) Access to health care
Tertiary-level hospital care should be accessible to all those who require it. It should thus be
available in sufficient quantity and be geographically accessible for all. Waiting lists should not be
cluttered up with patients who do not require tertiary care. It is thus vital that a referral system be
established. Participants were unanimous on this point.
In some countries, in France for example, there is no formal system of referral in place. In most
other countries. Teaching Hospitals are seen as the last resort in the health system, which means that
access is limited to certain patients: they do not have access to tertiary care unless referral is advised at a
"lower" level. This system of referral has the advantage of serving a gate-keeper function by maintaining
the specific function of Teaching Hospitals as the last referral level. This particularity was vouched for by
the representative of South Korea: "In South Korea, we expect Teaching Hospitals to play the role of last
referral centre for medical care".
It is, however, necessary to face facts: most of the time, this referral system does not function
satisfactorily: Teaching Hospitals attract patients because of the diversity of specialist treatments on offer.
This means that the secondary care level is often "short-circuited" and thus under-utilized, resulting in an
over-utilization of costly tertiary care.
Patients tend to assume that they will receive better care at a Teaching Hospital. However, this is
only the case if their condition actually necessitates tertiary care. In the majority of cases, they would
actually have been better treated by a health care institution providing secondary' level care (a general
hospital), providing it has adequate equipment and staff.
18
It is vital that patients be made aware of this fact through consciousness-raising campaigns
explaining how to make good use of their country’s various levels of health care.
A health care system must comprise three well-organized and properly delineated care levels before
Teaching Hospitals can assume their proper function; this would ensure both a balance in the activities at
the various care levels and the best use of available resources.
Even where this system of referral exists and manages to prevent unwarranted patient "congestion"
on the tertiary' waiting list, s last level may nevertheless not be able to fully meet demand. How then is it
possible to select patients lur treatment? Should money affect the choice? This is obviously not desirable,
but how is it to be avoided? This issue was debated at length by the participants, without however yielding
a properly satisfying answer.
2.
Training
(a)
Should clinical training only be provided in Teaching Hospitals?
Usually, medical training is provided in Hospitals which dispense tertiary care, namely in those
termed "Teaching" Hospitals during this seminar. Apart from some interesting experiments conducted in
Pakistan and in Australia, for example, clinical training tends to be based on complex diseases totally
divorced from daily medical practice. There is a risk in restricting physicians' training solely to tertiary
care institutions, for students might acquire a partial and distorted perception of what is to be their future
profession.
Medical Faculties ought to retain responsibility for organizing medical curricula, but several seminar
participants called for training to be carried out in all categories of hospital, and also in first-contact units,
so that training is not restricted merely to the institution with the highest concentration of financial, human
and technological resources.
Pakistan's experience here is noteworthy: in order to familiarize students with daily medical
practice, common diseases are taught in local health units, not strictly speaking part of the Teaching
Hospital.
Similarly, according to Chile, "training should not only be carried out in hospitals with advanced
technology: it is vital that it be supplemented by frequent visits to institutions at other care levels".
(b)
What sort of training should Teaching Hospitals be providing?
The role of Teaching Hospitals in providing training is important for two reasons:
It is at Teaching Hospitals that students learn the performance, operation and use of new
technologies. It is here that they are initiated to new diagnostic and therapeutic concepts which
will constitute the medicine of tomorrow.
- All physicians need to have a certain practical knowledge of complex treatments.
It seems obvious that those physicians destined to work within Teaching Hospitals or to practise
specialized medicine outside such Hospitals need to acquire these skills. However, this
knowledge is also useful for general practitioners who will need to know at what stage they
should hand their patients over to the last referral level. This points to the important
responsibility of Teaching Hospitals in providing continuous training for health professionals.
19
particularly for physicians, so that they remain in close touch with the spread of new medical
progress.
(c)
How many physicians should be trained?
The number of physicians to receive a diploma each year should be calculated according to
individual countries’ needs, but unfortunately this very rarely happens; this incidentally also applies to the
other health professions.
It is, indeed, difficult to measure the precise needs of a country in terms of physicians, since these
needs depend on many factors, in particular the exact role of physicians compared to other health
professions, the degree of urbanization of the country', its geographical situation and, finally, to what extent
the physician is at liberty to choose where to set up practice as opposed to being sent to where he is most
needed. For all countries, the debate over how many specialists to train as opposed to general
practitioners is most important. At this seminar, it was decided that a one-to-one ratio would be
reasonable (50% specialists, 50% general practitioners). This is the ratio France has opted for.
For Chile, as the Director of the Catholic Teaching Hospital stressed, ’’the most worrying aspect is
the dearth of information on the need for physicians in our country".
It must be emphasized that for health care needs alone, there is often the requirement in Teaching
Hospitals for a large number of clinicians, house physicians and resident physicians, greater than the
requirements for teaching personnel.
(d)
Training other health professionals
In some countries (in France, for example), it is Teaching Hospitals which provide theoretical
training for nurses. In other countries (the majority of Anglo-Saxon ones), theoretical training for nurses is
provided at teaching establishments such as universities. Everywhere, however, practical training is
conducted in Teaching Hospitals, at the
patient's bedside.
Teaching Hospitals are also an important training location for hospital managers, biomedical
engineers and laboratory technicians... All these professions are important for the smooth running of the
hospital system.
(e)
Financing
Who pays for the training provided by Teaching Hospitals? The Ministry of Health, the Ministry of
Higher Education or other institutions? After discussion, the participants agreed it was vital that
cooperation between responsible sectors be established, or that an agreement between faculties, health
care service funding bodies and communities be reached.
In many countries, the training provided by Teaching Hospitals is financed by the same budget
which covers care. This is why the participants at this seminar deemed it advisable to make an appeal for
this training to be financed separately, either by the Ministry of Education, or by the university funding
body when the institution is private.
20
3.
Research
(a)
What sort of research, if any, is conducted in Teaching Hospitals?
Research conducted at Teaching Hospitals is essentially clinical research - the last stage of medical
research, carried out at the patient's bedside.
The representatives of developed and developing countries expressed conflicting views on the
function of Teaching Hospitals with respect to research.
For most of the developing countries, research is not seen to be an indispensable function of
Teaching Hospitals. It is little present and considered more as a burden.
It must be remembered that in developed countries, most research is conducted outside Teaching
Hospitals. Fundamental research is carried out in universities, in the pharmaceutical industry, high-tech
industry or special institutions like the French Institut National de la Sante et de la Recherche Medicale
(INSERM) or the Centre National de la Recherche Scientifique (CNRS).
(b)
Does the research conducted in Teaching Hospitals make a significant contribution to
medical progress?
The participants emphasized the very slight link between research and medical progress, the
direction of research being for the most part uncontrollable. A discovery does not always necessarily lead
to the solution of the health problem being researched: a research project can result in a discovery well
outside the field of the original proposition. In most countries, the structures controlling research, whether
public or private, do not necessarily apply discoveries to the most acute public health problems.
Teaching Hospitals should participate as institutions (and not in a dislocated fashion under the
influence of individual professors) in the implementation and development of national research policies in
the field of health.
The appraisal of health service organization and management should be the focus of a particular
type of research.
Teaching Hospitals should remain the essential link between extra-mural multi-centre research by
including patients from non-university sectors. Teaching Hospitals could be persuaded to give guidance
and suggest research methods to these non-university health care institutions.
(c)
Research costs and funding
Despite the fact that it is difficult to evaluate the cost of research, it is well known that the cost is
very high. This is why it will be vital in future to separate the cost of research from the cost of health care
and, consequently, the funding of each of these. Several participants suggested that research should find
diverse sources of funding: the State budget, private foundations, the pharmaceutical industry,
sponsorship, etc.
4.
Should Teaching Hospitals be performing a social function?
According to the majority of those involved with the health system, whether they be patients,
physicians or funding bodies, social problems should not come within the remit of Teaching Hospitals. By
no means should there be confusion between health care and the tackling of social problems. Put
21
differently, Teaching Hospitals should not have to play the role of an orphanage or haven for the
have-nots. There is a need to avoid medicalizing problems which are of an essentially social nature simply
because the social institutions responsible for dealing with these problems are inadequate or non-existent.
Teaching Hospitals, however, often serve as the last resort for deprived people in large towns
wishing to gain access to health care. In some developed countries today, the newly deprived groups of
the population tum up of their own accord at Teaching Hospital casualty services, no doubt because more
appropriate places of refuge do not exist. Teaching Hospitals are forced to take them in, since other more
appropriate refuge structures have not been created.
Participants commented that it is easier to obtain funding for setting up medical as opposed to social
units, which explains the all too common medicalization of social problems, and why surveys of hospital
patients frequently reveal people with social problems who ought not to be in a hospital, especially one
dispensing tertiary care. These comments must, of course, be tempered by the fact that many truly sick
patients have social problems linked to their illness, and if these are left unresolved, they only prolong the
average length of hospital stay.
Finally, the urgent need in developed countries for more social sector personnel must be
emphasized, particularly for social workers capable of relieving the family unit from caring for sick
relatives: this role is still being fully assumed by the family in developing countries.
ECONOMIC, LEGAL AND POLITICAL IMPLICATIONS OF TEACHING HOSPITALS
1.
Economic implications
(a)
The burden on the economy of Teaching Hospitals
The cost of Teaching Hospitals was compared to the cost of hospitals as a whole, of the entire health
system and of the entire economy, measured by GNP.
The cost of running Teaching Hospitals is approximately 20% of overall hospital running costs, the
lowest figure being 9% in Colombia and the highest figures 25% in France and 40% in South Korea.
Teaching Hospitals represent 5% of overall health expenditure in Colombia and 21% in South
Korea, but the figure is generally approximately 10%.
Finally, Teaching Hospital expenditure represents 0.1 to 1.4% of GNP.
Of all these statistics, if extremes are disregarded (more the result of a problem of definition in the
case of South Korea, or of under-evaluation in the case of Morocco and Colombia), it should be noted that
Teaching Hospitals account for a fifth of a country's total hospital expenditure. Nearly everywhere,
hospitals attract one half of overall health expenditure.
Is this too much or not enough? It would be desirable to cany out studies on this subject in a country
(which one?) where the referral system recommended by the participants functions effectively, or where
the functioning of the system could be simulated in reports.
22
(b)
Is the health care dispensed by Teaching Hospitals more costly?
Is the treatment of a given illness more costly in Teaching Hospitals? If so, should this high cost be
attributed to the actual seriousness of the illness or simply to the fact that the Teaching Hospital
environment results in unwarranted costs?
In the document submitted by the Netherlands, we read: ’’The last referral function is expensive. It
requires additional efforts and manpower in order to maintain and expand both the knowledge and skills of
specialists and support staff and the necessary equipment”.
In the economic world, however, words will not suffice; statistical information is indispensable.
This, unfortunately, is hard to come by:
A comprehensive study of the cost of Australian hospitals provides us with an answer. Costs
studied on the basis of homogeneous groups of patients, the equivalent of the Diagnosis Related Groups
(DRG) in the United States, were collated in a manner permitting comparisons between public. Teaching
and non-teaching Hospitals and private hospitals. The reader will find details of this study in the annexed
document entitled "Australian Hospital Costs". As can be seen, the additional teaching expenditure for
14 surgical DRG varies from -26% (yes, believe it or not, a Teaching Hospital can be less costly!) to
+48%, with an average of 12%.
In the document submitted by South Korea, we read: "On average, mean case costs of DRGs in
teaching hospitals were 28% higher than mean costs in their non-teaching counterpart".
Without wishing to extract a universal truth from them, these highly fragmentary' statistical data do
point to an additional cost in Teaching Hospitals of between 10% and 30%, tempering some of the more
pessimistic assertions made.
(c)
Funding
Is treatment free or not? Reimbursed or not? If so, wholly or partially? Do the same rules apply
to all countries?
It would be too difficult a task to analyse minutely the rules governing the health systems of all
twenty-two countries present. Nevertheless, we can distinguish two main
tendencies in the overall organization of health services:
- institutional planning (care principally financed by the State budget and, for the main part,
cost-free for the patient);
market forces (theoretically, this would mean that patients would be able to compare the cost for
the same treatment in Teaching Hospitals and other hospitals).
In both cases, Teaching Hospital expenditure should be balanced with expenditure in other health
sectors. At any rate, management and quality control should be possible. Funding should increasingly be
determined with the aid of cost-efficiency studies, and studies of the quality of health care, training and
research. The mechanisms by which these objectives are attained will vary considerably depending on the
possibilities in each country. However, the tightening of resources, a fact of life in all countries nowadays,
makes a rationalization of the use of resources necessary. Everything cannot be done everywhere.
Choices do have to be made, and priorities earmarked. This is something for politicians, funding bodies.
23
health professionals and, also, consumers to decide, and how much of a say each group has will vary from
country to country.
2.
Legal implications
(a) Public or private status? Profit or non-profit making?
Teaching Hospitals can either belong to a university or be officially affiliated to one.
In most cases. Teaching Hospitals are public and come under the supervision of the Ministry of
Health or local authorities. Some examples of private Teaching Hospitals were, however, cited (Chile,
Japan, the Aga-Khan Hospital in Pakistan). Their problems remain more or less the same and their status
does not appear to be a major issue, except perhaps in the case of Chile where private status involves a
selection both of patients and students according to economic criteria...
(b)
Accreditation and standards appropriate to Teaching Hospitals
In some countries, regulations force Teaching Hospitals to comply with certain criteria (for example:
minimum size, range of disciplines). Such criteria, in addition to accreditation already existing in most
countries, can result in an ever greater complexity and in continually escalating costs. They must therefore
be accompanied by measures designed to limit direct access to these Hospitals (as, for example, in Japan,
where Teaching Hospitals must maintain a certain quota of referred patients in order to continue to be
eligible for special rates).
(c)
Is equal access to Teaching Hospitals guaranteed by law?
In the majority of countries it is, theoretically at least. However, certain obstacles remain (distance,
cost, waiting lists, preferential treatments...).
As a result of their inherent advantages (the presence of professors of medicine) as well as their
inconveniences (the presence of inexperienced students). Teaching Hospitals, interestingly enough,
continue to attract many patients, whether they be affluent people desiring to avoid waiting lists, or poor
people who have no other choice. This raises both a moral and financial dilemma. Are some people being
excluded? How can Teaching Hospitals attract the middle section of society?
The role of Teaching Hospitals should also include ensuring that equality of access to health units is
respected, and this ought to be enshrined in their mission.
3.
Political implications
(a)
The Teaching Hospital, pride of the nation
Any country is proud to demonstrate it is capable of offering state-of-the-art care, even if, for
obvious economic reasons, this can only be provided in a few places. Occasionally, these exceptional
places are the foundations of politicians. More often than not, it is Teaching Hospitals which are provided
with the necessary advanced technology.
In all cases, the effect on public health is insignificant, but the Teaching Hospitals undoubtedly
benefit.
24
(b)
The Teaching Hospital, symbol of political failure or success
Teaching Hospitals are the place where so-called miracles of modem technological medicine occur.
Politicians can thus make use of this reputation to enhance their own image. In contrast, if Teaching
Hospitals do not satisfy the public, they can rapidly become a symbol of political failure at local or national
level.
(c)
The Teaching Hospital, caught between two ministries
There are frequent conflicts between the Ministries of Health and Education and this has a
deleterious effect on Teaching Hospitals.
(d)
Medical power
The Teaching Hospital is an indispensable working tool for physicians and university professors; the
prestige which the latter have always enjoyed among the country's elite has now spread, as a result of
media exposure, among the general public. This results in a form of power: medical power which reaches
well beyond the boundaries of medicine. Paradoxically, this power can have a bad effect on public health
when those who wield it take advantage by favouring one particular discipline, or diverting budgetary
resources to finance luxury treatments.
The Teaching Hospital and the world of politics are thus closely linked. Teaching Hospitals ought to
be protected by law against political interference.
It is thus crucial that a national debate on Teaching Hospitals be encouraged. Teaching Hospitals
themselves should also help define national health objectives.
CONCLUSION
Teaching Hospitals are hospitals which provide the most complex care. They have an important
function in the health system and their burden on the economy is often not as great as is sometimes
presumed, since they account for slightly less than 10% of total health expenditure in the countries which
provided data. This result must be tempered by the fact that only 10 countries (5 of them in the highincome bracket) responded to questions enabling this percentage to be calculated.
The health system does, of course, have need of complex health care, but it must be provided
advisedly, namely when it has a reasonably good chance of success in instances where more simple
treatment would not. Such care is usually termed tertiary in contrast to the more basic "primary" and
"secondary" care. Teaching Hospitals thus have a legitimate function to play in a multi-layered health care
system which was not called into question at the seminar.
Do Teaching Hospitals play the role of last referral expected of them? The answer was sadly no.
In actual fact, even where formal referral systems are in place, the primary' and especially secondary
levels are all too frequently "short-circuited". Since patients apply to them direct, Teaching Hospitals are
thus perfectly able to operate in isolation from the rest of the health care system. In fact, they do not
hesitate to do so, and often maintain this situation by means of esoteric practices and patronizing attitudes.
In reality, two parallel systems coexist:
25
- on the one hand, overcrowded Teaching Hospitals dispensing costly treatments of all levels,
often unjustifiably;
- on the other hand, a primary and secondary health care system which fails to refer patients in need
of tertiary level care in order to keep them to themselves, to the obvious detriment of these
patients' health.
This isolation of Teaching Hospitals from the rest of the health care system occurs everywhere,
whatever the level of economic development of the country, and however its health care system is
organized.
It was unanimously recognized that the proper function of Teaching Hospitals involves dispensing
health care of a truly tertiary nature. The fact that Teaching Hospitals currently provide complex care in
isolation from the rest of the health care system was also recognized (and deplored). The next task is to
propose a strategy for reorienting Teaching Hospitals.
Firstly, it is necessary to be aware of the two tendencies which only serve to widen this chasm:
The first is a marked tendency on the part of the Teaching Hospitals to rely on advanced
technology, which they are perfectly capable of developing without any dialogue or cooperation
with the rest of the health system.
In contrast, the second tendency is for the Teaching Hospitals themselves to provide primary and
secondary care at inordinate cost and in unfair competition with the services and units set up for
that purpose.
Teaching Hospitals must then be integrated into the rest of the health care system:
- by formalizing the system of referral where necessary;
- by introducing arrangements to prevent short-circuiting of the system where formal referral
already exists;
- by creating, on the basis of national directives, opportunities for dialogue at regional level
between the units responsible for the three levels of care, using structures suited to the local
situation (regional health and social organization schemes, forums, etc.);
- by encouraging physicians and other health personnel to revise their way of thinking. Currently,
they are trained solely in Teaching Hospitals and often acquire wrong ideas. One of the means
suggested would be to conduct more practical teaching outside the Teaching Hospitals, -Another
--would be to involve Teaching Hospitals in continuous training;
by using all available health education techniques to make the public understand that
short-circuiting the secondary health care level carries risks;
by making the various levels financially interdependent. Several solutions are possible: Health
Maintenance Organizations or HMO (American model), funding of tertiary care by general
practitioners (British model), etc. It is also, however, necessary to be aw are of the possibly
pernicious consequences which could jeopardize the quality of Teaching Hospitals.
26
Finally, this seminar provided a reminder of the indispensable nature of tertiary care and urged both
national governments (or regional authorities) and the Teaching Hospitals themselves to reconsider the
function of Teaching Hospitals, with a view to transforming them into true "last referral hospitals” linked
to the rest of the health system and not alienated from it as is currently everywhere the case.
27
Annexe I
Comparaison statistique
des pays representes
Sources:
population totale et croissance de la population
pays a revenus eleves et Albanie: tableau 451
autres pays: tableau 231
population de moins de 15 ans: tableau 262
population de 65 ans et plus: tableau 262
population rurale
pays a revenus eleves et Albanie: tableau 441
autres pays: tableau 10*
PIB/habitant (USS ajustes): tableau I1
PNB/habitant
pays a revenus eleves: tableau 28‘
Albanie: tableau A92
Vietnam: tableau A92
autres pays: tableau 21
croissance du PNB/habitant
pays a revenus eleves: tableau 501
autres pays: tableau 271
IDH (indice de developpement humain):
tableau I1
esperance de vie: tableau 11
mortalite infantile/1000 naissances
Royaume-Uni: participant
autres pays a revenus eleves3:
autres pays: tableau 4'
nombre d’infirmieres
pays a revenus eleves: participant, sinon
tableau A82
autres pays: participant, sinon tableau 121
nombre de medecins
Pays-bas: tableau 352
autres pays a revenus eleves: participant,
sinon tableau 352
autres pays: participant, sinon tableau 12*
depenses de same par rapport au PIB: tableau 92
depenses de same par rapport au PIB secteur
public seul: tableau 92
autres donnees sur le systeme de same:
participant
nombre de lits d’hopitaux: participant, sinon
tableau A82
autres donnees sur les hopitaux: participant
etudes medicales et hopitaux universitaires:
participant
Les sources sont indiquees ci-dessus d’une maniere illustree par les exemples suivants:
•«tableau 92» signifie que la source des donnees se trouve dans le tableau 9 de la deuxieme reference
mentionnee en bas de page, en I'occurrence un rapport de la Banque Mondiale.
•« participant, sinon tableau 12'» signifie que les donnees ont ete fournies avant ou pendant le seminaire
par un participant et, qu’a defaut, elles proviennent du tableau 12 de la premiere reference en bas de
page, en I’occurrence un rapport du PNUD.
1. PNUD. Rapport Mondial sur le Developpement Humain, 1993, Economica, Paris.
2. Banque Mondiale. Rapport sur le developpement dans le monde, 1993, Investir dans la same, Banque
Mondiale, Washington.
3. OCDE. OECD Health Systems Facts and Trends, Paris.
29
La juste place des hopitaux universitaires dans les systemes de sante
Economies d revenu eleve
SWI
JAP
SWE
F
NL
AUS
UK
Demographie
population totale (Mhab)
croissance de la population
population de moins de 15 ans
population de 65 ans et plus
population rurale
6,8
0,6%
17%
16%
40%
124,0
0,4%
18%
12%
23%
8,6
0,5%
18%
18%
16%
57,0
0,4%
20%
14%
26%
15,0
0,7%
18%
14%
11%
17,3
1,4%
22%
11%
15%
57,6
0,2%
19%
16%
11%
Economie
PIB/habitant (US$ ajustes)
PNB/habitant (US$)
croissance du PNB/habitant
IDH (developpement humain)
20 874
32 250
1,7%
0,978
17616
25 840
3,5%
0,983
17014
23 780
1,8%
0,977
17 405
19 590
1,7%
0,971
15 695
17 570
1,4%
0,970
16051
16 560
1,7%
0,972
15 804
16 080
2,5%
0,964
Indicateurs de same
esperance de vie
mort. infantile/lOOOnaissances
77
6,8
79
4,8
77
5,8
76
7,7
77
6,8
76
8,7
76
7,0
4,1
3,0
70%
7,5%
5,1%
32%
16,7
6,5
1,7
43%
6,5%
4,8%
12%
40,7
9,3
3,0
67%
8,8%
7,9%
5%
23,8
5,4
2,7
48%
8,9%
6,6%
17%
23,7
8,3
2,2
57%
7,9%
5,7%
20%
16,8
8,7
2,2
34%
7,7%
5,4%
17,6
8,2
2,0
49%
6,1%
5,2%
9%
13,6
60%
55%
0,08
0,66
2,9
12,1
8,7
6,2
55%
5%
0,28
4,69
5,9
55%
0%
0,10
1,24
1,6
25,2
4,2
5,6
50%
25%
4,8
51%
9%
7,7
3,8
9,7
47%
18%
0,12
1,57
1,7
8,6
5,1
0,5
39,0
5,1
1,5
5,5
2,4
751
6
50%
5
694
5
50%
7
Systeme de same
emplois de la sante/lOOOhab.
infirmieres/1 OOOhab.
medecins/1 OOOhab.
specialistes
cout de la sante/PIB
idem (secteur public seul)
contribution personnelle
Hdpitaux
lits d’hopitaux/lOOOhabitants
cout des hop. /cout de la sante
pourcentage de lits prives
medecins/lit
autres employes/lit
lits de psychiatric/lOOOhab
lits long sejour/1000h> 65 ans
lits aigus/lOOOhab
10,2
43%
0,17
1,73
1,6
12,9
6,4
Etudes medicales
nouveaux medecins/an/lOMhab
duree des etudes de base
pourcentage se specialisant
duree de la specialisation
978
7
75%
5
621
1047
6
90%
7
614
6
60%
5
967
6
90%
5
Hdpitaux universitaires
lits de CHU/Mhab
lits de CHU/tous lits
lits de CHU/tous lits aigus
medecins/lit de CHU
autres employes/lit de CHU
cout/lit de CHU (1000 US$/an)
cout des CHU/cout des hop.
cout des CHU/cout de la sante
cout des CHU/PNB
1144
11%
18%
0,5
3,0
175
19,2%
8,3%
0,6%
677
5%
8%
0,4
1,1
164
11,0%
6,6%
0,4%
1181
19%
31%
0,4
5,0
207
21,2%
11,7%
1,0%
1610
17%
31%
0,4
2,4
126
24,8%
11,7%
1,0%
490
8%
12%
0,5
3,6
218
14,0%
7,7%
0,6%
30
Annexes
Economies d revenu intermediate
4>
K
CHIL
JAM
COL
MOR
PHI
ALB
Demographic
population totale (Mhab)
croissance de la population
population de moins de 15 ans
population de 65 ans et plus
population rurale
43,8
0,8%
25%
4%
28%
13,4
1,5%
31%
6%
14%
2,4
1,0%
33%
5%
48%
32,9
1,6%
35%
2%
30%
25,7
2,3%
41%
2%
52%
63,8
2,0%
39%
2%
57%
3,3
1,0%
35%
Economic
PIB/habitant (US$ ajustes)
PNB/habitant (USS)
croissance du PNB/habitant
IDH (developpement humain)
6733
5450
8,9%
0,872
5099
1950
1,1%
0,864
2979
1500
-0,4%
0,736
4237
1260
1,1%
0,770
2348
970
1,6%
0,433
2303
730
-1,5%
0,603
3000
640
Indicateurs de same
esperance de vie
mort. infantile/lOOOnaissances
70
22
72
17
73
15
69
38
62
72
64
42
Systeme de same
emplois de la sante/lOOOhab.
infirmieres/1 OOOhab.
medecins/lOOOhab.
specialistes
cout de la sante/PIB
idem (secteur public seul)
contribution personnelle
10,0
1,7
1,1
55%
6,6%
2,7%
61%
6,5
2,7
1,0
2,0
0,5
3,6
0,5
1,0
41%
4,0%
1,8%
11%
1,3
1,0
0,3
49%
2,6%
0,9%
63%
10,3
2,8
1,1
2,0%
1,0%
50%
1,3
48%
1,2
1,4
8%
44%
Hopitaux
lits d’hopitaux/lOOOhabitants
cout des hop. /cout de la sante
pourcentage de lits prives
medecins/lit
autres employes/lit
lits de psychiatrie/1 OOOhab
lits long sejour/1000h> 65 ans
lits aigus/1 OOOhab
Etudes medicales
nouveaux medecins/an/lOMhab
duree des etudes de base
pourcentage se specialisant
duree de la specialisation
Hopitaux universitaires
lits de CHU/Mhab
lits de CHU/tous lits
lits de CHU/tous lits aigus
medecins/lit de CHU
autres employes/lit de CHU
cout/lit de CHU (1000 US$/an)
cout des CHU/cout des hop.
cout des CHU/cout de la sante
cout des CHU/PNB
3,0
52%
21%
0,16
1,17
4,7%
3,4%
0,0
3,2
24%
72
3,5
1,8
25%
4,0%
3,4%
3,0
0,1
0,3
443
909
6
0,7
951
6
365
7
311
7
31%
5
4
126
10%
630
21%
27%
119
40,0%
20,8%
1,4%
0,699
0,16
2,3
658
6
87%
5
65%
0,5
0,8
3,7
68
18
9,3%
4,5%
0,2%
31
200
17%
30%
0,5
1,2
6
4,9%
0,1%
606
20%
0,9
2,4
19
0,2
1,2
La juste place des hopitaux universitaires dans les systemes de same
Economies d faible revenu
EGY
IND
PAK
CHIN
BEN
MG
TAN
VN
Demographic
population totale (Mhab)
croissance de la population
population de moins de 15 ans
population de 65 ans et plus
population rurale
53,6
2,1
39%
3%
53%
187,7
1,7
36%
4%
69%
121,5
2,7
44%
2%
68%
1170,7
1,2
27%
7%
67%
4,8
3,0
47%
2%
62%
112,1
3,1
46%
1%
65%
26,9
3,2
47%
3%
67%
68,1
2,0
Economie
PIB/habitant (USS ajustes)
PNB/habitant (USS)
croissance du PNB/habitant
IDH (developpement humain)
1988
610
2,1%
0,389
2181
560
4,1%
0,515
1862
400
2,9%
0,311
1990
370
7,9%
0,566
1043
360
-1,0%
0,113
1215
290
-3,0%
0,246
572
110
-0,7%
0,270
0,472
Indicateurs de same
esperance de vie
mort. infantile/lOOOnaissances
60
59
61
68
58
101
70
29
47
88
51
99
54
104
63
39
0,1
0,4
4,4
0,9
1,5
3,4%
1,8%
47%
3,5%
2,1%
36%
0,7
0,6
0,1
37%
4,3%
2,8%
0,6
2,4
Sysieme de same
emplois de la sante/lOOOhab.
infirmieres/1 OOOhab.
medecins/1 OOOhab.
specialistes
cout de la sante/PIB
idem (secteur public seul)
contribution personnelle
Hdpitaux
lits d’hopitaux/lOOOhabitants
cout des hop. /cout de la sante
pourcentage de lits prives
medecins/lit
autres employes/lit
lits de psychiatric/1 OOOhab
lits long sejour/1000 h > 65 ans
lits aigus/1 OOOhab
2,6%
1,0%
1,6
0,5
0,1
33%
2,0%
0,7%
2,0
0,6
1,3
1,3
2,7%
1,2%
1,4
0,9
0,2
0,0
27%
4,7%
3,2%
1,1
55%
30%
0,04
0,29
0,0
0,0
0,5
Etudes medicales
nouveaux medecins/an/lOMhab
duree des etudes de base
pourcentage se specialisant
duree de la specialisation
Hdpitaux universitaires
lits de CHU/Mhab
lits de CHU/tous lits
lits de CHU/tous lits aigus
medecins/lit de CHU
autres employes/lit de CHU
cout/lit de CHU (1000 USS/an)
cout des CHU/cout des hop.
cout des CHU/cout de la sante
cout des CHU/PNB
0,9
58%
1,1
0,2
412
7
76%
4
373
18%
0,6
2,2
6
32
393
0,9
0,9
104
19
5
45%
3
131
14%
14%
0,1
0,6
10
13,9%
8,1%
| 0,3%
56
5%
6%
0,2
2,7
11
22,2%
12,2%
0,6%
2
78%
1100
110
1,7
1,1
2,1%
1,1%
3,3
Annexe II
Liste des participants
Dr E. Goon, Division des Ressources
Humaines, OMS, Geneve
Dr F. Siemtjam, Division du Renforcement
des Services de Sante, OMS, Geneve
M. O. Teglgaard, Division du Renforcement
des Services de Same, OMS, Geneve
M. F. R. Inman, Conseiller temporaire, OMS,
Geneve
Pr M. Petrela, Directeur General, CHU de
Tirana, Tirana, Albanie
Pr J. Lawson, The University of New South
Wales, Sidney, Australie
Dr A. Rotem, The University of New South
Wales, Sidney, Australie
Pr P. A. L. Medji, Directeur General, CNHU
de Cotonou, Cotonou, Benin
Pr C. Montoya-Aguilar, Universidad de Chile,
Santiago, Chili
Mmc Chi Bao Lan, Ministere de la Same
Publique, Beijing, Chine
M Jing Zong Ren, Ministere de la Sante
Publique, Beijing, Chine
Mme le Dr P. Gomez, Centro de Gestion
Hospitalaria, Bogota, Colombie
Dr Y. Soo Shin, Korea Institute of Health
Services Management, Seoul, Coree du Sud
M. S. Fayyadh, Cairo Curative Organization,
Cairo, Egypte
Mmc C. Thayer, Direction des Hopitaux,
Ministere de la Sante, Paris, France
Pr D. Jolly, AP-Hopitaux de Paris, Paris, France
M D. Puzin, AP-Hopitaux de Paris, Paris,
France
Pr Wirjoatmodjo, Dr Soetomo hospital,
Surabaya, Indonesie
Dr Barry Wint, Ministere de la Same,
Kingston, Jamaique
Dr S. Kitagawa, National Institute of Health
Science Management, Tokyo, Japon
Dr K.Kawabuchii, National Institute of Health
Science Management, Tokyo, Japon
Pr H. Ohmichi, Nihon University School of
Medecine, Tokyo, Japon
Pr J. El Jai, Faculte de Medecine, Casablanca,
Maroc
Dr T. A. J. Ogunbiyi, Lagos University
Teaching Hospital, Lagos, Nigeria
Pr Mumtaz Husain, Aga Khan Hospital and
Medical College, Karachi, Pakistan
M D. van der Meer, Nationaal
Ziekenhuisinstituut, Utrecht, Pays-bas
M J. P. C. de Moel, Vereniging Academische
Ziekenhuizen, Utrecht, Pays-bas
Dr F. A. Estrella, Philippines General
Hospital, Manila, Philippines
Dr R. Maxwell, King Edward’s Hospital Fund,
London, Royaume Uni
Dr G. Berleen, Swedish Planning and
Rationalization Institute, Stockholm, Suede
M A. Griffiths, Health Management Institute,
Geneve, Suisse
Dr Chiduo, Muhimbili Teaching Hospital,
Daar Es Salaam, Tanzanie
Pr Pham Huy Dong, Centre des Ressources
Humaines en Sante, Hanoi, Viemam
33
Annexe III
Deux reflexions generales
sur les Hopitaux Universitaires
Ill-a Hospitals and the health of communities
Ill-b Etude sur les Hopitaux
Universitaires de quatre pays
35
Annexe Illa
Hospitals and the health
of communities
F. Siem Tjam,
Medical Officer, WHO
Introduction
The purpose of this text is to clarify the
role of hospitals in the pursuit of Health for All
in a system based on the principles of primary
health care, and to highlight the issues that WHO
is currently addressing in its programme on hos
pitals, which seeks to reorient hospitals and make
them more responsive to local health needs.
The most visible contribution of hospitals
to the health status of the populations they serve
is in the domain of restorative and rehabilitative
care. Their direct impact on the basic health
conditions of communities is less obvious, but
they can make essential contributions - particu
larly in the areas of preventive and promotive
care. Much of our knowledge about the physio
logical and biological factors that detract from
health, for example, usually originates in hospi
tals.
Because of their dedication to alleviating
suffering and avoiding death, as well as due to
their natural authority in their communities,
hospitals have a respected place in every natio
nal or local health system. They are an expres
sion of community and government concern to
provide technical health care interventions
which cannot be undertaken at the first contact
level. As such, they ensure the availability of ap
propriate care for those who, in spite of preven
tive efforts, become injured or sick and will be
in need of complex treatment. They provide
emergency care for the severely injured or the
critically ill, and serve as a bridgehead against
the onslaught of natural or man-made disasters,
providing relief from human suffering at such
times. They are a centre of learning: a place for
the transfer of knowledge and skills, and a basis
for continuing education for all levels of health
workers. At the same time they constitute an es
sential source of information, especially when
new health threats emerge, on the prevalence of
grave or complex health conditions in commu
nities. Finally, the hospital industry is one whose
product may be expressed in terms of restora
tion or rehabilitation for individual or social pro
ductivity, of charitable work or of financial gain.
District hospitals -in particular those at
the first referral level in a district health sys
tem- are, because of their geographical loca
tions, natural strong points in national health
care networks. And yet they tend to fall far be
hind in the pecking order when governments are
setting priorities and allocating resources. Dis
trict hospitals should be accorded the recogni
tion commensurate with their strategic value
which, for the purpose of Health for All, may
even exceed the input of large and university tea
ching hospitals and other high-tech medical
centres.
The Division of Strengthening of Health
Services is intent on focusing greater attention
on hospitals in general and district hospitals in
particular to promote that they receive the re
sources they desperately need to offer affordable
37
La juste place des hopitaux universitaires dans les systemes de sante
and good quality intramural care to the com
munities they serve. At the same time, the Divi
sion is seeking to identify the proper place of the
various levels of technological care necessary in
every community, including those of specialized
and teaching hospitals.
ment, it will share the opportunity and the obli
gation to provide effective and affordable health
services to the entire population and to involve
the community in the planning, implementation
and evaluation of those services.
The characteristics of hospitals
Hospitals and health systems
For some 800 million inhabitants of the
high-income countries, control of such healthrelated conditions as sanitation and exogenous
pathogenic conditions is well in hand. More and
more attention is being focused on genetic and
lifestyle-related diseases and problems associa
ted with managing the conditions of advancing
years. An increasing range of complex interven
tions is available and some can now be perfor
med on an outpatient basis, reducing the need
for hospital beds. But high overall utilization of
services, increasing investment costs and rising
wages have a negative influence on social equity
in health. The challenge for these high-income
countries is, ironically, how to cope with the cost
of their health and medial care.
By contrast, in the low-income and
middle-income countries, whose total popula
tion exceeds 4000 million, the challenge is how
to develop and strengthen the basic conditions
for health - such as relief of poverty, availability
of safe drinking water, sanitation, food, shelter
and literacy- and at the same time to provide
access to basic health services, including plan
ned parenthood, the control of endemic diseases
and essential medical care.
Thus, while far apart in levels of service
delivery, health systems all over the world share
a similar concern: that of social equity in access
to health care, together that is of an affordable
quality. In the context of primary health care and
of Health for All, the hospital at the first refer
ral level in a district health system must be much
more than a curative facility functioning at a
single level in a health system; it must in fact be
closely linked with every aspect of health deve
lopment within its district. With the community,
±e PHC services and other sectors of develop
38
Subjectively, hospitals have been regar
ded by the layman as awesome institutions built
largely to cure ills but partly also as places in
which to die. The health professions have vie
wed them as centres of technical excellence for
learning and practice; while budget officers in
national ministries of health have struggled to
justify their relative cost.
Over the past centuries, concerns and ac
tion for health care developed in a variety of
ways. One major approach was individual care
for the suffering, the sick and the dying. This ap
proach gave rise to the development of ambula
tory and institutional clinical care services, fun
ded in various ways -by individuals and by
charity, by direct and indirect payment methods.
Another approach arose from individual
and collective empathy, feudal and religious
obligations, and, in general, the desire of go
vernments to promote order and protect pro
ductivity. This gave rise to public health care,
administered through legislation and services for
entire groups of populations, which was usually
funded through government and other collective
mechanisms such as taxes, mutualities, insu
rance and - more recently - a variety of co-payment schemes.
Both approaches changed in size and na
ture over the centuries to match the ideology,
wealth and social structures of nations, and so
did health care technologies. Hospitals today of
fer a picture of striking similarities and curious
differences in the distribution, availability and
performance of health care services in the world.
They may include a mix of several concepts in
their operational behaviour, but most fall into
one of the following main categories:
a) The private hospital, conceived as an income
generating service whose performance is measu-
La juste place des hopitaux universitaires dans ies systemes de sante
• hospitals use a large proportion of the most
highly trained health personnel; thus, in Kenya
60 p. 100 of the total number of physicians and
80 p. 100 of the nursing officers are assigned to
hospitals.
There can be no doubt that the problem
of the “brain drain” still bedevils Third World
countries; a certain percentage of the bright
young medical and nursing students sent (ex
pensively) abroad for further study will remain
abroad. There is also increasing evidence of was
tage within the health sector. In the Americas,
wastage was estimated at 40 p. 100 of all the re
sources available for health services. In cash
terms, this wastage amounted to some ten thou
sand million dollars per year in 1989 among the
low and middle income developing countries of
that region. Clearly, concern about finances,
costs and efficiency in the health system should
give rise to probing questions about how the hos
pitals utilize their resources.
Thus, there is a need for detailed coun
try-level study of hospital cost and performance
data, in order to make planning and manage
ment decisions. This will call for an examination
not only of the actual expenditures and their
trends but also of the principles and practices
which underlie and explain those trends. For any
of these questions to be fully explored, the pat
terns of hospital expenditure must be known and
the hospital’s functional mission needs to be ca
refully identified.
• Cost-effectiveness and quality
Hospital physical infrastructure are also
important factor in the determination of cost-ef
fectiveness and quality of care. Since hospitals
consume a major part of health care budgets, in
appropriately designed, constructed and equip
ped hospital plants may lead to an unacceptably
high wastage of resources. Poor choices of
equipment and poor planning of facilities, ins
tallations and medical equipment result in costly
and ineffective maintenance, an unsafe environ
ment and low quality of care, in turn affecting
both the morale of staff and the confidence of
patients. On the other hand, there are many
examples in developing countries where appro-
39
priate and cost-conscious planning of health fa
cilities and well-functioning technical services
have ensured reasonable selection and procure
ment procedures, good maintenance and safe
use of equipment.
Generally speaking, very little attention
has been paid over the last two decades to hos
pitals as a self-sustaining service industry. Be
cause many hospitals in developing countries
are owned and operated by the state, they tend
to be perceived primarily as government-subsi
dized and civil service-managed social institu
tions, implementing some variant of govern
ment charity.
In reality, hospitals stand in acute need
of improved resource management and better
monitored clinical “output” - that is to say, qua
lity of care. Regardless of prevailing ideology,
internal resource configuration and internal ma
nagerial capability, the hospital to a large degree
depends for its success on the functioning of
other services operating in its immediate envi
ronment. Among these are the presence or ab
sence of: first contact level services, long-term
care services, transport and communications,
the level of technical capacity in the surrounding
community, and the state of social and econo
mic development, including literacy levels.
As a service industry, the hospital must
learn to cope with resource management and
consumer demand, as well as issues of effective
ness, efficiency and quality of care. While there
is no shortage of information concerning the ma
nagement of the hospital as a private or indus
trial enterprise, serious problems do arise with
management within government owned and
operated hospitals. This raises the question whe
ther what is perceived as a need for management
improvement is really related to the way in which
government hospitals were designed and inten
ded to operate. It should be clear that no amount
of management can make an institution desi
gned as a ship behave and fly as an aeroplane.
There is clearly a need for some hard thinking
about whether large central hospitals can truly
serve a nation’s health without a major review of
their functions and possibly a shake-up and ove
rhaul of their administration.
Annexes
require the specific concentration of technolo
gies and inpatient care that can only be provided
by hospitals?
2. What criteria can be used to evaluate quality
of care, and how can quality of care be integra
ted into all of the hospital’s functions so as to
ensure optimal effectiveness while, at the same
time, considering community needs and re
source limitations?
3. Which policies within national financing and
within district health systems will most favour
the appropriate use of such a concentration of
technological and manpower resources?
4. What alternative ways of delivering health
care may be possible? The advance of techno
logy and the development of social infrastruc
tures has made a number of “elective” interven
tions (e. g. cataract and plastic surgery) possible
with little or no inpatient care, thus reducing ins
titutional cost. Inevitably, in the developing
countries, priority will still have to be given to
emergency and life-threatening conditions that
cannot be undertaken without inpatient care.
5. What architectural and engineering planning
and design decisions, construction methods and
equipment demands are most appropriate for
the local needs and conditions?
6. What about the hospital’s “image”? In The
Hospital of Tomorrow, Jolly and Gerbaud sug
gested: “The hospital ought to create friendlier
environments to cater for those of its clients who
are not ill (those admitted for childbirth, pre
ventive care etc.), to improve its staff recruit
ment, and to update its image for chronic pa
tients (long-stay, psychiatric) in order to
motivate its staff positively. These ‘friendly en
vironments’ should halt the deterioration in re
lationships between the general public, the hos
pital staff and the hospital management. Some
experts analyze them in terms of ‘image and
product. ‘ They see them as a way to escape from
the image of the hospital as a place of disease
and death, a source of anxiety, and transform the
hospital into a place that meets the needs of the
‘major stages in life’: birth, procreation, acute di
seases in adulthood, aging and death. This ap
proach already exists in the areas of paediatrics
and maternity, and ought to be applied more ge-
nerally. The experts believe it is vital for hospi
tals, in particular the public hospital, to change
its image in this way.”
Here, at whatever hour you come, you
will find light and help and human kindness.Ins
cribed on the lamp outside the jungle hospital at
Lambarene, Gabon, of Dr Albert Schweitzer,
1875-1965
Performance of hospitals
Developed countries have recently enga
ged the Struggle of the Rapid Increase for the
Cost of Health Care, and particularly the share
of the budget allocated to hospitals, that ou
tranks anything else in the health sector. There
is general recognition that controlling hospital
costs can generate tremendous savings for the
health system. As a result, extensive studies have
been undertaken on hospital utilization and fi
nancing in an effort to reform health services po
licy and to control the cost of medical care; in
some countries, reform includes reducing beds
and closing down hospitals in addition to expe
rimenting with limitations to demands and ne
gotiating prices.
It is a different story in developing coun
tries. Decision-makers and policy analysts have
almost exclusively emphasized primary health
care, despite all the evidence that the core spen
ding of the nations’ health system’s resources
-finances, facilities and personnel- is concen
trated in hospitals. As a result, hospitals have
been left out of the reckoning when health sec
tor financing is under discussion in developing
countries. Yet as we have seen, in many coun
tries a high proportion of government health ex
penditure is for hospitals.
In fact, a World Bank/WHO study of
hospital economics and financing in developing
countries published in 1992 found more specifi
cally that:
• hospitals utilize nearly half of the total national
expenditure for the health sector;
• hospitals commonly account for 50 p. 100 to
80 p. 100 of government recurrent health sector
expenditure;
40
*
A
La juste place des hopitaux universitaires dans les systemes de sante
medical economists, and therefore may not al
ways take into account such practical considera
tions as where a hospital is sited, whom it is in
tended to serve and how measures taken will
affect accessibility.
A final condition for success is the effec
tive and efficient management of physical re
sources, including buildings, engineering instal
lations, medical equipment and stocks, so as to
achieve the maximum of coverage with an affor
dable quality of care. This will require awareness
and understanding on the part of the adminis
tration in order to ensure an equal standing of
the technical service within the hospital; a team
approach to equipment selection and procure
ment; availability of qualified engineering per
sonnel; and proper maintenance facilities.
However, even if all the elements of an
integrated health service are technically in place,
the system can still be easily upset by problems
of self-referral by patients who have little faith in
anything but hospital care; by inappropriate re
ferral by inexperienced or overworked PHC
worker; by inappropriate or misguided hospital
treatment; or by the provision of inadequate re
ferral or discharge information. An essential part
of Health for All and the health care revolution
is the fully integrated coordination of hospital
and primary health care activities.
The planning of hospitals
within Health for All
Old approaches to hospital planning, for
instance by calculating so many beds per thou
sand population, have been abandoned. The Ex
perts who prepared the WHO Study Group re
port on the functions of Hospitals (TRS 819)
advised that Hospital functions and their plan
ning be reviewed periodically, thereby taking
into consideration changes in the effectiveness of
other health care providers in the community, in
addition to such factors as profiles of population
- and socio-economic distributions, epidemiolo
gical patterns of severity and frequency, and lo
cal availability of human resources, utilities,
communications and transport facilities. The
41
challenge remains of how to provide adequate
hospital care of affordable quality to those who
really are in need of it.
This conceptual model of a District
Health System was suggested by a WHO Expert
Committee on the role of hospitals at the first
referral level, held in Geneva in December 1985.
At sub-national level, the district as a more ma
nageable unit for operational purposes, is repre
sented as a cube. The components of the sys
tem: the levels of service delivery, programme
elements and functional infrastructure elements
are represented as the three dimensions of a
cube. This takes into account the fact that the
resources and capacity of a District Health Sys
tem are finite, while showing the scope for in
teraction and interdependency. For real progress
to occur, the box needs to expand (develop
ment) and the wastage inside the box should be
reduced (better coordination or collaboration)
The first referral level hospital forms a
cornerstone of the cube - but claims no priority
of attention or resources. In fact, no single ele
ment at any one level can be developed in isola
tion, and development of the total system is a
preliminary to the better functioning of all its
parts. Conversely, the improvement of any part
should be undertaken with due consideration of
all the other components (i. e. replacing compe
tition by collaboration), so as to increase effi
ciency and avoid duplication, destructive rivalry
and unnecessary waste within a finite system.
In any realistic setting, an essential “pac
kage” of services will have to include treatment
of trauma and infections. Efficient delivery of
these essential services will require a well-func
tioning district health system consisting of health
posts and health centres as the first point of pa
tient contact, and district hospitals or Reference
health centres as referral facilities - with the two
levels linked by normal or emergency transport.
Hospital planning will need to take into account
such a “minimum package of essential clinical
services.”
In planning and organizing hospitals wi
thin the HFA framework, the responsible health
authorities need to consider the following:
1. Which part of a community’s health needs will
Annexes
The transfer of technologies and their ap
plication in hospitals equally appear to proceed
on separate official and unofficial lines. Govern
ments have difficulty in imposing ceilings on the
adoption and use of technologies. The evolution
of new technologies can be perceived as enri
ching the medical care industry but, without me
chanisms to control the expenditure involved,
governments are hard put to it to ensure a mi
nimum quality and affordability of basic hospi
tal care for the population under their responsi
bility.
It seems reasonable to expect that a consi
derable number of new medical technologies will
enter the “health market” within the next ten
years. Some of these may have a cost-reducing
effect, for instance, by making hospitalization re
dundant for certain medical conditions. Others
on the other hand may permit interventions that
may be life-saving or merely of a convenience na
ture, but that have not been foreseen when faci
lities or financing mechanisms were originally
planned. Governments, especially those of deve
loping nations and particularly those that have
not formulated a specific hospital policy as part
of their national health policy, will be caught at
a disadvantage when these evolutions hit their
health systems. To counter such situations, it
will be necessary for WHO to develop some gui
dance on the assessment and selection of rele
vant technology and its social control in hospi
tals as well as to assist member states in
developing their own national and local hospital
policies as part of an overall Health policy.
Conditions determining
the functions of hospitals
• Some external conditions
The level of socio-economic develop
ment of the community in which the hospital is
situated has a bearing on the availability and the
quality of staff, including appropriate recurrent
training and career structures. Also, whether
there are many general practitioners or other
health workers operational within the hospital’s
area of service or none at all, will have an in-
fluence on the patterns and level of referrals and
self referrals coming to the Hospital. Other
considerations will include education, support
structure, roads, communications and transport
facilities, and the availability of water and elec
tricity, all of which may determine the case mix
coming for treatment from, as well as the capa
city for maintenance and repair in the commu
nity.
A second major condition is the prevai
ling financing structure and tradition in the com
munity, and the degree of development of a mo
netized economy with concurrent availability of
sufficient foreign currency. This to a high degree
determines the sustainability and quality of func
tions, including regular access to consumable
supplies such as pharmaceuticals, X-ray films,
spare parts and so forth.
Thirdly, its location -both in terms of
physical accessibility by locally available trans
port and of organizational linkages in the local
health system network- to a high degree deter
mines the way in which the hospital will be cal
led upon to act.
• Intramural Conditions
Of the intramural conditions that deter
mine the functions to be undertaken by a hospi
tal, perhaps the most important is its “mission”
or “goal,” as set by its governing body. On this
depends the types of care and interventions un
dertaken, the admission and discharge criteria,
and the medical and ethical standards of quality.
Then, the hospital and its staff should be
clear about their own tasks and how to meet the
health needs of the community. This will be re
flected in administrative and clinical decisions
that favour a holistic rather than an incidental,
“fire-fighting” approach to care delivery.
Many of the complex problems facing
hospitals in developing countries and determi
ning their functions and outputs relate directly
or indirectly to the financial resources -issues
falling within the three major areas of resource
allocation, management of expenditures and re
venue generation. In some instances, the pro
blem may not so much be one of management
but of design; health economists are invariably
42
4
La juste place des hopitaux universitaires dans les systemes de sante
neously building up its internal strength. These
tasks are interdependent; district health services
without hospital support are severely deprived,
while hospital services and support capacities
unrelated to community and district needs can
not realize their full potential. Overall, the focus
of activity at the first contact and first referral le
vels is the community - the people. Success at
either level means meeting all the people’s needs
to their satisfaction.
Large and teaching hospitals
a
Another area of the health scene that has
been little explored in the context of Health for
All is that of the significance of large and tea
ching hospitals. Many countries have such large
institutions, which are further denominated ac
cording to prevailing customs as central, state or
provincial hospitals or medical centres, and of
course as public and private or university hospi
tals. Many of these institutions may have in ad
dition to first referral and secondary referral
functions also a full or partial training function
for medical, nursing and other personnel.
In this latter function, these large training
institutions imprint on the nation the directions
that its health-related activities are likely to take
in the future, and serve as an incubator or hat
ching-ground for future leaders in the health sec
tor. For better or for worse, they set a pattern
and a standard that their former trainees will
ever after seek to emulate, and strongly influence
the formulation of official and unofficial hospi
tal policy in the minds of national decision-ma
kers.
Since they have such a determining role
in the introduction and consumption of techno
logies, they also have a major influence on the
determination of health care demands. They
tend by their very nature to promote the medicalization of the health care industry, and their
product is not always considered in the light of
benefits for the whole of society.
Large and teaching hospitals are extre
mely complex industries and difficult to manage
in wealthy, industrialized countries. In develo-
43
ping countries, they are usually constituted as a
multi-mission entity, with multiple owners or fi
nanciers and multiple constituencies. As a result
they can sometimes appear wasteful and poorly
managed, consuming a high proportion of avai
lable health resources while serving only a mi
nority of the population.
Many countries still have no specific hos
pital policy as part of their national health po
licy, and these large institutions may be looked
after by a separate department within the Mi
nistry of Health that is quite detached from and
competes with other health responsibilities of the
Ministry for attention and resources. In addition
there is often little coordination or agreement
between the Ministries of Health, Education and
also Social Affairs over the quality and quantity
of Human resources needed for the health sec
tor. Worse still, there is rarely any truly up-todate and relevant legislation in place to govern
the existing hospital subsystems including the
private, industrial and NGO hospitals.
There is a current tendency for govern
ments, even in wealthy countries, to be no lon
ger able to fund and operate hospitals from tax
based sources. Instead, the move is towards
co-payment, user charges, health insurance,
HMOs and other preferred payment systems, all
promoting a “privatization” approach to hospi
tal care that is likely to be a dominant feature in
the decades to come.
National governments, particularly in the
developing world and in the former socialistoriented countries, will be caught unawares by
the upsurge of private clinics and hospitals. In
the absence of any government policy on how to
govern such hospital and clinical care, govern
ments will find themselves increasingly unable to
keep pace with social developments.
The continued existence of archaic hos
pital legislation, often inherited from colonial
days, will be of very little help in those circum
stances. What is needed is a contemporary vision
at the decision-making level of what a country’s
true health needs are, and appropriate legislation
to ensure that the hospital sector serves the na
tional and local needs for intramural care in an
efficient, effective and equitable manner.
Annexes
■
tive and rehabilitative health activities. And the
functions of the hospital at the first referral level
may be defined in terms of patient referral,
health programme coordination, education and
training, and management and administrative
support.
The Study Group emphasized that half of
the world’s people live in villages, where the or
ganization of health services may be hampered
by remoteness, adverse climatic conditions, poor
communications and poverty, and perhaps by
illiteracy and superstition. The first referral hos
pital may be very small, with a tiny staff that is
limited in experience and expertise. The other
half of the population live in cities, some of en
ormous size, where poverty is again a factor, and
where overcrowding, pollution and stress may be
overwhelming. The problems that city hospitals
must face are different from those of village hos
pitals, yet both types of hospitals provide essen
tial services. It is vital that they should be incor
porated into district health system if they are to
provide efficient, effective, affordable and equi
table services to their communities. Large or
small, of course, a hospital where surgery is car
ried out will require proper clinical support.
The Study Group added: “This is not to
underrate good clinical care and diagnosis,
which are still the bedrock of hospital practice at
the first referral level, but rather to emphasize
the importance of making such care available to
those most in need of it.”
Consequently a hospital at the first refer
ral level has to be a place to which patients with
complex medical conditions can be referred for
diagnosis, treatment and care; and it can act as
a resource centre for the health work of the dis
trict. Such a hospital will have the following cha
racteristics:
• It has a place in the national system of health
services, providing 24-hour clinical care;
• It can relate effectively to the district health sys
tem, and is concerned with the health and well
being of the entire population of the area it
serves;
• It supports primary health care (e. g. by sup
porting such services as antenatal and maternity
care, growth monitoring and immunizations),
and ensures continuity of care between the PHC
services and the hospital;
• It can relate effectively to communities and is
committed to helping them to attain eventual
community self-reliance and independence;
• It has referral functions - that is, it can respond
appropriately to the needs of all patients refer
red from health facilities at first contact level, or
can refer them safely to more complex levels of
care;
• It has a training function, including developing
training and continuing education programmes
for all levels of its own staff; (it may be noted
here that the training of nurses and doctors
should be as much outside the hospital as within
it!);
• It relates to other sectors of development;
• It is a problem-solving resource, meaning that
it can address problems that have a bearing on
the health of the people and the effectiveness of
the health services.
The important thing is that the hospital should
serve as a cornerstone rather than the apex of the
District Health System, which in turn provides
the vital functional linkage of a two-way referral
system that is essential for the efficiency of all in
volved.
Not only is the hospital in a position to support
the district health service: it has an obligation to
do so. Areas of support may include:
• collection of information, including epidemio
logical surveys, analysis and information sharing;
• planning for health-related activities, including
emergency work following disasters;
• supervised field training of health personnel at
health centre and community level to maintain
their efficiency and upgrade their skills in line
with changing patterns of health problems;
• assistance in procuring, storing and distribu
ting essential drugs and supplies, and in procu
ring and maintaining equipment;
• involvement in quality assurance programmes
and the evaluation of disease control pro
grammes.
The true challenge to the hospital is that
of achieving effectiveness in two spheres of acti
vity: reaching outwards to strengthen peripheral
health services in the district, and simulta-
44
La juste place des hopitaux universitaires dans les systemes de sante
cently been a declared goal of national health
services around the world. The Declaration of
Alma-Ata in 1978 may not have been the only
affirmation of the need for social justice in
health, but it makes a convenient marker for the
dawn of a new era. Its emphasis on Primary
Health Care as the means of bringing about
Health for all by the Year 2000 triggered a re
volution in health services - in the industrialized
world as well as in developing countries- and
obliged everyone concerned with health to look
afresh at the role of the hospital.
In fact, there has been confusion about
the role which hospitals, and in particular hos
pitals at the first referral level, should play in this
great movement for health. Some have felt that
hospitals are too concerned with the technologi
cal aspects of sickness to be able to play any use
ful role in the promotion of health in the com
munity; others, that the resources any hospital
possesses should be used in the service of the
Health for All movement.
Certainly, in the past the lack of clearly
defined roles and responsibilities for different
elements of the health system has resulted in a
fragmented system with widespread disparities
in financial and human resources between hos
pitals and primary health care facilities. The
consequences of hospitals not being functionally
integrated into the local health system can be
seen in the contrasts in utilization at different le
vels: hospital outpatient facilities are overcrow
ded, while peripheral units are under-utilized
due to non-functioning referral systems, public
perceptions and popular self-referral. While a
certain number of activities must be carried out
in a hospital, only a small proportion of all health
activities really need to take place there.
Once the appropriate roles have been de
fined in an integrated health system, it becomes
possible to deal systematically with resource is
sues concerning the allocation of health person
nel, facilities and finances. The determination of
roles will permit changes in the health system
which can improve the effective use of health
sector resources. Hence, the central issue of the
role and functions of the hospital in the health
system must be addressed by countries if they
45
are to answer questions about the proper num
ber, type and size of hospitals as well as the hu
man, physical and financial resources which
should be allocated to them.
A basic premise of hospital involvement
in PHC is acceptance of the principles of Health
for All. A hospital must seek to promote the
health of the whole population that it serves, in
cluding the health of individuals who never en
ter it. This ought to be as true for the big city
hospital as for a small rural hospital serving a wi
dely scattered handful of villages; of course,
there are large discrepancies in available re
sources, whether financial, technological or in
terms of human resources.
Whereas in past years there was a ten
dency on the part of health authorities to be
preoccupied by large hospitals, it is now being
increasingly recognized that the majority of po
pulations, both rural and urban, are better cared
for by smaller, more manageable institutions.
Such units make more sense because of their
proximity, flexibility of functions, efficiency and
adaptability to changing needs in their environ
ment. The question that arises is: “How much
and what type and level of hospital care is truly
needed, is realistically accessible, and is affor
dable in a specific social and economic environ
ment?”
After all, hospitals are a major part of
every health systems and account for a large pro
portion of their financial, human and capital re
sources. In developing countries health spending
may account for as much as 5 p. 100 of gross
domestic product and 5 p. 100 to 10 p. 100 of
government expenditures.
Hospitals at the first referral level
A WHO Study Group on the Functions
of Hospitals at the First Referral Level, which re
ported in 1992, pointed out that a district health
system based on PHC, serves a well-defined po
pulation living within a delineated area. It in
cludes all relevant health care agencies. It needs
to be managed as a single entity with a fully com
prehensive range of promotive, preventive, cura-
Annexes
red in annual dividend. To a certain degree, the
medical services it offers will depend on the abi
lity of its clientele to pay for them.
b) The charity hospital: often conceived by a re
ligion-based non-govemment organization, its
success measured in terms of mercy and com
passion. That is to say, its admission and di
scharge criteria and the management approach
in such institutions may be quite different from
that of the previous kind of hospital.
c) The industrial and military hospitals. These
institutions are intended to provide the best care
available to ensure optimal work performance
for a defined population. Their success is mea
sured in the reduction of days of work lost and
their contribution to objectives achieved.
d) The public hospital, intended to provide care
based on government responsibility and general
funds. Initially focused on the indigent, its clien
tele soon came to include state employees, civil
servants and - finally - all citizens who by prefe
rence, circumstances or means, do not enjoy ac
cess to other services. Its ultimate goal is to pro
mote social equity and public harmony. On the
other hand, in view of its often civil service cha
racter and tax based budget nature, public hos
pitals today are finding it painfully difficult to
provide the services they are called upon to of
fer.
Nobody doubts the old adage that pre
vention is better than cure, and indeed many
studies have shown the effective impact on
health of introducing elementary hygienic or
even a limited scope of primary health care pro
vision. Yet despite sincere declarations at go
vernment level, the bulk of the health care bud
get is still devoted to relatively high technology
hospitals in urban areas. Large city hospitals ra
rely have anything more than a workaday rela
tionship with the populations living nearby; in
extreme cases their activities may even serve to
undermine the work of nearby health centres.
A WHO Expert Committee on the Role
of Hospitals at the First Referral Level urged the
need for the community to be involved in a
much more practical way in such hospitals, and
commented in its 1987 report: “On the whole,
hospitals have lagged behind other sectors of the
health service in terms of community involve
ment; there are all sorts of explanation, such as
over-emphasis on the disease model of hospital
care and the lack of contact with a defined com
munity. However, these it is essential that these
attitudes change if hospitals are to play their pro
per role in a comprehensive care that includes
both prevention and treatment. Moreover, with
resources becoming increasingly scarce, hospi
tals have no right to decide alone for the com
munities they serve which health issues should
be given priority; technical decisions are one
thing, but priority choices are generally at least
as much social and political as technical.”
District hospitals generally have 50 to
200 beds, serve 50 000 to 200 000 inhabitants
and include departments of medicine, surgery,
paediatrics, obstetrics and gynaecology, and
dentistry. They also provide clinical support ser
vices such as essential anaesthesia, radiology and
clinical laboratory services. The district hospital
constitutes by and large the first level of referral
from health centres, and provides complemen
tary services such as essential surgical proce
dures. It mainly offers inpatient care but also ty
pically provides some outpatient care, day
surgery and emergency services of a kind not
available at health centres.
Hospitals have in the past evolved as ins
titutions isolated from the lives and comprehen
sion of the mass of the people. This isolation has,
if anything, been exacerbated by the march of
modern scientific medicine over the past 50
years or more. Today the gaunt impersonal
image of a “building for dying in” is being re
placed by true places of care for the community.
The metaphorical hospital walls - no less real to
the patients for being abstractions- are at last
beginning to sway in the wind of change, and the
day is surely coming, even though yet still some
way off, when that wind will finally blow the
walls to the ground.
Equity and Health for All
While equity may have been a utopian vi
sion for more than a century, it has only very re
46
*
Annexes
w
*
• Basic planning issues
Among the basic issues to be considered
in the planning of hospitals are the following:
1. The small hospital, whether in a rural area or
in an urban district, will have special problems
which have hitherto rarely been addressed. Such
hospitals need to develop links “upwards” - to the
larger hospitals but also to the health authorities
in its area; “downwards” - to the health centres
which are dependent on it; and “sideways” -to
such partners as district health committees, civic
groups, funding agencies and donors.
2. With the larger hospitals the problems may be
of another nature. They have a high profile at
the Ministry of Health, and enjoy all advantages
and disadvantages that go with such status. They
all too often it absorbs more than a lion’s share
of the available resources in cash and personnel
but, as in the case of University teaching hospi
tals, are also put to extremely complex and de
manding tasks. More clarity in their mission and
better transparency is needed in the financing
and management of such “big beasts,” and they
must become much more responsive to the
needs of remote and/or undeserved communi
ties. Research is lacking on these aspects of the
big hospital.
3. Too little attention is paid to quality assurance
in the hospitals, of all sizes. Perhaps perfor
mance should be looked at almost in industrial
terms of input -process- output. Hospital ad
ministrations themselves should be regularly
evaluated, to ensure that their managerial per
formance is as good as it should be. On the other
hand, it may not be appropriate to judge large
public hospitals by the standards of small private
hospitals; as we have seen, their “mission”, their
functions and their ownership differ fundamen
tally.
4. Even less research is being carried out in the
need to integrate hospital policy within national
health policy. This does not imply that hospital
policy must necessarily be laid down at national
level only or even explicitly; on the contrary, de
centralization of policy making beyond some
strategic principles laid down at national level,
may be healthier both for the hospitals and for
the communities they serve, permitting opera
tional policy setting and regular adaptation by
local or district government or management
teams. Research is needed in this field to clarify
actual intramural care needs, to make the finan
cing of hospitals more “transparent” and - even
tually- to arrive at a more equitable carving up
of the cake, i. e. of the available resources. Ho
wever, it does help if there is some guidance
from the central authorities to permit local go
vernment some point of departure. Such re
search should pay specific attention to the func
tions, administration and performance of
hospitals in district health services, in both ur
ban and rural areas, and should also look care
fully into whatever enabling legislation exists or
needs to be developed.
«
47
Annexe Illb
Etude sur
les hopitaux universitaires
de quatre pays
c
Christine Thayer, Octohre 1993
Etude effectuee pour la Direction des Hopitaux
au Ministere des Affaires Sociales
de la Same et de la Ville - Paris-France
a
Cette etude met en lumiere les pratiques
actuelles concemant certains aspects de la gestion des hopitaux universitaires dans quatre
pays: 1’Allemagne, la Belgique, les Pays-Bas et
le Royaume-Uni.
Quaire aspects ont ete examines:
- la mission de l’hopital universitaire: recon
naissance de sa specificite dans les approches
de la planification et du financement
- 1’organisation du personnel relative aux activites cliniques, d’enseignement et de recher
che : les differentes categories de medecins
(universitaires et autres), leur statut, leur sys
teme de remuneration
- la formation specialisee: son organisation, le
role accorde aux hopitaux non-universitaires
- la recherche: 1’importance relative accordee a
cette activite et les modalites de son finance
ment
Il est toutefois important de souligner
que les regies et les pratiques peuvent varier d’un
hopital universitaire a un autre. C’est notamment le cas de la Belgique. Par consequent, cette
etude ne peut qu’en esquisser les grandes lignes.
La mission de Phopital universitaire:
reconnaissance de sa specificite
dans les approches de la planification
et du financement
• L’Allemagne
L’hopital universitaire est per?u pour
1’essentiel comme lieu d’enseignement pour les
etudiants et mene dans cette optique des activites cliniques hautement specialisees. Il est sous
la tutelle du Ministere de 1’Education du Land,
qui lui verse une contribution (estimee entre 11
et 25 p. 100). Un nouveau systeme de remboursement, base sur les groupes homogenes de
malades, est prevu pour 1996. Selon les previ
sions des caisses d’assurance maladie, une forte
proportion d’etablissements pourraient se trouver deficitaires avec ce systeme. Une autre
consequence serait une specialisation accrue des
hopitaux universitaires.
Les hopitaux universitaires sont, par
ailleurs, les seuls en Allemagne ayant le droit de
foumir des soins ambulatoires, et ceci de fa<?on
tres limitee, uniquement en fonction de leur role
d’etablissement d’enseignement. La proposition
faite dans les annees 70, visant a 1’introduction
d’un systeme integre de planification et de fi
nancement pour tous les hopitaux, universitaires
et autres, a ete rejetee des deux cotes.
Plus recemment, un financement specifique a ete accorde a certains hopitaux non-universitaires, dans des regions ayant besoin d’un
hopital universitaire supplementaire, pour leur
permettre d’ameliorer leurs prestations.
49
o’*”
La juste place des hopitaux universitaires dans les systemes de sante
Les deux types de professeurs sont remuneres de la meme fapon, et ont les memes
possibilites d’activite privee. Comme en Allemagne, 1’hdpital retient un pourcentage des honoraires, sur une echelle qui varie de 10 p. 100
a un taux assez dissuasif de 90 p. 100 selon Facte
et le montant des revenus.
Si, a premiere vue, les postes de professeur academique et de professeur clinique peuvent paraitre de poids egal, il existe neanmoins
des differences subtiles de statut. Les professeurs
cliniques n’ont pas, par exemple, le droit de por
ter la toge. Il se trouve aussi que les criteres de
selection des professeurs cliniques sont en pleine
evolution. Des maintenant la nomination a un
poste de professeur clinique ne se fera plus en
fonction de 1’anciennete. Les commissions seront plus exigeantes et selectives et demanderont
1’agregation comme c’est le cas pour un profes
seur academique.
• Les Pays-Bas
Les medecins travaillant dans les hopi
taux universitaires sont tres largement des uni
versitaires. Il y a trois grades principaux: pro
fesseur, «hoogtdocent» et«docent». En prenant
en compte les medecins chercheurs, il y a un rap
port approximatif d’un poste de professeur pour
5.5 postes universitaires. Le nombre de postes
de professeur a ete limite en 1984, et en meme
temps les criteres de nomination a un poste de
4 docent»sont devenus plus stricts. Les postes de
professeurs comprennent deux grades, profes
seur chef de departement et professeur charge
d’un programme specifique de recherche. Tout
le monde est loin d’acceder a un poste de pro
fesseur. Cela depend surtout de 1’interet du medecin pour les aspects cliniques ou d’enseigne
ment du travail. Apparemment cela ne souleve
pas de problemes et ne semble pas etre un point
particulierement sensible en ce qui conceme le
statut du medecin.
Les professeurs sont nommes par la Faculte de Medecine, mais avec une participation
de I’hopital universitaire, qui insiste surtout sur
des elements cliniques et de management. Jus
qu’a recemment, tout le personnel medical etait
paye par 1’universite, mais aujourd’hui, a la suite
52
de changements, certains medecins sont remuneres par I’hopital universitaire en fonction de la
repartition de leur temps entre les fonctions cli
niques et universitaires. C’est le cas de la plu
part des radiologues et des anesthesistes, par
exemple.
Les salaires de tous les medecins, payes
par 1’universite ou non, sont assez semblables.
Pour faciliter le recrutement de medecins dans
les hopitaux universitaires - les possibilites de
remuneration sont plus interessantes dans les
autres hopitaux- les autorites ont introduit re
cemment des dispositions permettant un certain
niveau d’activite privee. Les honoraires, geres
par I’hopital, sont payes a une fondation, et les
medecins eux-memes s’occupent de la reparti
tion entre recherche, deplacements professionnels et complements de salaires.
• Le Royaume-Uni
A 1’interieur de 1’hdpital universitaire il y
a un ratio d’environ 40 professeurs pour 60 specialistes non-universitaires. La difference est essentiellement une question d’interet pour des activites cliniques ou d’enseignement. Il existe
aussi plus de possibilites d’activite privee pour
les non-universitaires. La remuneration pour les
deux groupes est en general du meme niveau. La
reforme recente a pourtant donne au directeur
general une liberte totale en matiere de remune
ration. Les deux categories de medecins ont la
possibilite de gagner des complements de salaire,
appeles «paiements au merite», qui vont jusqu’a
doubler leurs salaires.
Tous les specialistes du NHS ont une responsabilite d’enseignement et la plupart d’entre
eux y participent de fa?on active. Il y a meme
des non-universitaires qui participent autant aux
activites d’enseignement que leurs collegues,
professeurs de medecine. Dans ces cas ils resol
vent un contrat d’honoraire, le plus souvent de
«senior lecturer » mais quelquefois de professeur.
Apparemment il n’y a pas de sensibilites particulieres entre medecins a 1’interieur de I’hopital
universitaire concemant des questions de statut,
la grande difference etant entre les medecins travaillant a I’hopital universitaire et ceux qui travaillent ailleurs.
cr
3
Annexes
La formation specialisee: son organisation,
le role accorde aux hdpitaux non-umversitaires
I
A
5
4
<# *
• L’Allemagne
La formation specialisee en Allemagne
dure en regie generale quatre ans. Ceux qui veulent poursuivre une carriere universitaire doivent
obtenir une «Habilitation», 1’equivalent de
1’agregation. Dans la plupart des hdpitaux uni
versitaires il y a la possibilite d’un contrat de
«specialiste en formation» qui, dans le cas de la
Baviere, peut etre renouvele jusqu’a 13 ans pour
permettre au medecin de terminer son «Habili
tation ». La selection du futur specialiste est basee sur un certain nombre de criteres et depend
du chef de departement.
Deux autres types d’hdpitaux peuvent
etre associes a la formation medicale. D’abord
les hdpitaux normaux peuvent accepter des etu
diants pour des stages de sensibilisation de
4 mois. Ensuite les «hdpitaux d’enseignement»
ont un contrat avec 1’hdpital universitaire pour
la formation pratique de jeunes medecins sur
une periode de 18 mois. Le Ministere de 1’Education du Land contribue au financement de ce
type d’hdpital selon le nombre de medecins en
formation, et finance egalement deux ou trois
postes de professeur. Il peut y avoir aussi un soutien financier pour des modifications structurelles ou pour des equipements lourds. Environ
un tiers des jeunes medecins resolvent cette for
mation pratique a 1’exterieur de 1’hdpital univer
sitaire.
En ce qui conceme 1’accreditation de ces
hdpitaux, il n’existe pas de systeme formel. Tout
depend du nombre de places requises et des
connaissances du personnel medical de 1’hdpital
universitaire concemant la qualite des services
dans les hdpitaux generaux.
La formation specialisee a lieu uniquement au sein de 1’hdpital universitaire.
•La Belgique
La formation specialisee en Belgique varie entre 4 et 6 ans selon la specialite et suit un
modele de compagnonnage. La selection des
candidats pour la formation specialisee s’etablit
sous la responsabilite des commissions de selec
tion de specialistes au sein du Ministere de la
Same Publique, composees pour 50 p. 100 de
medecins du syndicat et pour 50 p. 100 de medecins universitaires.
Pour la formation specialisee, il y a une
majorite de places en dehors de 1’hdpital universitaire. Pour les Cliniques St. Luc les nombres
sont de 200 a 1’interieur de 1’etablissement et
300 a 1’exterieur. Ceci est necessaire pour repondre a la forte pression de la demographic me
dicale. Une commission d’agregation, composee
pour la moitie d’universitaires et pour le reste de
representants des organisations professionnelles,
est responsable de 1’evaluation des hdpitaux souhaitant participer a cette formation. Ceci est fait
a partir de criteres lies pour 1’essentiel aux lits et
a 1’effectif, et sur la base de plans de stages soumis par 1’hdpital demandeur. Les criteres de re
connaissance des maitres de stages sont publics
dans la loi et mis en application par le Conseil
Superieur des Specialistes, qui inclut, par
ailleurs, les generalistes.
En ce qui conceme les etudiants en medecine, au cours des deux dernieres annees
d’etudes qui sont consacrees a des stages pra
tiques, seulement 3 a 6 mois se passent a 1’hd
pital universitaire, faute de places en nombres
suffisants.
• Les Pays-Bas
La formation specialisee est la responsa
bilite de 1’hdpital universitaire a 1’exception de
celle des generalistes, qui est organisee par la faculte de medecine. 60 p. 100 de la formation
specialisee se deroule a 1’hdpital universitaire,
tandis que 40 p. 100 a lieu dans les hdpitaux
communautaires.
Aujourd’hui le futur specialiste re^oit sa
formation dans 1’un ou 1’autre etablissement. A
la suite de changements en cours, un systeme de
rotation sera introduit. Ainsi les specialistes en
formation seront re?us dans les deux types d’etablissements, et passeront environ quatre annees
a 1’hdpital universitaire et deux dans les hdpitaux
generaux. Des contrats seront negocies selon les
besoins de ces hdpitaux, d’une part pour la for
mation en soins cliniques de base, d’autre part
pour la recherche. Cette tendance, qui conceme
53
La juste place des hopitaux universitaires dans les systemes de same
non seulement les specialistes en formation, mais
egalement les etudiants en medecine pour leur
deux annees de formation pratique, est liee a la
specialisation accrue des hopitaux universitaires.
La tache d’accreditation d’hopitaux pour
la formation specialisee est du ressort des asso
ciations de specialistes. L’agrement est fonde sur
des criteres tels que la taille de 1’etablissement,
le nombre de specialistes, les categories de malades soignes etc. Les associations de specialistes
decident aussi du nombre de places a mettre a
disposition. Cette procedure est reconnue et acceptee par le Ministere. Les membres des asso
ciations de specialistes ont un interet pecuniaire
a limiter le nombre de specialistes, et done la
concurrence en matiere d’honoraires. Ils ont plafonne le nombre de places, une situation qui,
globalement, a convenu au Gouvemement pour
des raisons liees a la maitrise des depenses de
same. Plus recemment une penurie de specia
listes a mene le Gouvemement a s’interesser de
plus pres a ces questions.
• Le Royaume-Uni
La formation specialisee peut durer jusqu’a sept ans selon la specialite et suit un modele de compagnonnage. Sa conclusion est re
connue par un certificat. Un comite de liaison a
I’interieur de I’hopital universitaire est responsable de 1’organisation. Depuis de longues an
nees, plus de la moitie de cette formation a lieu
dans des hopitaux generaux. Depuis la reforme
recente, qui a modifie de fa^on assez radicale le
systeme de financement des hopitaux, les etablissements commencent a remettre en question
la rentabilite de cette participation a la forma
tion. Pour repondre a cette nouvelle situation,
un budget, qui represente 50 p. 100 environ des
salaires des medecins en formation, a ete accorde au «doyen de formation specialisee». En
outre il revolt un financement pour tous les
couts directs de cette formation, tels 1’organisation des cours, les frais de fonctionnement des
centres d’enseignement et les voyages d’etudes.
L’accreditation des hopitaux pour la for
mation specialisee est organisee par les «Royal
Colleges», les associations de specialistes. La
procedure est extremement rigoureuse et com-
54
prend 1’evaluation des services cliniques et me
dico-techniques au regard de normes - nombre
et qualite du personnel, qualite des locaux etc. et de 1’organisation detaillee de la formation. Un
comite preside par le doyen de la formation spe
cialisee a la tache de preselectionner les candidats aux postes de formation specialisee avant
leur embauche par les hopitaux.
♦
Recherche: Vimportance relative accordee
a cette activite et les modalites de financement
• L’Allemagne
Dans les hopitaux universitaires le
nombre de postes est majore d’environ 30 p. 100
par rapport aux besoins cliniques, pour permettre une activite de recherche. Les modalites
d’organisation de la recherche restent a la dis
cretion du directeur du service.
Quant au financement, une part importante vient de la «Deutsche Forschungsgemeinschaft» ou une commission decide des priorites
et des subventions. Une «liste bleue» a ete creee
pendant les annees 70. Des instituts qui y etaient
inscrits en reconnaissance de leur excellence en
matiere de recherche etaient subventionnes
d’une part par le Gouvemement, d’autre part
par le Land. Un certain nombre d’instituts medicaux ont done ete selectionnes.
En 1976 un programme nomme «Re
cherche et Developpement pour la Same» etait
introduit. Sous ce programme des contrats de
recherche etaient offerts dans des domaines specifiques qui correspondaient a des priorites na
tionales. Les criteres etaient tres stricts et les uni
versites n’etaient pas specialement favorisees.
Plus recemment un nouveau programme appele
«Recherche Sante 2000» a ete mis en place qui
favorise surtout la recherche clinique et en same
publique. Le Gouvemement accorde une sub
vention pour une periode de cinq et huit ans a
condition que le Land accepte de continuer le fi
nancement.
• La Belgique
La plus grande partie du soutien officiel
a la recherche, en termes de postes de fonction-
' V
Annexes
t
t
nement, est attribuee aux Universites via le
Bonds National de la Recherche Scientifique
dont les commissions selectionnent les projets.
En outre, certaines Universites, telle 1’Universite
Catholique de Louvain, consacrent une part de
leur budget (3 p. 100) au soutien de la Re
cherche, selon leur propre systeme de selection
de projets.
Les Facultes de Medecine beneficient de
leur part de ces fonds. De plus, dans les hopitaux universitaires, jusqu’a 20 p. 100 du temps
contractuel peut etre consacre a la recherche. En
outre, ces Facultes resolvent des contributions
de mecenats, de fondations, et de societes pri
vees. Ces financements exterieurs representent
environ un tiers de leurs budgets de recherche.
La recherche fondamentale est souvent privilegiee par rapport a la recherche clinique. Les Fa
cultes s’efforcent actuellement de corriger ce
desequilibre.
La recherche clinique appliquee (environ
vingt pour cent des recherches cliniques) est generalement financee par 1’industrie, avec les
risques de contraintes de rentabilite que ceci
comporte;
Il convient enfin de souligner que la re
cherche est consideree comme un element im
portant de la reputation des Facultes. C’est
pourquoi le curriculum de recherche constitue
un des criteres majeurs de la selection des professeurs.
• Les Pays-Bas
Dans les hopitaux universitaires, jusqu’a
40 p. 100 du temps contractuel peut etre consacre a des activites d’enseignement et de re
cherche. Le financement pour la recherche vient
pour 1’essentiel du Ministere de 1’Education et
de la Recherche. Cette partie represente probablement entre 50-65 p. 100 du budget. Le res
tant provient d’une variete de sources: hopitaux
universitaires, fondations etc. Aujourd’hui la po
litique du gouvemement dans ce domaine met
1’accent davantage sur la necessite pour les facultes de justifier leur projets de recherche. La
competition pour les moyens disponibles a augmente et il y a un lien plus marque entre le fi
nancement et les resultats.
• Le Royaume-Uni
Les activites de recherche des hopitaux
universitaires sont bien developpees car le fi
nancement est tres lie au nombre des contrats
de recherche. A Birmingham, par exemple, un
tiers du budget de la faculte provient de ces
contrats, ce qui permet de salarier une cinquantaine de personnes. L’allocation accordee
par le gouvemement a la faculte est a la hauteur
du montant obtenu par d’autres sources, telles
que les fondations, les societes privees etc. Ce
montant est ainsi double. Au cours de ces pro
cedures une attention particuliere est pretee a la
qualite de la recherche menee. Comme conse
quence de cette approche, la reconnaissance
dans le domaine de la recherche est un des facteurs dominants de la nomination d’un professeur de medecine.
Conclusion
En ce qui conceme la mission de I’hopital universitaire, elle parait assez bien differenciee de celle des autres hopitaux dans les quatre
pays de cette etude. Dans deux cas (Allemagne,
Pays-Bas), les hopitaux universitaires sont sous
la tutelle du Ministere de 1’Education. Dans les
autres (Belgique, Royaume-Uni), ou ils sont
sous la tutelle du Ministere de la Sante, il y a des
dispositions particulieres pour leur financement,
du moins pour des activites tres specialisees. La
tendance dans tous les pays est plutot vers une
specialisation accrue.
Pour ce qui est du personnel medical des
hopitaux universitaires, la pratique dans les
quatre pays est relativement uniforme dans la
mesure oil tous les specialistes, universitaires ou
non, peuvent participer a 1’enseignement pour
autant que cela presente un interet pour eux et
pour I’etablissement. Dans trois pays (Belgique,
Pays-Bas, Royaume-Uni), les non-universitaires
touchent la meme remuneration que leurs
confreres. En Allemagne, en Belgique et au
Royaume-Uni, les specialistes qui participent a
la formation ont un type de contrat d’honoraire,
qui constitue une reponse apparemment satisfaisante a leur revendication de reconnaissance.
55
Dans trois pays (Belgique, Pays-Bas,
Royaume-Uni), une forte proportion de jeunes
medecins est accueillie pour leur formation specialisee dans des hopitaux generaux. Les systemes mis en place pour 1’accreditation de ces
hopitaux qui participent a la formation specialisee sont assez rigoureux. Dans les trois pays
concemes, les associations de specialistes ont la
responsabilite de 1’accreditation, ou jouent, au
moins, un role majeur dans cette procedure.
Dans chacun des quatre pays, de nombreux
etudiants en medecine sont egalement re^us
dans des hopitaux generaux pour leur formation
pratique.
Dans le domaine de la recherche, trois pays
(Allemagne, Belgique, Pays-Bas) prevoient qu’une
proportion specifique du temps contractuel d’un
professeur de medecine peut etre consacree a la re
cherche. Pour 1’ensemble des pays, la plus grande
partie du financement de la recherche provient du
Gouvemement. Il y a des indications que les Gouvemements s’interessent, de fa^on croissante, aux
domaines retenus pour la recherche et aux ques
tions de leur rentabilite economique.
I
56
Annexe IV
Quelques contributions de pays
4-a Australie
4-b Chili
4-c Coree du Sud
4-d Pakistan
4-e Philippines
4-f Royaume-Uni
4-g Suisse
57
Annexe IVa
Australian hospital costs
by James S. Lawson
*
Are public hospital costs more expensive
than private hospital costs? Are teaching and re
ferral hospital costs greater than non-teaching
hospital costs?
The results of the Australian National
Costing Study-version 1, conducted by the ac
counting firm KPMG-Peat Marwick on behalf
of the Australian and State governments have
been released1. For the first time, costs based on
diagnosis related groups (DRG’s) have been col
lected in a form which allows some comparisons
to be made between public teaching, non-tea
ching and private hospitals.
Regardless of the limitations of the me
thodology and the limited availability of data the
National Costing Study provides the best cur
rent information about the costs of Australian
hospitals.
• Methods
The data in this paper is wholly based on
the National Costing Study, which is based on
the financial experience of 102 Australian hos
pitals for a 6 month period during 1992 and
1993. The assumptions and methodology used
in the National Costing Study are outlined in de
tail in the summary report (1). Costs of teaching,
research, accident and emergency services and
non-inpatient care have been excluded.
1. National Costing Study Version One. Summary
Report.
The degree of accuracy of the data is dif
ficult to assess. With respect to the average costs
of specific DRG’s it is possible that the accuracy
is as high as 95 p. 100. However the accuracy
lessens with respect to cost centres such as ward
nursing, theatre costs and overheads within spe
cific DRG’s.
Comparisons of costs between public tea
ching and non-teaching costs are valid. Howe
ver direct comparisons between public and pri
vate hospital costs are not, partly because
medical, imaging and pathology costs are not in
cluded in the data for private hospitals. For this
reason the costs for medical, imaging and pa
thology have been deducted from the public hos
pitals so as to allow comparisons to be made
with the private hospitals. In an era of “privati
sation” such comparisons are inevitable and
even desirable.
In addition DRG’s have been selected
which allow comparisons between the different
hospital sectors. This has been acheived by se
lecting DRG’s with the following characteristics:
a) the DRG’s contain a single procedure (in
contrast to the purpose of DRG’s which is to
group diagnoses and procedures)
b) the procedure is common in both the public
and the private hospital sector
c) there are separate DRG’s for complicated and
uncomplicated cases.
Selection of DRG’s according to these
characteristics largely removes the criticism that
teaching and referral hospitals treat patients with
much more difficult and therefore expensive
problems despite being in the same diagnostic
group. For the same reason all DRG’s with the
59
La juste place des hopitaux universitaires dans les systemes de sante
qualification “complications” have been exclu
ded. A single exception is the DRG 317 “ap
pendicectomy with complications” which has
been retained because this DRG represents ap
prox. 15 p. 100 of all appendicectomies and be
cause it also provides a good example of the ex
pensive adverse effect that can be caused by
complications for even simple procedures.
• The analysis
As shown in Table 1 the average cost per
DRG in Australian public teaching and referral
hospitals at $2807 is much higher than the non
teaching hospital cost of $2088 and nearly
double the private hospital cost of $1571.
However it is crucial to indicate that com
parisons on such a global basis are extremely
misleading. This is because the teaching and re
ferral costs include the provision of very expen
sive procedures which are rarely or never provi
ded in the non-teaching or private hospital
sector. Examples include transplantation of the
liver at an average cost of $100,314, heart trans
plant at $30,699, care of extremely low birth
weight infants at $48,620, and extensive bums
at $62,460. In Australian teaching and referral
hospitals at least half the workload is of a routine
nature and is directly comparable to the work
load of non-teaching and private hospitals. Se
lected and comparable procedures and condi
tions are shown in table 2. The average total
costs of the selected DRG’s are $1,601 for non
teaching public hospitals and $1,479 for teaching
and referral hospitals and $1,767 for private hos
pitals. Again such comparisons are misleading
because with one exception, myringotomy
(DRG 124), all surgical procedures in the private
sector are less costly than the same procedures
in the teaching hospitals. Private hospitals costs
for surgical procedures are with the exception of
cleft lip repair, tonsillectomy and myringotomy
similar to public non-teaching hospital costs.
However costs associated with obstetrics in pri
vate hospitals, namely Cesarian section and nor
mal birth are more costly than both the public
teaching and non-teachii.^ hospitals
An examination of the length of stay and
the key cost centres, ward nursing and ove-
60
rheads, as shown in table 2, gives some indica
tion of the possible reasons for these differences
in costs. For those DRG’s where the length of
stay in the three different hospital sectors are si
milar the ward nursing costs are also similar but
the overheads in the private hospitals are consis
tently lower. These DRG’s are 27, 122, 124,
239, 314, 316, 317, 603, and 683.
With respect to the obstetric DRG’s, Ce
sarian section (673) and normal birth (675), the
length of stay in the private hospitals is up to
30 p. 100 longer than in both the public teaching
and non-teaching hospitals. This longer stay in
hospital is reflected in higher ward nursing costs
in the private hospitals and appears to account
for the higher overall costs. Despite these higher
overall costs the overhead costs in the private
hospitals for these two DRG’s are lower than in
both public hospital sectors.
• Can any helpful conclusions be drawn from
this analysis?
In my view the National Costing Study
has been a valuable experience even if any
conclusions are tentative or even speculative be
cause several important hypotheses can be de
veloped from the data. These hypotheses are:
1) For common or routine surgical procedures
(but not obstetrics) public non-teaching and pri
vate hospitals appear to be less expensive than
public teaching hospitals.
The main reason for the lower costs of
the private sector appears to be the lower ove
rhead costs.
2) For routine Cesarian sections and for normal
births the private sector appears to be more
costly than the public sector.
The main reason appears to be the much
longer stay in hospital in the private sector.
3) Length of stay appears to be an important fac
tor in the average cost of specific DRG’s-the lon
ger the stay the greater the cost.
Based on these hypotheses some practi
cal steps can be taken immediately. For example
with respect to some DRG’s such as cleft lip and
palate repair, the much longer stay and hence
greater cost in the public sector deserves detai
led examination.
Annexes
On the other hand while it has long been
known that discharge from hospital soon after
birth can be safe for mothers and babies, enfor
ced early discharge may well have adverse effects
on the well being if not the safety of the mother
and child and the expense of the longer stay may
well be justified. In other words judgements have
to be made about the ideal length of stay. Cost
is only one, albeit an important one, of the fac
tors which have to be taken into account. Again
such issues deserve close attention.
Finally, this National Costing Study will
lead to many similar questions and hypotheses,
including even more detailed costing studies.
Table 1. Australian hospital costs 1992/93
(Teaching, Non-Teaching, Private Hospitals [102Hospitals]).
Public
Public
teaching
non-teaching
DRG
cost/ LOS % for % for cost/ LOS % for % for
ward over
ward over DRG
DRG
(1)
nursing heads
nursing heads
1.7
15.6
33.3
36.0
1361
27
1049
1.6
17.3
35.4
36.6
2479
7.6
2266
28.8
36.8
113
5.1
26.2
32.1
1137
1.6
1257
30.7
32.5
122
1.6
33.3
739
1.1
16.6
1.1
15.9
39.5
124
996
17.4
35.6
34.4
3.1
19.6
1658
239
1515
3.1
19.2
36.4
3.7
1836
23.4
36.1
314
1654
3.8
35.9
3112
6.6
21.1
5.7
34.3
316
2128
25.3
36.1
19.8
3.7
34.6
1929
3.5
1521
25.0
317
22.9
32.3
5.7
31.5
2717
5.2
2359
25.6
367
27.7
37.2
37.0
3148
8.9
9.3
2958
32.3
495
36.7
25.8
5.8
2318
38.0
5.6
2146
29.0
603
38.3
35.5
33.5
10.8
4049
8.7
40.9
3683
673
4.4
43.5
38.3
1736
1854
44.7
35.6
675
4.0
16.4
33.0
1334
1.2
1.2
17.6
35.5
901
683
(1) Meaning of DRG codes
27. Carpel Tunnel Release
113. Cleft Lip + Palate Repair
122. Tonsillectomy < 10 years
124. Myringotomy < 10 years
239. Vein Ligation
314. Hernia Repair > 9 years
316. Appendicectomy wi± complications
Private
cost/
LOS
DRG
996
1106
915
820
139
1506
2181
1600
2010
2750
1903
4189
2255
800
1.4
2.4
1.3
1.1
2.9
3.3
5.8
3.6
4.12
7.7
5.2
9.1
6.1
1.2
% for % for
ward over
nursing heads
15.9
27.2
30.3
23.9
26.3
26.3
30.0
17.3
28.7
19.4
25.8
23.4
30.8
28.2
23.7
25.0
5.4
23.0
27.3
34.3
32.9
27.0
45.6
27.9
29.5
49.0
14.1
27.1
317. Appendicectomy without complications
367. Cholecystectomy
495. Mastectomy Major
603. Transurethral Prostatectomy
673. Caesarean no complications
675. Vaginal delivery no complications
683. Abortion plus Dilation & Curette
Table 2. Australian hospital costs (Average costs for all separations).
S 2807
1. Public Teaching
(63 hospitals)
$ 2088
2. Public non-teaching
(41 hospitals)
S 1571
3. Private
(28 hospitals)
61
Annexe IVb
The right place
of teaching hospitals Chilean
experience and perspectives
Dr. Carlos Montoya Aguilar
Professor of public health, University of Chile:
Head, Equity Approach Programme,
Ministry of Health, Chile.
Background
• Health and health care in Chile:
situation and trends.
The health status of the fourteen million
people of Chile (30.6.1994) may be described in
general by the following three indicators:
life expectancy at birth: 72 years (1990-1995)
crude death rate:
5.4 per thousand (1992)
infant mortality rate: 14.3 per thousand (1992)
These levels should be assessed in the
light of the country’s gross national product of
USS 3.000 (end of 1992), which is below the
world average income.
There are significant inequalities of the
mortality rates of children and young adults
among regions and municipalities. This may be
related to the existing economic disparities: the
latest national social survey showed that
32.7 p. 100 of the population are “poor” and
that 9.0 p. 100 are “extremely poor” (1992).
While these percentages have been reduced in
the last few years, the income distribution has
not changed (1987-1992)
The most frequent causes of death are
the circulatory diseases and cancer. However,
the greatest number of potential years of life lost,
for the population aged between one and sixtyfour years, is due to accidents, poisoning and
violence, followed by tumors. Respiratory condi
tions occupy the fourth place among causes of
death, while infections and parasitic diseases
rank seventh, accounting for only 2.8 p. 100 of
all deaths. Alcohol abuse affects 20 p. 100 to
30 p. 100 of the adult population.
In short: Chile is far advanced along the
path of an epidemiological transition that puts
mental and social conditions, in close relation
ship with accidents, violence, as well as circula
tory diseases and cancer in young adults, high
up among the health priorities.
The health care situation is also changing
in Chile, and this is due more to policy decisions
than to the epidemiological transition. Until 1973
the country had a National Health Service finan
ced mainly by the central budget (65 p. 100) and
by compulsory insurance contributions paid by
salaried workers and their employers (20 p. 100).
Afterwards, neo-liberal and structural adjustment
policies led to a significant reduction of the cen
tral Government contribution and of personal re
munerations. The revenue gap was filled by di
rect user payments and by an increase in the
compulsory health insurance premium collected
from the workers, In 1980, a new legislation abo
lished the National Health Service as such and
favoured the creation of private for-profit inter
mediary organizations which are allowed to sell
individual health insurance plans against the afo
rementioned compulsory contribution.
Only the higher-earning salaried popula
tion are able to meet the prices charged by those
63
La juste place des hopitaux universitaires dans les systemes de same
organizations, which means that the majority of
the population continue to rely on the public
subsystem of care.
The present democratic government
(1990-1994) has substantially increased the cen
tral budget contribution. The overall revenue of
the public sector of health care has risen by
about 40 p. 100 In real per capita terms. Howe
ver, the expansion of the government-subsidized
private sector, which now covers around
25 p. 100 of the population, has increased costs
and induced an exodus of doctors and nurses to
wards that sector. This makes recovery difficult
for the public institutions, including the State
Medical Schools and Hospitals. These are also
affected by the lack of investment in mainte
nance and in new technology during the seven
teen years of the previous goverment (19731990).
The changes just described have created
new demands and a new environment for the
health professions, medical education and tea
ching hospitals in Chile.
• The Universities and their Medical Faculties.
A University was created in the eigh
teenth century by the Spanish Government and
this offered some medical courses since 1769.
After Independence a Medical School was star
ted in 1833. The oldest existing University was
founded in 1840, with the name “Universidad
de Chile” and the Medical School was establi
shed as its Faculty of Medicine in 1843. Its first
Dean was a french physician, Lorenzo Sazie.
New Universities sprang up, starting in
the 1920’s and at the same time the University
of Chile branched out into the main provinces.
During the 1980’s and 1990’s market incentives
have favoured the proliferation of twenty or so
small private Universities, while at the same time
the government has greatly reduced its financial
support to the “traditional” institutions, com
pelling them to obtain revenues from student
fees and externally funded projects.
At present there are eight medical or
health sciences faculties in the country. In 1992
they produced a total of 489 new doctors of me
dicine, as follows:
64
University of Chile (Santiago)
University of Valparaiso
University of Concepcion
University of Temuco (“La Frontera”)
University of Valdivia (“Austral”)
Catholic University (Santiago)
226
42
81
36
43
61
Los Andes University
(Santiago)
32 as from 1997
San Sebastian University
(Concepcion)
24 as from 2000
There are an estimated 14.900 doctors
active in 1994, with a ratio of 1 per 960 inhabi
tants.
In 1987 the ratio of full-time teaching
staff to annual number of medical graduates was
2.2 and the ratio of part-time teaching staff, 6.4.
Only two of the six “Traditional” schools had si
gnificantly lower ratios; they accounted for
28 p. 100 of all graduates.
The development of teaching hospitals
and teaching in hospitals, in Chile.
Ever since the beginning of the first Me
dical Faculty, clinical teaching has been entirely
based on hospital practice by the students. At
present this starts during the third year and is
completed by a full-time internship in the sixth
and seventh years.
Every one of the six “traditional” Medi
cal Schools which now exist utilizes the govern
ment hospitals and other government health fa
cilities located in its own region.
In the xix century, clinical practice by
students of the University of Chile was done in
the main hospital of Santiago, “San Juan de
Dios”. As new public hospitals were created,
they became, one by one, clinical fields for the
national university.
Possibly due to the arisal of periodic
conflicts between the hospital administrators
and the Faculty, the latter repeatedly tried to
gain control of one large general hospital. The
target was the “San Vicente de Paul”, which was
next to the Medical School building. They at
last succeded, in 1931: the “San Vicente” be-
*
Annexes
came the Clinical Hospital of the University of
Chile.
When the old building, erected in 1872,
was replaced by a new one at the beginning of
the 1950’s, the hospital was rechristened with
the name of a former Dean, “Dr. Jose Joaquim
Aguirre”.
However, the University, with its nearly
two thousand medical students, undergraduate
and postgraduate, has continued to utilize most
of the general and specialized hospitals and cli
nics of the Government Health System in the
city of Santiago.
The Catholic University of Santiago ope
ned its own Clinical hospital in 1943. It also
sends students to one other hospital, this one be
longing to the government system.
All the other Medical Schools are based
on the corresponding regional public hospitals.
To summarize, there are two University
Clinical (Teaching) Hospitals in Chile, but tea
ching is done in all the main hospitals of the pu
blic health system.
Statements by authorities of the two tea
ching hospitals, and of one important Govern
ment Hospital (San Juan de Dios), in which tea
ching takes place, are summarized in the next
section.
Views from the Hospitals
• The present situation
Teaching
The main problems underlined by the
Director of the Catholic University Hospital are:
the lack of information on the country’s needs
for doctors and the lack of coordination among
the Schools of Medicine.
The Dean of the Medical Faculty of the
University of Chile has recently prepared pro
jections of the ratio of doctors to population for
the year 2003 - 1: 871 -, at the present rates of
admission; although he believes that this is not
far from the right proportion, he also points to
the need for further studies on related issues,
such as the geographical distribution of physi
cians, the need for specialists and the availability
of nurses and other members of the health team.
In the public hospital, San Juan de Dios, the
quality of medical education provided by the cli
nical departments is criticized as paying little at
tention to the generation of positive attitudes
and to the type of doctor required by the coun
try. On the other hand, there is the risk of fal
ling behind in regard to new technologies, and
this concern is reflected in high costs, as expres
sed in the University of Chile Hospital.
Research
Clinical research is done in all the main
hospitals of the country, with the two University
hospitals ranking high in this respect.
Medical Care
In the University Hospitals and also in the
main public ones, the patients are mostly com
plex cases. In the University of Chile this has been
aggravated by its separation from the general
health care system (around 1975). In Sanjuan de
Dios Hospital teaching and care are done mainly
in the wards where teaching requirements tend to
overrule patient needs and specialists displace the
general clinicians. However, in the Catholic Uni
versity and other hospitals these problems are
partly compensated by the trend towards dayhospitalization and ambulatory care. As mentio
ned before, they are also mitigated by student at
tendance at less specialized hospitals and clinics.
Resources and costs
Whereas the public hospitals are mainly
supported by the budget of the Ministry of
Health, both University Hospitals have had to
become mainly self-sustained.
This implies in the case of the latter, a se
lection of both patients and students on econo
mic grounds. Student fees are higher in the Ca
tholic University, where they amount to the
equivalent of US$ 2.250 per year, a sum that
does not cover the whole of the educational costs.
Research depends mainly on outside funding.
This situation represents a drastic change in the
case of the University of Chile, which by virtue
of its ownership by the Government was suppor
ted by the Ministry of Education budget until the
structural adjustment policy, applied since the se
venties, greatly reduced that source or funding.
65
La juste place des hopitaux universitaires dans les systemes de sante
Social benefits
The University of Chile Hospital main
tains a social role as a declared objective. The
public hospitals participate in the substantial
contribution that the public health care system
takes to the improvement observed in the health
status indicators of the population,
• Views on what should be the right place
of the teaching hospitals
Teaching
Views from the San Juan de Dios and
from the Catholic University Hospital are that
there should be less information and more for
mation. Teaching, according to them, should be
oriented to meet national needs. Both agree on
the need to train “basic specialists” and “diffe
rentiated generalists”.
Teaching cannot be done only in hospi
tals with a high level of complexity: it should be
completed at other levels.
Whereas in the public hospital patient
needs are foremost and this in itself is conside
red an educational asset, in the Catholic Uni
versity Hospital teaching is seen as the main ob
jective - care, research and productivity being
tools at the service of that purpose.
Research
Ideally more research in clinical and preclinical disciplines should be done in the hospi
tal, and this would improve the clinical educa
tion function.
Care
In San Juan de Dios Hospital, patient
care at all levels is seen as the basis of continued
education, with the specialists being trained in
sophisticated hospitals.
The Catholic University Hospital strives
to provide best quality care in the patients’ in
terests.
Regulations
Teaching hospitals and hospitals in which
teaching is done should be supported in a coor
dinated manner by a university and by the Mi
nistry of Health.
They should be protected from political
disturbance and economic policy changes.
66
Costs and financing
In the view of the public hospital there is
a need for additional resources: full-time tea
chers are required, and they should be paid ap
propriate salaries; there should be joint Univer
sity and Ministry of Health positions, under
uniform career conditions. It is always possible
to keep expenditures under control.
The director of the private University
Hospital feels that teaching and research costs
should be separately accounted for: care should
thus prove to be not more expensive than in a
non-teaching hospital of the same level of com
plexity. Unavoidably, patients that pay more
have less contact with undergraduate students.
Social benefits. Ethics.
According to the public hospital, tea
ching promotes health care quality and thus be
nefits the patients.
• Answers to questions on strategy
The answer to the dilemna “intensify the
sophistication of teaching hospitals” versus “im
pregnate clinical teaching into the health sys
tem” is entirely eclectical in the case of the Ca
tholic University: the first alternative is valid for
the hospital, the second one, for the school.
The answer from San Juan de Dios Hos
pital is more in favour of the second option: ra
ther than speaking of “teaching hospitals”, we
should speak of “areas of health care in which
health teaching in carried out”. In such areas,
persons needing care should receive it at the le
vel of complexity that their condition requires,
in a network where facilities are “communica
ting vessels” at the service of the patients; in the
Chilean experience, the dissemination of this
“coordinated care-and-teaching” approach
across the country did, at one time, facilitate the
development of new medical schools.
Main issues for further discussion
In the light of the Chilean situation the
following issues may be singled out for discus
sion:
Annexes
• National health care system design and
financing:
This is the frame in which the place of
the teaching hospitals should be considered.
One option for Government Medical
Schools is to utilize the facilities of the public
network for clinical teaching, incorporating Uni
versity resources for the educational and re
search functions. In that situation the possibility
of conflict arises, but this can be minimized
through agreed regulations, accurate cost-ac
counting and joint governing bodies. On the
other hand, there will be advantages for the users
of the public services in terms of quality of care,
and the students will benefit from teaching done
in a more “realistic” setting.
Private Universities may also reach agree
ments with the Health Ministry in order to send
their students to public hospitals, different from
those utilized by the government schools. If they
are able to develop their own hospital, this may
perform a needed function within the system or
else it may cater for a specific user-group, selec
ted on the basis of affluence, charity, religious
denomination, etc.
• National health manpower policy:
This is an intersectorial subject.
Decisions on quantity and type of health
manpower required will provide orientation on
the types of facilities in which clinical teaching
should take place, as well as on the recommen
ded syllabus.
• Health Sciences research policy:
In Chile, health sciences research may
take place in Faculties of Sciences, in Faculties
of Medicine or in specialized Research Institutes,
public or private. Within Faculties of Medicine,
research work may be divided between pre-clinical and clinical departments. Research may and
possibly should also be done by as many health
care teams as possible throughout the country.
A research policy should throw light on
the kind of research that should take place in tea
ching hospitals and on how it should be funded.
Final Comment
In developing countries, the national ob
jectives of clinical education should be clearly
fixed and then pursued in the most effective and
efficient manner. Teaching should become a
function of the general health system, serving the
system. Particular institutions designated as
“teaching hospitals” should, if required or al
ready existing, be seen in that context.
67
Annexe IVc
Improving the Role
of Teaching Hospitals
in Tertiary Care
Youngsoo Shin, M.D., Dr. PH
Professor and Chairman
Department of health Policy and Management,
College of Medicine
Seoul National University
Introduction
Teaching hospitals play a pivotal role in
medical care in Korea as is the case in western
countries. There were 41 university teaching
hospitals which were affiliated to 32 medical
schools in Korea in 1992. The number of beds
in those 41 hospitals were 27,600 which ac
counted for 23.9 p. 100 of total beds. About
80 p. 100 of university teaching hospitals were
owned by non-profit private organizations.
Teaching hospitals in Korea share simi
lar problems as teaching hospitals in other
countries: l) they use disproportionately high
percent of national health care resources, II)
they treat mainly rare and complicated cases al
though they are supposed to prepare students
for their future practice in which they treat
mainly common and simple cases and in) their
care tends to be bureaucratized, dehumanized,
and impersonalized as their size and organiza
tion grow larger and more complex. In a study
by the Seoul National University Institute of
Hospital Services (1991), the case complexity
of teaching hospitals measured by Diagnosis
Related Groups (DRGs) and their intensity of
resource utilization was 38 p. 100 higher than
the complexity of non-teaching hospitals. On
the average, mean case costs of DRGs in tea
ching hospitals were 28 p. 100 higher than
mean costs in their non-teaching counterpart.
It was estimated that about 40 p. 100 of inpa
tient care costs were incurred in teaching hos
pitals however they operated about 24 p. 100
of total beds.
One of the features of the Korean Na
tional Health Insurance is a two-tier referral
system which categorizes hospitals into tertiary
care hospitals and primary and secondary care
hospitals. To be eligible for the insurance pay
ments, visits to a tertiary care hospital should
be referred by a primary or secondary care pro
vider with some exceptions. There were 35 hos
pitals designated as a tertiary care hospital as of
July 1,1993 and 32 of them were university tea
ching hospitals. This indicates that teaching
hospitals in Korea are expected to play a role
as a final referral center in medical care.
Tertiary care hospitals are entitled to a
10 p. 100 surcharge presuming that they treat
complex cases requiring resource intensive
and/or high tech cares. Mainly due to this ad
vantage in the insurance payments, hospitals
want to become a tertiary care hospital and a
number of hospitals apply for the tertiary care
hospital status every year. The only criterion
used to evaluate the application was the num
ber of beds to be over 500. This resulted in a
trend toward large scale among hospitals in
Korea and over supply of tertiary care beds. A
69
La juste place des hopitaux universitaires dans les systemes de sante
The Government expects the impacts of
this new policy in two ways:
I) redefine the role of tertiary care hospitals
II) keep the case complexity of tertiary care hos
pitals at the level where it should be.
In the long run, this will improve the qua
lity of tertiary care by monitoring the behavior of
tertiary care hospitals and will contribute in
containing the growth of national health care ex
penditures by enhancing the efficiency of health
care resource utilization at tertiary care hospitals.
9
72
Annexe IVd
The University hospitals
in Pakistan. The case of
the AGA Khan University
Hospital
By Dr Mumtaz Husain
The Aga Khan University
Department of Community Health Sciences
Karachi, Pakistan
February 1994
Introduction
The design and development of health care
delivery systems globally, are undergoing signifi
cant changes. The evolving definition of health as
not mere absence of disease and infirmity but a
state of optimum physical and mental well-being
which would enable populations to be productive
socially and economically, implies a justified em
phasis on preventive and promotive aspects of
health and health-related activities. Health ser
vices are now being exhorted not to restrict them
selves to care of the individual but broaden their
horizons to include the family and the community.
Incidence of ill-health is seen progressively in the
social context and greater stress is laid on equity,
relevance, access and utility of health services. In
the developing countries, these concepts are even
more relevant in order to conserve meagre re
sources and ensure appropriate resource alloca
tion to ensure benefits for maximum numbers ra
ther than provide for the few.
Against this evolutionary background, hos
pitals (including tertiary and teaching facilities)
have to find their relevant place in the system.
Health care reform efforts even in various
developed countries are increasingly pressuring
the hospitals to become more efficient in costconstrained environments. In particular, the
hospitals can no longer be seen as free-standing
institutions, whose high technology, low volume
services are selfjustifying, with demands for
them that are so strong that they can not stand
in isolation from the rest of the system. Latest
trends because of rising costs, managed care sys
tems for defined populations, competition from
rapidly growing ambulatory care technology are
resulting in hospitals either closing or transfor
ming their styles of action in the direction of
being integral parts of evolving health systems,
relating to defined populations.
Perhaps it is not too strong to say that
hospitals that remain in yesterday’s pattern of
the grand isolation of a tertiary care institution
may be trapped in a set of circumstances that
will put their entire existence at risk. New Zea
land has even “abolished” the hospital as an in
dependent administrative and fiscal unit; it must
now negotiate its services horizontally across the
system with program system managers (mental
health care, for example).
These debates have naturally promoted a
close look at the role hospitals-particularly ter
tiary and teaching hospitals - should now play in
the health systems to ensure an effective and re
levant health care delivery for the benefit of po
pulations and focussing attention on the depri
ved and under-served segments.
73
La juste place des hopitaux universitaires dans les systemes de sante
Historical Background
Present Organization
Evolution of hospitals, historically, has its
origin from the days of discovery of major infec
tious diseases when special hospitals were requi
red to not only address themselves to treatment
and control of these diseases but also to protect
the rest of the community. The hospitals, thus,
became a refuge for those people who, having
been afflicted with these diseases, could not
continue to live in the community; conversely,
the community, too, needed to be protected
from them. Advances in epidemiological practice
of medicine and effective preventive measures
transformed that picture. Development of public
health and community medicine while leading to
organization and development of community
health systems, also made the hospitals reposito
ries of sophisticated technology concerned with
curative aspects only. There was misallocation of
resources with bulk going to the hospitals. Laun
ching of preventive and eradication programmes
targeted at specific diseases like malaria, tuber
culosis, smallpox, leprosy etc. became the
concern of the community health services. Pu
blic health departments, therefore, got progres
sively engrossed with care of the community
while hospitals were concerned with care of the
individual with coordination between the two, at
best, remaining casual and incidental. Hospitals
have, thus, continued to function in isolation
from the health problems of concern to the com
munity as a whole resulting in “disease model”
of health care rather than community-based,
problem-oriented health care.
The teaching hospitals, too, have remai
ned in near isolation and the teaching they im
part, therefore, may have little relevance to the
health problems of real concern to the commu
nity. The output from the teaching hospitals,
thus, find the concepts of practice of medicine
not quite relevant to major health problems.
Whatever the historical reasons for this isolation,
none of them is valid in the present day context
and therefore, out of line with development of a
relevant educational system which should be res
ponsive to the needs of a comprehensive and ef
fective health care delivery system.
Hospitals, in general, no doubt, consume
the largest share of health resource allocation
particularly in developing countries where re
sources are scarce. Teaching hospitals, whether
from educational or medical research angle or
because of being at the center of health care de
livery systems, may even be more disproportio
nate beneficiaries in this inequitable allocation.
At the same time, in the context of Primary
Health Care programmes, hospitals should be an
essential and integral link in the chain of such
programmes. An equitable resource allocation,
however, is essential for the success of the very
programme which the hospitals should be desi
gned to support and sustain. By ensuring that
hospitals provide appropriate support to the pri
mary care level and that they are integrated into
national health systems, the effectiveness of hos
pitals, in general and the tertiary and teaching
hospitals, in particular, can be much enhanced.
The vital importance of this concept and prac
tice in these days of fiscal constraints needs no
emphasis. Not withstanding the high or dispro
portionate consumption of resources, the ter
tiary and teaching hospitals are vital to the tea
ching, research and curative activities as well as
for development of health leadership potential
for the health care system of a country.
An important objection leveled against
tertiary facilities is that they are located in ma
jor urban areas and that they consume a dispro
portionate share of scarce national resources.
The validity of this objection, however, is beco
ming increasingly less significant as health plan
ners and decision makers become aware of this
anomaly and take remedial measures. The urban/rural divide among populations is also pro
gressively showing lesser tilt in favour of the ru
ral sector even in developing countries due to
migration into cities in the wake of industriali
zation. Increasing numbers are moving to large
cities in search for employment, attraction from
relations who have already migrated and chan
ging social patterns in the rural areas themselves
by virtue of which lesser and lesser numbers of
young people stay attracted to agriculture as
74
Annexes
means of livelihood. An added factor, perhaps,
is advance in agricultural techniques, resulting in
less labour intensive measures (tube wells, trac
tors, mechanized crop harvesters replacing ob
solete agricultural tools and practices), releasing
large numbers from traditional/hereditary occupationswho then have to seek alternative means
of livelihood in towns. This influx, in turn, re
sults in squatter settlements and shanties on
outskirts of towns producing large numbers of
under-served and deprived segments of society
with relatively higher incidence of morbidity and
mortality and therefore, in dire need of extensive
health care. The need for effective health care fa
cilities (both secondary and tertiary) in urban
areas is, therefore, not as regressive as it may ap
pear.
A re-organized and balanced health care
delivery system is, therefore, required within
which these institutions can have their rightful
place without detracting from the significance of
lower level health facilities at the periphery and
without themselves being in-undated with pa
tients who could easily have been looked after
lower down in the health system.
Conceptual Changes
Alma Ata’s introduction of PHC concept
should not be seen as detracting from the im
portance of secondary, tertiary and teaching hos
pitals; on the other hand, it emphasises their si
gnificance as vital links in the chain of health
care delivery systems. Primary Health Care,
while laying emphasis on promotive and pre
ventive measures, is designed also to give essen
tial curative and life-saving care to the needy at
the first point of impact with the health system.
This would need support from both secondary
and tertiary referral facilities for ambulatory care
and for more sophisticated investigations and
treatment of complicated cases. Inclusion, in
deed integration, of these referral and supportive
facilities and ensuring easy access to them,
should be an essential component of an effec
tive PHC programme and the health systems
that support it.
The major international organizations are
on the move with a series of policy-influencing
documents; among these are: Disease Control
Priorities in Developing Countries (World
Bank); Health of Adults in Developing Coun
tries (World Bank); Human Development Re
port (UNDP); State of the World’s Children
(UNICEF) and 9th General Programme of
Work of WHO. The World Development Re
port (WDR) is at the center of these and will in
fluence development support strategies of the
major donors and also of governments.
There are now available methods for
measuring burdens of disease along with the be
nefits that can come from the alternative inter
ventions (the basic measure is expressed as Di
sability Adjusted Life Years -DALYs). In short,
we will soon be able to say what burden a given
disease represents on a society and the gains
from reducing that burden that will come from
alternative interventions. The resultant data al
ready tell us that the greatest burdens are asso
ciated with diseases for which there are cost-effective interventions that generally are
responsive to PHC, including hospital back-up
at the district level. Stated differently, well staf
fed and equipped district hospitals can handle
most of the hospital components of those inter
ventions.
The principles of equity, community in
volvement and empowerment, and decentraliza
tion of decision-making, far from being dimini
shed as the years pass since Alma Ata, are
gaining further emphasis. The World Develop
ment Report (WDR) orients its cost-effective
ness methodology toward equity. The Human
Development Report of UNDP, and the upco
ming Global Summit on Social Development,
will give increased emphasis to making these
principles operational. The implications for
health services are clear - universal coverage,
care according to need, and communities’ in
volvement in decisions and operations.
The capacities for hospital-based care,
therefore, must be decentralized to the district
level, and the teaching hospital can contribute to
that capacity building by assisting in developing
prototype district hospitals, guiding the equip-
75
La juste place des hopitaux universitaires dans les systemes de same
ping of those institutions, developing standardi
zed procedures of care appropriate for that level,
working out appropriate referral patterns bet
ween the teaching and district hospitals, and
training staff including rotating their own faculty
and trainees through such facilities.
The district hospital cannot be isolated
from its district, but must become the hub of the
district health system. It must be supportive of
the surrounding network of services that reach
throughout the district, to health centers, health
posts, and beyond to communities, with preven
tive, promotive and curative services, including a
carefully developed referral chain. This is com
plex system development, with many aspects re
quiring field-based research, evolving training
systems, monitoring, and evaluation of proto
types. It is here that the teaching hospital and
university of which it is a part, can play a key role.
By designing a health system where, minor/uncomplicated cases can be looked after at
lower level facilities, the tertiary facilities can be
saved from un-necessary overcrowding, at the
same time cutting down cost of curative care
which, in turn, can be diverted to health care in
general. The teaching hospitals retain a vital role
in this reorganisation for re-oriented medical
education and because of their capacity to ad
dress the needs of rare and complicated afflic
tions, for providing facilities for research in fur
therance of practice of medical science.
Such an evolving health system, focused
on defined populations, provides an excellent op
portunity for the education of health personnel.
The defined population represents an important
contrast to patient care. The patient, as an indi
vidual, is the focus for clinical problem solving.
The defined population is the focus for problem
solving with respect to the health of the entire po
pulation. Here the population as a denominator
is the key factor that makes it possible to deter
mine coverage, rates, impacts, and evaluation of
interventions. The university and teaching hospi
tal must be involved in both of these approaches.
Either alone is insufficient. It would be inade
quate for the students and faculty to be involved
only in district-based services - they would miss
too much of the important advances in biomedi
76
cal science and the care of complex problems. But
it would also be inadequate for them to be invol
ved only in patient care in the teaching hospital
and to miss the levels of care that will reach most
of the population and the experience of adjusting
health care to achieve desirable impacts. The two
are complementary and synergistic.
The medical students, on graduation,
will also be protected from getting a distorted
view of practice of medicine and the teaching
hospitals, by looking outside their four walls and
towards the community, would transform them
selves into essential components of the health
care delivery system.
In an age where emphasis on compre
hensive health care is at its highest and when di
sease (or its treatment) cannot be perceived wi
thout taking into account the community as a
whole, tertiary and teaching hospitals cannot be
seen as separate entities or rivals. This, indeed,
would be a dangerous imbalance. With the de
mand for universal coverage gaining ground, it
is essential that hospitals should not be conti
nued to be seen as devouvering maximum slice
of the meagre resources but should be integral
part of the health care delivery system and the
refore, what happens inside the hospital should
have a clear-cut and close interrelation with
health activities going on outside of them and in
the community. The tertiary and teaching hos
pitals have an important role in support of all
links in the chain of health care delivery (inclu
ding primary health care), be it for referral,
continuing education, preventive and promotive
activities and also for rehabilitation services.
This transformation would also facilitate
the teaching hospitals to play a more meaning
ful role for medical research. The teaching hos
pitals, by virtue of dealing with patients suffering
from rare conditions are eminently suitable for
conducting such research, while taking on a sup
portive role to the primary health care facilities.
Awareness of health problems of the community
at large would add a another valuable dimension
to research potential of teaching hospitals and
equip them with information and material re
quired for involvement in health systems re
search. Thereby essential health policy issues ge-
Annexes
nerated outside (in the community at large and
its environs) can be addressed in the teaching
hospitals in an academic climate and the results
of such research then made available to the po
licy makers facilitating realistic and relevant
heal± systems planning.
Role of Teaching and Tertiary Hospitals
The goals for health care set by WHO
enshrined in the philosophy of “Health for All
by the year 2000” and identifying Primary
Health Care as the strategy to achieve that goal,
also emphasize the fact that Primary Health
Care cannot be realized without support from
- and access to - a network of hospitals. And ter
tiary hospitals, including teaching hospitals,
must be at the hub of that network. These hos
pitals must extend their activities and responsi
bilities into the communities they were designed
to serve. There may be financial, managerial and
organizational resource considerations hampe
ring such extension in roles. It is imperative, ho
wever, that Governments and health planners
encourage development of integrated health sys
tems in which role of hospitals is redefined and
highlighted and none of the health facilities func
tion in isolation from each other or from the
community at large.
Curricula in teaching hospitals in the de
veloping world are even more out of tune and ir
relevant to the needs of the people which they
are intended to serve. Leadership for health ser
vices generally, is not trained for what ails the
society in which they serve. Teaching methods,
content and technology is very often outdated, a
relic of perhaps the colonial past and too tech
nology intensive. That this imbalance is begin
ning to be redressed can be shown by a few outs
tanding examples.
Some Examples of Right Place
of TertiaryITeaching Hospital
One of the examples of the right place for
a teaching hospital may be found in the integra-
ted set up of University Center for Health
Sciences, Ben Gurian University of Negev, Beer
Sheba, Israel where four institutions and services
were merged in 1974. The local hospital, local
public health services of the community, health
network of peripheral clinics in the region and
the faculty of health sciences of the university
merged into a consortium called the University
Center for Health Sciences. The purpose was to
integrate medical education with health services
and the hospital and to make the medical faculty
a full parmer in the designing and administra
tion of comprehensive health services for the re
gion, all under one head. The Dean of the Fa
culty also serves as Director of Health Services
responsible for coordination and integration of
education, services and research through speci
fic division and departmental heads. Chiefs of
medical specialties in the hospital are also res
ponsible for quality of care in their respective
specialties in the health services. This reorgani
sation has brought about strengthening of lower
level facilities. At the same time reference from
lower level facilities has been made mandatory
for reporting to specialized/tertiary facilities in
order not to overload the latter with cases which
could easily be dealt with at lower levels. This,
in turn, brings down the treatment costs and
more proportionate allocation of resources.
Another such example is that of the Patan Hospital Lalitpur, Nepal, which is organised
to establish a close interaction between Com
munity Health Care Programme and the tertiary
facility. The health workers in the community
care projects have many opportunities to parti
cipate in the work of the hospital and its educa
tional programmes. Patients are referred back to
health centers from the hospital whose doctors
send recommendations and comments for fol
low-up treatment, check-ups etc. Health wor
kers come to the hospital each month for lec
tures and physicians from the hospital go to
health posts for support, supervision and conti
nuing education of health workers. Thus the
hospital, in addition to fulfilling its tertiary func
tions and educational role, assists in strengthe
ning skills available at lower health facilities and
effectiveness of the health care delivery system.
in
La juste place des hopitaux universitaires dans les systemes de sante
Another outstanding example in a deve
loping country is that of The Aga Khan Uni
versity Hospital, Karachi Pakistan) as a tea
ching hospital and integral part of the Aga
Khan University Medical Center. While ful
filling the role of a teaching hospital for pro
moting classical sciences and training physi
cians, it has neither been designed (nor has it
chosen to remain) merely a well-equipped ivory
tower but has opened a window to the com
munity it aims to serve. Rather than continue
to turn out physicians in the traditional mould,
the institution graduates medical professionals
who are in tune with the community and dee
ply involved in their health problems. The Uni
versity’s dual mission of graduating community
oriented physicians and training leadership for
the developing health services of Pakistan, is
being achieved by devising a curriculum almost
a quarter of which, throughout the five years of
training, is devoted to teaching problem-orien
ted, community-based course content. The stu
dents are exposed from the very beginning to a
well-defined, under served and deprived com
munity where they learn to assess morbidity
and mortality patterns, socio-cultural back
grounds and identify major health and health
- related problems, define priorities and over
the next few years devise solutions for those
problems. The approach is very much in
conformity with WHO defined principle of
“Health for All” and Primary Health Care as
the strategy to achieve that objective. The tea
ching hospital being at the hub of this philoso
phy of medical education is not only a clinical
teaching institution but also serves ±e purpose
of a tertiary link in the PHC programme. Its cli
nical faculty and various specialized disciplines,
apart from providing the requisite support, lend
their expertise for developing the secondary su
pervisory and referral links and ambulatory care
within the PHC programme. In addition, the
hospital by facilitating and supporting essential
curative care at the basic health centers, re
sponds to some of the main concerns of the
community. By providing care for emergency
and complicated problems, the value and ef
fectiveness of the PHC programme for the
78
community is enhanced. The clinical disci
plines and supportive facilities laboratories, xray department etc.) are actively involved in the
Primary Health Care and secondary referral fa
cilities.
The concept is being translated into ac
tion by organisation, by the Community Health
Sciences Department of the University, of PHC
modules in seven squatter settlements in the ur
ban metropolis of Karachi, a city of 12 million
where almost 40 p. 100 of the population re
sides in about 360 such settlements. The squat
ter settlements are characterized by poverty,
poor housing, unhealthy environment, and lack
of access to water and sanitation. Small area stu
dies reveal high morbidity and mortality among
all groups of population, but mothers and chil
dren under 5 years of age have been found to
be at much higher risk than other population
groups.
The modules set up in these settlements
for well-defined populations, are designed as
prototypes for PHC systems that could be repli
cated by Municipal and Provincial tiers of Go
vernments. More importantly, these field sites
provide training facilities for AKU’s medical and
nursing students in order to prepare them for
dealing with the major health-related problems
of Pakistan.
By giving effective support to this PHC
program, the teaching hospital of AKU unders
cores the responsiveness and relevance of such
an institution to the needs of the community it
aims to serve.
The Hospital’s staff and the faculty of
the University is also involved in development
of PHC systems in rural and inaccessible areas,
lending another dimension to comprehensive
ness of teaching imparted by the institution. A
rural area, Thatta, about 100 kilometers from
Karachi, has been selected for developing inter
ventions in the existing health services to streng
then management skills and capacity-building
of training institutions. Similar community sup
ported PHC modules have been set-up in the
Northern Areas of Gilgit, Chitral etc. where the
medical and undergraduate students as well as
staff from clinical disciplines participate. The
Annexes
undergraduate medical teaching, therefore, ex
poses the students to varying scenarios of pro
viding services to under served populations of
urban, rural and mountainous inaccessible
areas.
The teaching of community medicine is
also advanced by the clerkship component for fi
nal year students for 12 weeks. This programme
is also organized by the Community Health
Sciences Department and actively participated
by clinical disciplines of the hospital, especially
by Obstetric and Gynaecology, Paediatrics and
Family Medicine departments. Staff from CHS
as well as collaborating clinical disciplines act as
resource persons to assist students to identify
problems and issues and guide them through the
process of critically appraising health care pro
grammes.
The clerkship programme trains the stu
dents in skills which would enable them to as
sess health problems and disease patterns of in
dividuals and families and capacity of health
systems in a community setting with respect to
bio-psycho-social aspects, to plan effective
health care in line with minimum resources re
quired at primary and secondary levels.
The field sites also provide eminent set
tings for conducting research programmes per
taining to specific diseases like Tuberculosis,
ARI, Hepatitis, Diarrhoea, HIV etc. as well as
addressing health systems research issues. Clini
cal disciplines of the teaching hospital are clo
sely involved in these research programmes.
The AKU hospital’s pioneering trends in
medical education, health systems and research
has generated interest in other teaching institu
tions as well as regulatory bodies in Pakistan for
remoulding the instructional methods of medi
cal education in conformity with needs of the
country. For this purpose a workshop, sponso
red and promoted by the Government of Pakis
tan and Pakistan Medical and Dental Council
(the regulatory body for practice of medicine in
Pakistan) and participated by majority of princi
pals of medical schools and Deans of Universi
ties, deliberated on the need for reorientation of
medical and nursing education. The workshop
formulated several consensus recommendations
for bringing about desirable changes which have
now been approved for implementation. The
hospital, therefore, does not restrict its concep
tual and operational relevance to its own activi
ties but is also beginning to have wide implica
tions for the people of Pakistan and the health
services that serve them.
Implications for Teaching Hospitals
The examples of Aga Khan University
Hospital and few others have been quoted to un
derscore the pivotal and legitimate role tertiary
and teaching hospitals can and should play in an
effective health care delivery system and in pro
duction of appropriate health manpower. It is by
no means a hundred percent success story kee
ping in mind the fact that the institution has
been an operational entity for only eight to nine
years. It is, however, a plea for recognition of the
right place of teaching hospitals for a relevant
and effective health policy formulation and im
plementation. No where is such an argument
more applicable than in developing counties
where resources are scarce and whatever is avai
lable, needs to be harnessed in the interest of
equity, accessibility, affordability and effective
ness of a health system.
The time is passing when the teaching
hospital can stand in isolation from the sur
rounding health care system, because it has the
largest number of specialists, the highest tech
nology, and a claim on excellence (in some
countries, it is only a slight exageration to say
that this is already seen as a quaint vestige of the
past!). These qualities are of undoubted value,
but they become diminished in importance and
cost-effectiveness unless they are strongly and
deliberately supportive of the surrounding sys
tem of which they would like to be the pinnacle.
Even the definition of excellence is ready for mo
dification, away from its high tech meaning, and
toward achieving equity at affordable costs.
The positive side of this change for the
teaching hospitals is that the picture will not
change as fully as is needed without their full in
volvement. That involvement will necessarily
79
La juste place des hopitaux universitaires dans les systemes de sante
previously renovated was further upgraded. This
was completed in 1993, mainly thru the Andres
Soriano Cancer Research Foundation, a private
institution.
Patient care services increased considera
bly. There was a 41.79 p. 100 increase in inpa
tients, from 26,932 in 1986 to 38,187 in 1992.
This was brought about by a 45.92 p. 100 in
crease in the beds, from 882 (of which there
were only 35 private beds) in 1986 to 1,287 (of
which 293 beds were private) in 1992. The out
patients rose by 68.98 p. 100, from 269,364 in
1986 to 455,163 in 1992. The emergency pa
tients had a 12.22 p. 100 increase, from 74,395
in 1986 to 83,488 in 1992.
Likewise, laboratory services increased by
54.18 p. 100, from 1,175,092 examinations in
1986 to 1,811,765 in 1992. Surgical operations
increased by 538.42 p. 100, from 4,386 opera
tions in 1986 to 28,001 in 1992. The new OPD,
completed in 1989 can now perform many ope
rations on an outpatient basis.
Therapeutic and radiologic procedures
increased from 30,237 in 1986 to 127,165 in
1992 (altho it was highest in 1989 at 154,481).
Other services (e. g., dental, dietary, EKG, phar
macy, rehabilitation medicine, medical social
services) rose from 1,422,419 in 1986 to
3,392,155 in 1992.
Students/trainees increased from 2,453
in 1986 to 2,990 in 1992. There was also a rise
in researches, from 399 in 1986 to 473 in 1992.
PGH studies have consistently won awards in
various research contests.
Due to the expansion of the physical
plant and services, there was a corresponding
28.94 p. 100 increase in the staff complement,
from 2,305 in 1986 to 2,978 in 1992. Exemp
tion from the attrition law was sought by the
PGH and granted by the Department of Budget
and Management. Dormitory facilities for the
staff were also improved.
Budget and expenditures increased from
P 123,680,656.00 (of which P 7,652,578.88 was
82
the income) in 1986 to P 642,563,396.87 (with
P 92,043,331.00 as the income) in 1992. It is to
be noted that unlike the other income-genera
ting government agencies, the PGH is allowed
to keep its income instead of remitting them to
the National Treasury. It is also able to spend its
entire budget. In 1992, its expenditures in pesos
were as follows:
P 182,420,453.87
Personnel expenses:
Maintenance and
Other Operating Expenses: P 203,153,612.00
Equipment, Building
P 164,948,000.00
and Structure Outlay:
P 550,522,065.87
Total:
(Note: SI.00 = P 27.00)
There are other things to be done inclu
ding the opening of the cardiac catherization la
boratory and organ transplantation unit, expan
sion of the dialysis unit and blood bank, and
operationalization of the renovated old OPD.
The changes in the PGH were made pos
sible not only thru the subsidy from the govern
ment. Agencies, both government (e. g., Philip
pine Amusement and Gaming Corporation,
Philippine Charity Sweepstakes Office) and pri
vate including pharmaceutical firms conti
nuously donate cash and materials (supplies,
equipment) to the PGH. Private individuals in
cluding medical alumni also contribute to the
hospital. With the improvements in PGH, it can
now be proud not only of its medical and other
allied health personnel but also of its physical
plant and equipment. It can compare with the
other government specialty hospitals (e. g., Phi
lippine Heart Center, National Kidney Institute)
and private hospitals in providing care to service
and private patients. Thus, it is on its way to its
goal of contributing “to the national effort to
wards development in the area of health by ser
ving as a center for health services and by pro
viding oppotunities for training and research for
health workers. In pursuit of this goal, the PGH
adheres to its tradition of excellence and leader
ship.”
Annexe IVf
Teaching hospitals in the UK
By Robert J. Maxwell
Chief Executive
King Edward’s Hospital Fund for London
To understand the UK teaching hospitals
requires, on the one hand, a grasp of their his
torical development and, on the other, an awa
reness of where they fit into today’s National
Health Service and into the broader context of
European medicine.
Historical Development
The oldest UK hospitals, such as St Bar
tholomew’s and St Thomas’, are mediaeval
foundations, initially offshoots of monastic ins
titutions. Others emerged at a later date as phi
lanthropic initiatives, particularly in the 18th
and 19th centuries. Originally there was nothing
particularly distinctive about “teaching” hospi
tals. Medical practitioners learned by observa
tion and apprenticeship. Students followed their
teachers wherever their teachers worked, in the
home, dispensary, clinic or hospital. Until the
19th century there were three distinct branches
of the medical profession in Britain, namely phy
sicians, surgeons and apothecaries (this last
group being the forerunners of today’s General
Practitioners), all with their own arrangements
for training, licensure and governance. Only in
1858 were they all brought together into a single
medical register administered by the General
Medical Council (GMC). Today it is the GMC
which is the instrument for self-regulation by the
medical profession, acting in conjunction with
the universities for undergraduate medical edu
cation, and with the Royal Colleges for postgra
duate education.
In England - as distinct from Scotland
and most of continental Europe - medical schools
were initially private initiatives, closely linked to
particular hospitals, with which they shared staff.
Often they had no separate legal status, apart
from the hospital concerned, and were not ne
cessarily affiliated to a university. As a result, the
apprenticeship model of professional training
continued to dominate. Medical students lived an
enclosed, hospital-based life, largely segregated
from the students of other Faculties. The same
was true for nurses and for entrants to the other
professions allied to medicine.
While there were obvious weaknesses to
this approach, there were also some strengths.
The educational function was embedded in, and
ultimately subsidiary to, a service role. Teachers
in clinical subjects were first and foremost clini
cians, not academics, and it was clinical educa
tion which was paramount.
To a substantial degree this history still
influences medical, nursing and allied professio
nal education in Britain today. While medical
and nursing schools are more strongly knitted
into multi-faculty universities than they once
were, and pre-clinical subjects are more excitin
gly taught than was once the case, the core of a
British education in these subjects remains cli
nical experience in relatively small student
groups, working alongside hospital clinicians. All
sorts of valid criticisms can be levelled at the sys-
83
La juste place des hopitaux universitaires dans les systemes de sante
Table 1. British postgraduate teaching hospitals and associate institutes.
Hospitals
Institutes
Bethlem Royal and Maudsley
Psychiatry
Eastman Dental
Dental Surgery
Hospital for Sick Children
Child Health
Moorfields Eye
Ophtalmology
National Heart and Lung
National Heart and Chest (The Royal Brompton)
Royal Marsden
Cancer Research
Royal Postgraduate Medical Institute
Hammersmith and Queen Charlotte’s
tern, but historically a lack of basic clinical ex
perience has not been one.
The development of the postgraduate
teaching hospitals shadows that of the under
graduates, in that their service function came
first and their educational function second. All
of them except The Royal Postgraduate Medi
cal School (The Hammersmith Hospital) are
specialist institutions where a hospital or group
of hospitals and a postgraduate institute exist
side by side (table 1). All of them are, as it hap
pens, London-based, whereas the undergra
duate teaching hospitals and medical schools are
much more widely distributed around the Uni
ted Kingdom.
The Current Situation
There are now 27 undergraduate schools
- 8 in London, 12 in the rest of England, 5 in
Scotland and 1 each in Wales and Northern Ire
land. The combined entry of home students at
all the schools is approximately 4000. It is
controlled at this level by the UK Government
and the total is reviewed from time to time, in
order to produce the number of doctors thought
to be required in medical careers, mainly in the
National Health Service. While medical manpo
wer numbers have increased steadily over the
years, the ratio to population is relatively low by
OECD standards and has never been uncon
trolled. There is virtually no medical unemploy
ment in the UK, although there are long-stan
ding problems of imbalance in the medical
career structure between training and career
grades, particularly in the hospital service. Basi-
84
cally there have been too few posts at the consul
tant level for the number of junior (theoretically
training) posts. The imbalance has partly been
maintained by importing foreign medical gra
duates to fill the junior posts in the less popular
specialties and hospitals, and partly by delaying
the age at which hospital doctors can expect to
reach the consultant level. Hence there are
considerable numbers of specialists at the senior
registrar level who are in fact frilly trained and
qualified. Bringing UK qualifications into line
with the rest of Europe highlights this problem
and requires a solution to it. The official res
ponse, which has the backing of the profession
and the Government, calls for formal recogni
tion of the completion of specialist training and
for a substantial increase in the number of
consultants. How that will actually work out re
mains to be seen.
Another uncertainty concerns the ba
lance between men and women in medicine. In
recent years, all the UK medical schools have
moved close to equality between the sexes at en
try. However, women are still grossly under re
presented at the top in many branches of medi
cine, for example, in surgery. To some degree
this reflects a past history of conscious or un
conscious discrimination against women candi
dates, and a lack of role models. It is not clear
how quickly this will change and to what degree,
if any, women’s choices about their lives and ca
reers will affect their availability for jobs, and
hence the overall balance between candidates
and medical posts in the NHS in the future.
The conventional shape of the undergra
duate medical curriculum is shown in Table 2.
However there is variation among the schools.
Annexes
Table 2. The conventional pattern of basic medical education and training as followed in some UK
medical schools.
Year
Preclinical
Anatomy and cell biology
Biochemistry and molecular genetics
Physiology and biophysics
Biometry and medical statistics
Psychology; sociology
Exams
1
Sessional
MB Pt 1
2
Body systems
Pharmacology
General pathology
Sessional
MB Pt 2 & 3
Clinical
Introductory medicine and surgery
including communication skills, ethics
Paediatrics
Obstetrics ans gynaecology
Psychiatry and neurology
General practice; public health;
accident and emergency
Pathology (histopath.; microbiol.;
heamatol.; immunol.)
General medicine
General surgery
3
Course exams
4
MB Pt 4
5
Elective
Surgical specialties (ENT*; eyes; orthopaedics)
Medical specialties (Dermatology; STD**)
Anaesthetics
Clinical pharmacology and therapeutics
General medicine
General surgery
MB Pt 5-8
5
Medical degree
Provisional registration with GMC
6
Preregistration year
Working as qualified doctor under supervision;
6 months surgery and 6 months medicine, or
4 months surgery, 4 months medicine and 4 months
general practice
Full registration with GMC
* Otorhinolaryngology
** Sexually transmitted disease
Source: (Richards P in Oxford Medical Companion 1994 p 517)
In particular a few have integrated the pre-clinical and clinical years, on the grounds that this
lessens abstract, rote learning and makes much
clearer what the clinical point is of mastering the
basic science. A number of schools have intro-
duced the option of an ‘intercalated’ extra year,
leading to a BSc or equivalent, in order to pro
vide a stronger basic science foundation for
those who may want to follow a career that in
cludes a substantial research element.
85
La juste place des hopitaux universitaires dans les systemes de sante
w
Basic medical qualification, usually after
5 years, is followed by a compulsory year of hos
pital medicine prior to registration by the GMC.
Entrants to General Practice can then opt for vo
cational training, which lasts 3 years overall, in
cluding 4 six-month periods of training in ap
propriate hospital specialties and a compulsory
year as a trainee in General Practice. Those who
do not immediately opt for vocational training for
General Practice, follow a 2 to 3 year period of
general professional training at the senior house
officer (SHO) grade in a variety of hospital spe
cialties, before beginning higher specialty trai
ning at the registrar level (later continuing to se
nior registrar) in the specialty of their choice.
Over 50 specialties are recognised in the Natio
nal Health Service. The combined period of ge
neral professional training and higher specialist
training will last at least 6 years and more typi
cally 10. Until recently, and in large measure
prompted by the need for harmonisation with
continental European practice, there was really
no formal recognition of the completion of higher
specialist training until eventually the individual
gained an NHS hospital consultant appointment
in open competition.
One other career option is public health
medicine. Entrants to the specialty are normally
expected to have completed 2 years’ general pro
fessional training in a clinical specialty, post-re
gistration, before beginning a 5 year training in
public health medicine.
The Place of the Teaching Hospitals
Britain’s most famous hospitals are wi
thout exception teaching hospitals. They stem
from ±e voluntary hospital tradition and were
not owned or administered by Government un
til after the Second World War when they were
nationalised at the inception of the National
Health Service. In virtually every case, the medi
cal school (and even more clearly the nursing,
physiotherapy or radiology school) was an off
shoot of the hospital.
From the inception of the NHS until
1974 these hospitals had a separate structure of
86
governance from other hospitals. They had their
own Boards of Governors, answerable direct to
Ministers rather than to the Regional Hospital
Boards. The associated medical schools received
funding from the Department of Education via
the University Funding Council. In addition, ho
wever, the hospitals themselves were more gene
rously funded than other hospitals. The margin
of generosity was determined more by history
than by any attempt to cost their teaching func
tion. Indeed when, in 1976, a national funding
formula was introduced for resource allocation in
the National Health Service, the Service Incre
ment for Teaching (SIFT) was simply calculated
by taking the historical difference in expenditure
between non-teaching and teaching hospitals. It
was essentially therefore a “fudge” factor which
might, or might not, be justified by the costs of
teaching, research or differences in case mix in
these hospitals. Since then more systematic at
tempts have been made to quantify what the cost
differences ought to be, but they remain quite
elusive.
By law, it is the responsibility of the Na
tional Health Service to provide the facilities ne
cessary for teaching. Academic funding, on the
other hand, is the responsibility of the Depart
ment of Education. By implication academic fun
ding must include an element of research infra
structure costs, and increasingly academic
funding allocations reflect research ratings. But
the principal funding for medical research comes
from other sources - namely the Medical Re
search Council, the medical research charities
and commercial organisations- and normally
comes on a project or programme basis.
A word should be said about the place of
the teaching hospitals in the broader service
context. Since 1962, when Enoch Powell as Mi
nister of Health published A Hospital Plan for En
gland, British hospital policy has been based on
district general hospitals and regional hospitals.
District general hospitals (DGHs) were expected
to provide all but the most specialised hospital
services for a local population of around
250,000. In addition there would be at least one
hospital for each of the 14 NHS regions in En
gland that would also provide the hospital spe-
4
Annexes
cialties like neurosurgery, bums and transplanta
tion that needed to be planned on the basis of
substantially larger populations. Virtually all un
dergraduate teaching hospitals served as DGHs,
though not necessarily as the sole DGH in their
vicinity. In the larger cities, in particular, the
boundaries between hospital catchment areas
were not at all clear-cut. But any undergraduate
teaching hospital that did not provide hospital
services to an NHS population of around
250,000 was potentially in a position of weak
ness. In addition, they frequently served as the
major medical centre for regional services. The
situation was clearest in those regions like Oxford
where the teaching hospital was the sole DGH
within the main centre of population and was
also the sole teaching hospital for the region.
Historically a few NHS regions initially
had no medical school, which led to the founda
tion of the “new” medical schools at Southamp
ton, Leicester and Nottingham. These in fact
proved to be pace-setters in medical education
and in influencing patterns of service delivery
throughout their regions.
Some Current Policy Issues
Three issues are currently affecting tea
ching hospitals in Britain. The first is one of iden
tity, the second of comprehensiveness and the
third of cost.
• Identity:
In the days when medical school and hos
pital were synonymous, students were by and
large educated from start to finish in their own
teaching hospital. This is no longer the case. As
a matter of policy many medical schools now
seek to root a substantial proportion of the stu
dent’s clinical experience in general practice and
in the community. In addition with hospital in
patient stays shortening and with fewer routine
referrals into the teaching hospital, there are
good arguments for sending out students to other
hospitals for part of their course. Some medical
educators argue strongly that it is essential that
the “parent” teaching hospital maintains a do-
minant enough place in the scheme of things to
ensure that every student learns certain skills to
a high level in a standard way, such as how to
examine a patient or how to record clinical fin
dings, but it seems inevitable, at least at the un
dergraduate level, that most medical schools will
deal with a substantial number of institutions and
individuals to provide clinical experience and tea
ching for their students, rather than rely on a
single hospital.
As a result it is becoming steadily less
clear in Britain which are, and which are not, tea
ching institutions.
• Comprehensiveness:
This issue is one that affects all hospitals,
not only the teaching hospitals. Whereas the or
thodox view in Britain for the past 50 years has
been to favour the large, general hospital as a
provider of virtually all inpatient and specialist
outpatient services for its local population, this
assumption is increasingly under challenge. Why
not, for example have specialised centres for elec
tive surgery, thus separating it from the pressures
of emergency admissions, and concentrating ex
pertise? Equally, an increasing proportion of
what has in the past required inpatient admission
can now be done on an ambulatory basis, for
example the treatment of diabetes or asthma.
Much of that might in time be decentralised to
general practice or to community-based clinics,
albeit with close contact with the hospital for
some of the diagnostic services and for specialist
advice. What happens to the notion of the tea
ching hospital if services are much more hetero
geneous and decentralised?
• Cost:
The problem of defining what teaching
hospitals ought to cost, as distinct from what they
actually cost, has been mentioned already. In the
United Kingdom, the National Health Service is
now organised on a basis that separates the task
of commissioning health care for a given popula
tion, from that of actually running services. With
very tight budgets, it is hardly surprising that the
commissioners have no interest in meeting costs
that they see as unjustified extras. If a teaching
87
La juste place des hopitaux universitaires dans les systemes de same
hospital can show that its case-mix or the quality
of the outcomes that it produces justify its costs,
that is fine, but they will get nowhere in negotia
tion by claiming that their unit prices should be
higher by divine right, or that the prices they
charge for patient services should subsidise tea
ching and research.
As in the United States, major medical
centres in the UK are under the threat of a down
ward spiral once commissioners decide to move
services away from them on the grounds that they
are too expensive.
The King’s Fund interest
in these issues
The remit of The King’s Fund (which
was founded in 1897 and is a royal foundation,
independent of government) is to support the
work of the hospitals of London, defining hospi
tals very broadly to include, for example, clinics,
hospices and homes. Since many of the country’s
teaching hospitals are located in London, we
could not escape an interest in the issues touched
on in this paper, even if we wished to do so.
In recent years my colleague Dr Angela
Towle has made important contributions to po
licy on medical education, particularly the de
bates around the undergraduate curriculum.
There is widespread agreement that the curricu
lum is overloaded with fact, that most medical
students find it a treadmill, and that it does not
provide a good foundation for a life-time of en
quiry and continual adjustment of practice. Part
of the problem is the perceived need to ensure
that medical graduates are safe practitioners on
the day that they graduate. Another is the en
trenched ownership of slices of the curriculum by
pre-clinical and clinical departments which are
often resistant to any change that lessens the sta
tus and power-base of their subject. The GMC
Education Committee has for more than a de
cade called for radical change. In 1991 it recom
mended that the curriculum should include a
core, which all students must study, and a variety
of options, to reduce the factual overload and to
allow them scope for personal choice. The
88
trouble then is agreeing what can be excluded
from the core. Dr Towle has been working with
Deans and other medical educators to take this
forward, and to continue the reform process into
the pre-registration year, and into general profes
sional training and continuing medical education.
Another King’s Fund initiative, led ini
tially by Jane Salvage (now at WHO, Copenha
gen) and more recently by Barbara Vaughan, has
been the development of nursing practice. Here
the focus is not the undergraduate curriculum
but stimulating the work of nurses as reflective
clinical practitioners. There is now a large natio
nal network of individual practitioners and of
nursing development units which provide in their
hospital (or equivalent community-based ser
vice) a capability to evaluate practice and to dis
seminate the results.
We also have a strong interest, under the
leadership of Angela Coulter, in evidence-based
clinical practice, taking account of the views of
patients as well as of the professions. With re
sources tightly constrained in the National
Health Service, and increasing pressures on those
resources from demographic and technological
change, and from rising expectations, one indis
pensable response is to look systematically at the
evidence of what is - and what is not - worth
doing.
Finally, through the independent inquiry
conducted by The King’s Fund’s London Com
mission, and through related initiatives, we are
intensely concerned with reshaping the pattern of
health services in London to select a number of
basic principles. We are seeking to strengthen
primary health care in London, and the commu
nity-based support for people who have chronic
illnesses. We are trying to give Londoners, indi
vidually and collectively, more say in their own
health care and more responsibility for their own
health. We believe that fewer main hospitals will
be needed, particularly in Central London, be
cause of changes in population that have already
taken place and because of likely changes in
treatment patterns. And we want to see fewer,
stronger tertiary medical referral and research
centres, able to compete nationally and interna
tionally in the 21 st century.
Annexe IVg
Switzerland
The right place
of teaching hospitals
by Adrian Griffiths
Health Management Institute
Statistical profile: Switzerland
•Demographic and economic data (box 1-a)
Switzerland has a population of almost
6.9 million growing very slowly at 0.77 p. 100
annually (1989-91). As in other developed coun
tries, the population is ageing demographically.
Between 1981 and 1991, the proportion aged
under 19 years fell from 27.3 to 23.4 p. 100
while those aged 65 and over rose from 14.3 to
15 p. 100 and those aged 75 plus rose from 6.0
to 7.1 p. 100. Life expectancy is amongst the hi
ghest in the world at 80.9 years for women and
74 years for men and still rising. Switzerland is
also one of the richest countries in the world,
with a Gross Domestic Product per head of
$ 21,747 (using the purchasing power parity of
SFR 2.2141 rather than the exchange rate of
SFR 1.43/$1, which would give a grossly infla
ted S 33,913 per head).
•Health System (box 1-b)
In 1991 there were 20,600 doctors,
3/1,000 population (compared to 2.5 in 1981),
of whom over 70 p. 100 are specialists.
Total health spending in 1991 was esti
mated at SFr 26.2 billion, or 7.9 p. 100 of GDP,
up from 7.3 p. 100 in 1981. This represents
$ 11.75 billion (at purchasing power parity),
which makes an average of $ 1.713 per head. It
should, however, be noted that health sector sta-
Box 1-a. Switzerland statistical profile demographic and economic data.
1981
6.354
Population (millions)
Average annual growth p. 100 (1981-91)
27.3
p. 100 under 19
14.3
p. 100 65+
6.0
p. 100 75+
72.40
Life expectancy: Male
79.00
Life expectancy: Female
0.76
Infant mortality per 1,000 live births
184,755
Gross Domestic Product (GDP) S.Fr. millions
2.25
Purchasing power parity / S
82,113
Gross Domestic Product (GDP) $ millions
12,923
Gross Domestic Product (GDP) per head $
GDP Growth p. 100 (1981-91)___________
Source: OECD. Health Systems Facts and Trends
89
1991
6.860
0.77
23.4
15.0
7.1
74.00
80.90
0.62
332,685
2.23
149,186
21,747
5.6
La juste place des hopitaux universitaires dans les systemes de sante
Box 1-b. Switzerland statistical profile: Health system.
1981
15,865
Number of doctors
p. 100 specialists
13,482
Health spending S.Fr. millions
5,992
Health spending $ millions
943
Health spending per head 8
7.30
Health spending p. 100 GDP
Financing:
68.3
public p. 100
31.7
private p. 100
Hospital doctors
Hospital other staff
Hospital beds
Acute
Psychiatric
Chronic
Other
Total
Hospital In Patient care spending p. 100 total
Source: OECD. Health Systems Facts and Trends. Hospitals beds figures come from Hopitcd Suisse
tistics in Switzerland are still not coordinated at
national level (health services are essentially un
der cantonal jurisdiction) and real health spen
ding data tend to be understated. Real spending
is probably at least 8.5-9 p. 100 of GDP.
Switzerland finances almost a third of to
tal spending (31.7 p. 100) from private sources,
and two thirds from public sources, as do Aus
tralia and Austria. Among OECD countries,
only Turkey (64.4 p. 100), the USA
(56.1 p. 100) and Portugal (38.3 p. 100) rely
more heavily on private financing. Most other
OECD countries derive only 10-25 p. 100 of fi
nancing from private sources.
In 1992, the country had an estimated
69.295 hospital beds (10.11/1, 000 population),
of which 43.301 (6.4/1,000) were in acute hos
pitals, 13.988 (2.0/1,000) were chronic hospi
tals, and 10,612 (1.6/1,000) were in psychiatric
hospitals, and in-patient care accounted for al
most 43 p. 100 of health spending.
•Teaching hospitals (box 1-c)
The definition of teaching hospitals impli
cit in the briefing papers issued for this meeting
90
1991
20,594
70
26,200
11,749
1,713
7.88
68.3
31.7
11,553
119,730
43,301
10,612
13,988
1,394
69,295
42,8
is university teaching hospitals, and affiliated ser
vices, and the analysis below is restricted to these
hospitals. It should, however, be remembered
that a wide range of other hospitals are recogni
sed for post-graduate specialty training.
Switzerland has eight universities, of
which five have medical faculties and teaching
hospitals: Basle, Bern, Geneva, Vaud and Zu
rich.
The statistics published by the Swiss hos
pital association (VESKA) for 1992 (detailed
breakdown in box 2) indicated 6,004 somatic
teaching hospital beds (0.87/1,000 population)
and 1,778 psychiatric teaching hospital beds
(0.26/1,000), making 7,782 in all (1.12/1,000).
Overall occupancy was 81.7 p. 100
(80.9 p. 100 for somatic care beds and
84.2 p. 100 for psychiatric beds). These beds
treated 171,310 cases, of which 163,642
(95.5 p. 100) were somatic cases. The average
stay was 10.8 days for somatic beds and 71.3 days
for psychiatric beds (overall average 13.5 days).
Teaching hospitals cost SFr 3.03 billion
($ 1.36 billion) to run (in 1992 not including
major investment and equipment costs), of
Annexes
Box l~c. Switzerland statistical profile: Teaching hospitals.
1992
665
7 years
75
4-5 years
Annual undergraduate medical enrollment
Length of undergraduate medical training
p. 100 of graduates specializing
Average length of specialist training
Teaching hospital staff
Total doctors
Professors and assistants
Residents
Non medical staff
27,090
3,529
na
na
23,561
Teaching hospital beds
Somatic
Psychiatric
Total
6,004
1,778
7,782
Teaching hospital patient days
Somatic
Psychiatric
Total
1,772,986
546,561
2,319,547
Teaching hospital discharges
Somatic
Psychiatric
Total
163,642
7,668
171,310
1992
Teaching hospital spending (1,000)
Somatic
Psychiatric
Total
S.Fr.
2,619,450
414,558
3,034,008
8
1,174,641
185,900
1,360,542
Teaching hospital average cost per patient day
Somatic
Psychiatric
1,477.42
758.48
662.52
340.13
Teaching hospital average cost per discharge
Somatic
Psychiatric
_____________
Source: Same as box 1-b.
16,007
54,063
7,178
24,244
Box 2. University versus non university hospital costs.
no. Beds Occ. Occ. % Cases Average Spending Cost/day Cost/case
Hospital type
SFr
stay SFr (000 s) SFr
beds
~
2,619,450
16,007
1,477.42
6,004 4,857 80.90 163,642 10.83
University somatic
10,067
6 4,064 3,303 81.29 104,218 11.57 1,049,168 870.13
Non-university 500+ beds
9,040
Non-university 250-499 beds 22 7,771 6,147 79.10 186,915 12.00 1,689,723 753.11
54,063
758.48
414,558
71.28
7,668
84.22
1,497
1,778
7
University psychiatric
42,690
47 8,834 7,360 83.32 19,791 135.75 844,875 314.49
Non-university psychiatric
Source: Hdpital Suisse
91
La juste place des hopitaux universitaires dans les systemes de same
Box 3. University beds by UHC: Switzerland 1990.________
Bed ratio/1,000
Theoretical
Theoretical
UHC I Canton Beds
catchment
catchment
population (000)
population
153
Basle
1,767
500
0.89
1,607
Bern
1,800
4.92
Geneva
2,458
500
1,736
1.74
Vaud
1000
Zurich
2,051
0.68
3000
9,619
1.41
Total_______
6,800
Source: RIGONI
which the somatic care hospitals represented
SFr 2.62 billion ($ 1.17 billion) or 86 p. 100.
Average costs per day were therefore SFr 1,477
(5 663) in somatic and SFr 758 (S 340) in psy
chiatric university hospitals. Corresponding
costs per case were SFr 16,007 (S 7,178) and
SFr 54,063 (S 24,243).
However, specific requests addressed to
the health authorities of the five cantons
concerned revealed 9,619 teaching hospital
beds, in 1990, including recognised teaching
beds under the responsibility of academic staff
in affiliated hospitals, distributed as shown in
box 3.
Assuming that each university hospital
centre serves a certain hinterland beyond its
own cantonal population gives the theoretical
catchment populations in column 3 of box 3,
and the corresponding bed ratios shown in co
lumn 4. These range from only 0.89 for the
Bern region to 4.92 for the Geneva region, a
range of 5.5 times in the provision of teaching
hospital beds!
These theoretical catchment popula
tions are over-generous. In practice, the net im
portation of patients from outside the cantons
where the teaching hospitals are located ave
rages only some 12 p. 100. The resulting catch
ment populations and bed ratios are shown in
columns 5 and 6 of box 3. The range is from
1.43 for the Bern region to 6.15 for the Geneva
region (still a range of 4.3 times).
This large variation is explained by the
fact that the five cantons with teaching hospi-
92
Estimated
effective
catchment
population (000)
400
1,120
400
650
1250
3,820
Bed ratio/1,000
effective
catchment
population
4^42
1.43
6.15
2.67
1.64
2.52
tals have followed radically different policies.
The extreme case is Geneva. While its total bed
ratio is lower than that of many other Swiss re
gions, virtually all its public sector beds are uni
versity hospital beds, the only non-university
beds are the 550 or so beds in the canton’s pri
vate clinics. If Geneva had the same university
bed ratio as Bern, it would have less than 600
university beds. The proportion is roughly the
reverse for Bern, where less than a quarter of
beds are teaching hospital beds, the remainder
being in various public and private nonteaching
hospitals.
Box 4-a shows schematically, the normal
structure of health service and hospital pro
vision, with a pyramidal form, fitted to the
pattern of morbidity to be treated, and reflec
ting the fact that most needs can and should
be met in non-university beds, as is done in
Bern.
Box 4-b schematises the massively
top-heavy structure of hospital services in Ge
neva.
The economic implications of such
heavy overprovision of university beds can be
seen in the last two columns of box 2, and in
boxes 5-a and 5-b. A day in a teaching hospi
tal costs an average of SFr 1.477, compared to
only SFr. 870 in a large (500 beds or more)
acute nonuniversity hospital, and SFr 753 in a
non-university hospital of 250-499 beds. In
other words, needlessly putting patients in uni
versity hospitals when smaller acute non-uni
versity hospitals would be perfectly adequate,
Annexes
p
E
C
I
A
L
I
S
A
T
I
O
N
p
E
C
I
A
L
I
S
A
T
I
O
N
TERTTARY
SECONDARY
PRIMARY
4
SECONDARY
PRIMARY
PROMOTION & PREVENTION
DECENTRALISATION
DECENTRALISATION
MORBIDITY PYRAMID
MORBIDITY PYRAMID
c
C
O
M
P
L
E
X
I
T
Y
LNFREQUENT
HIGHLY
COMPLEX
CONDITIONS
LESS FREQUENT MORE
COMPLEX CONDITIONS
SIMPLE & FREQUENT
CONDITIONS
INFREQUENT
HIGHLY
COMPLEX
CONDITIONS
LESS PREVALENT
MORE COMPLEX CONDITIONS
SIMPLE & FREQUENT
CONDITIONS
POPULATION AT RISK
POPULATION AT RISK
PREVALENCE
PREVALENCE
Box 4-b. Mismatching service and morbidity
pyramids.
Box 4-a. Matching service and morbidity
pyramids.
represents an extra cost of at least SFr 607
($272) per day, or SFr 221.555 ($ 99,352) per
occupied bed per year, that is 70 p. 100 more
than necessary.
1,600.00 r
TERTIARY
4
PROMOTION & PREVENTION
0
M
P
L
E
X
I
T
Y
SERVICE PYRAMID
Is
SERVICE PYRAMID
Is
The same applies to psychiatric
beds. Those in a university setting cost SFr 758
($ 340 per day), compared to only SFr 314
($ 141) in non-university psychiatric hospitals.
1,477.42
1,400.00
1,200.00
1,000.00
870.13
753.11
800.00
758.48
600.00
400.00
314.49
200.00
0.00
University
somatic
________ L_J_____
;
Non university Non university University Non university
500+beds
250-499 beds psychiatric
psychiatric
93
Box 5-a. University ver
sus non university hospi
tal costs per day (S.Fr.).
La juste place des hopitaux universitaires dans les systemes de sante
60,000 r
54,063
50,000 42,690
40,000 “
30,000
20,000
10,000
0
tl
University
somatic
10,067
9,040
Non university Non university University Non university
500+beds
250-499 beds psychiatric psychiatric
International comparisons
Boxes 6-a - c show that Swiss hospital
bed provision is not only irrationally varied bet
ween University Hospital Centers (UHCs), but
also excessive compared to international levels
First, simply looking at average popula
tions per UHC, and allowing 1.66 million as in
the two smaller countries Belgium and Holland,
Switzerland would have 4 rather than 5 UHCs.
Concretely, this would mean one UHC rather
than two for French speaking Switzerland’s po
pulation of 1.5 milion.
Second, looking at the ratio of university
beds per 1,000 population (boxes 6-a and b),
France is clearly unusually high, with 1.88, and
Switzerland is not far behind with 1.42, (Even
taking the VESKA figure of 7,782 university
beds, Switzerland still has 1.15 university
Box 6-a. International comparisons 1990.
France
Population (000)
56,735
University hospital centres (UHC)
29
1.96
Population (millions) / UHC
106,939
UHC beds
1.88
UHC beds /1,000 population
5,339
Medical graduates
94.1
Medical graduates / million population
20.0
UHC beds / medical graduate
94
Box 5-b. University ver
sus non university hospi
tal costs per case (S.Fr.).
beds/1,000 population) In comparison, Belgium
and Germany have only 0.7 and the Netherlands
has only 0.5. If Switzerland had the same uni
versity bed ratio per 1,000 population as Ger
many and Belgium, it would only have 4,757
beds, that is 40-50 p. 100 less, depending on
whether we use 7,782 or 9,619 as the actual
number of beds
Third, looking at the “need” for univer
sity beds in terms of the number per medical gra
duate, (boxes 6-a and 6-c) we find a similar pic
ture. France is exceptionally high at 20
university hospital beds per graduate, which pro
vides strong suggestive evidence that there is a
problem of definition, that all its UHC beds are
not really university beds in the same sense as
those of other countries. Switzerland is again in
second place with 12.4 university beds per me
dical graduate (10.0 if we use the VESKA figure
Switzerland
6,796
5
1.36
9,619
1. 42
776
114.2
12.4
Belgium
9,983
6
1.66
7,374
0.74
1,104
110.6
6.7
Germany Netherlands
77,516
14,944
9
40
1.94
1.66
7,372
53,921
0. 49
0.70
9,717
1,451
97.1
125.3
5.5
5.1
Annexes
2.00 “
1.88
1.80 1.60 -
1.42
1.40 -
1.20 1.00 “
0.74
0 80 -
0.70
0.49
0.60 0.40 “
0.20 ”
0.00 L
France
Switzerland
Belgium
Germany
of 7,782 beds). The arithmetic average for the
other three countries in box 6-a (Belgium, Ger
many and the Netherlands), is 5.77 university
beds per medical graduate. If Switzerland had
tills average bed ratio per medical graduate, its
776 medical graduates in 1990 would have re
quired 4,475 beds, which is about the same as
the number obtained in the previous paragraph,
using the bed ratio per thousand population.
If, in addition, we allow for the fact that
Switzerland will probably follow other European
countries in reducing the number of doctors
being trained per million population, the ‘need’
for teaching hospital beds would be still lower.
Indeed, though no formal restrictions have been
introduced, the number of doctors graduating
has already fallen from 776 medical graduates in
Netherlands
Box 6-b. UHC beds /
1,000 population.
1990 (a rather high 114/million population com
pared to 94 in France and 97 in the Nether
lands), to 665 in 1992, ie. about 96/million.
• Implications for change
The above situation arises largely from a
lack of clarity about the triple role of teaching
hospitals and the alternative ways in which they
may be fulfilled:
- basic and specialist training of doctors and pa
ramedical professionals
- clinical research and development
- provision of secondary and tertiary hospital
services.
A critical look at these roles leads us to a
number of important conclusions and implica
tions for change.
25.0 r
20.0
20.0 ~ MM
15.0 “
12.4
10.0
6.7
5.5
5.1
Germany
Netherlands
5.0
0.0
France
Switzerland
Belgium
95
Box 6-c. UHC beds per
medical graduates.
La juste place des hopitaux universitaires dans les systemes de sante
Basic training
Basic training of doctors and paramedi
cal professions in the basic clinical skills they will
need in general hospital practice, requires a
broad range of patients typical of what they will
encounter in their later professional practice.
This implies that teaching hospitals should to a
large extent serve as general hospitals, providing
secondary care to their local catchment area.
The data show that this is commonly the case.
For example, in Switzerland, 85-90 p. 100 of
their patients come from within the canton in
which they are located, most of them from the
local catchment area.
This raises a fundamental question. To
what extent does basic clinical training need to
be based in university teaching hospitals, and to
what extent might it be conducted under the su
pervision of the medical faculty in non-teaching
hospitals?
In addition, there is an accelerating trend
towards ambulatory and non-hospital care, and
an increasing recognition that teaching hospital
based training, largely confined to in-patients, is
neither sufficient nor appropriate, and that more
training needs to be done in out-patient clinics,
health centres, and primary care settings. Hos
pital based training, while good for teaching ba
sic clinical history taking and physical examina
tion, and the diagnosis and management of
serious conditions, often entailing team care
using high technology equipment, involves a
highly selected patient population not represen
tative of the overall morbidity in a population. It
also tends to focus on the biomedical model of
disease and has not been good at pulling toge
ther the physical, psychological and social as
pects of clinical care. In short, future teaching
requirements will need to be based on a more
realistic unit than the teaching hospital bed. Cli
nical teaching needs patients in appropriate care
settings not beds.
This conclusion is reinforced by a large
consensus that the content of the undergraduate
curriculum in most countries is overcrowded,
uncoordinated, and often irrelevant.
A recent survey in Britain by Towle pro
posed ten major reorientations:
96
-Reduction in rote learning of facts.
-Teaching ba^ed on active learning and critical
reasoning.
-Concentration on core knowledge, skills and
attitudes.
-Development of general clinical competences
on which to build more specialised skills.
-Integration between the preclinical and clinical
stages and between disciplines.
-Early clinical contact and teaching of all sub
jects from the standpoint of clinical practice.
-Balance between hospital/community, curative/preventive.
-Inclusion of the wider psychological, social,
ethical and economic aspects of health care.
- Preparation for interprofessional collaboration.
-Use of learning, teaching, and assessment me
thods consistent with the above principles.
The last point opens the way to more in
novative teaching methods such as clinical skills
laboratories (skillslab) such as the one developped by VanDalen at Limburg University in the
Netherlands since 1975. A skillslab enables stu
dents to learn a full range of clinical skills in a
protected environment on simulated patients
- trained volunteers, other students, and in
creasingly sophisticated mannequins- in much
the same way as pilots learn on flight simulators.
The skillslab concept offers many advan
tages.
-Students are not dependent on the patients
that happen to be available.
-Complex clinical tasks can be broken down
into simpler teachable skills.
- Skills can be repeated until mastered.
-Mistakes can be allowed, with no risk to pa
tients.
-Immediate detailed feedback is provided.
- Procedures are taught in a standardised way.
-Team work can be practised.
-Long term care situations can be telescoped
into a short period.
- Students are more competent and less stressed
when they move on to real patients.
Specialist training
Specialist training is largely done with
the same types of patients as are needed for ba-
Annexes
sic training, only a relatively small part involves
tertiary services. This is amply demonstrated by
the fact that most specialty residencies are done
in non-university hospitals.
Ternary services
Tertiary services are highly specialized
services beyond the capability of general hospi
tals, and requiring considerably larger catch
ment populations to be clinically and economi
cally viable. Teaching hospitals have a clear
comparative advantage for such services, which
are in addition closely related to specialized cli
nical research and development. It must, ho
wever, be recognized that the dissemination of
sophisticated technology and skills has enabled
increasing development of tertiary services in
non-teaching hospitals within regional hospital
networks. For example, in Switzerland, regions
without a local UHC, but having sufficient
catchment populations, are increasingly esta
blishing cardiac surgery centres in designated
non-teaching hospitals locally.
Clinical research and development
Here too, teaching hospitals also have
comparative advantages. First, they have
concentrations of highly specialised staff, with
international reputations, which enables them
to attract more research funds. Second, they
also concentrate tertiary clinical services and
supporting basic research capacity in other
parts of the medical and science faculties. Ne
vertheless, here again it is clear that hospital ba
sed clinical research and development is in no
way the exclusive preserve of university tea
ching hospitals. Much research is done inde
pendently by specialists in non-teaching hospi
tals. In addition, it is now commonplace to find
multi-centre projects including researchers and
patients from both teaching and non-teaching
hospitals.
• Proposals for change
The inappropriate development of
UHCs described above persists, because
though their roles are increasingly clearly
agreed, little change has been made to the way
they are funded. Hospital services, clinical trai
ning, and clinical research and development
continue to be paid for as an inseparable
bundle. This makes it easy to use “black box”
arguments to defend the high costs of UHCs.
They argue that they have a unique set of mul
tiple functions, whose interactions are very
omplex and hard to understand, but which
fu’y justify their costs. In fact, there is nc rea
son why the bundle of services provided by
UHCs can not be unbundled and j lid for se
parately. On the contrary, this would improve
transparency and make for much more efficient
resource allocation.
Unbundled purchasing of the different
services of UHCs could be implemented rela
tively easily. The main obstacle is the vested in
terests of the UHCs themselves. Prominent
UHC clinicians can usually muster equally
prominent political support.
Clinical services could be purchased se
parately using price and volume contracts or
Diagnosis Related Group (DRG) based pri
cing. UHCs would compete on equal terms
with non-UHC hospitals for cases and would
be granted higher prices only when they could
demonstrate higher severity, and consequently
higher costs of care, within a DRG. Tertiary
care services would in any case receive higher
payments corresponding to their higher cost
DRGs.
Training of undergraduate doctors and
paramedicals could be purchased as such at an
agreed cost per student. The price would be
paid to the medical faculties not to the univer
sity teaching hospitals. The faculties would
then be free to allocate this money as they
thought appropriate between different teaching
settings - university hospitals, non-university
hospitals, out-patient and day care services,
health centres and general practice groups,
skillslabs etc.
Post-graduate specialty training could
be paid for on a similar basis, bearing in mind
that doctors doing residencies are normally
included as part of the medical staff bud
gets, already included in the cost of clinical ser
vices
97
La juste place des hopitaux universitaires dans les systemes de sante
Clinical reasearch and development could
similarly be paid for independently, through a
combination of block programme budgets and
individual research projects, both awarded as
far as possible on a competitive basis, open to
98
all clinical services, university and nonuniver
sity. Indeed, much clinical research is already
funded on this basis and a wider application
would improve both transparency and accoun
tability.
Annexe V
Document preparatoire
du Seminaire
La juste place
des hopitaux universitaires
dans les systemes de sante
Introduction
Suite a la conference d’Alma Ata en
1978, 1’importance capitale des soins de same
primaires comme facteur essentiel pour atteindre 1’objectif de la Same Pour Tous en 1’an
2000 a ete largement reconnue. Il en a decoule
que les soins secondaires, et plus encore les
soins tertiaires (auxquels les hopitaux universi
taires se rattachent) devaient recevoir une at
tention moindre. Et il est vrai que les hopitaux
universitaires peuvent etre consideres comme
ayant peu d’impact sur 1’etat des same des po
pulations compte tenu que...
(l) ils traitent principalement les maladies rates
et les cas complexes
(il) ils sont generalement situes dans de tres
grandes villes, loin des vastes espaces ruraux
ou la majorite des hommes sont encore eparpilles.
Les hopitaux universitaires peuvent
meme avoir un impact negatif sur la same si
1’on considere que...
(i) ils absorbent les rates ressources (tant en
hommes qu’en argent) qui pourraient etre em
ployees plus utilement dans les soins primaires
et secondaires Cette remarque est tout particulierement vraie s’agissant des pays en developpement ou les hopitaux universitaires peuvent
consommer plus de la moitie de routes les depenses du pays qui, trop souvent ne s’eleve qu’a
moins de 20 p. 100 du Revenu National per ca
pita.
(Il) ils donnent aux etudiants en medecine une
image partielle et deformee de leur future pro
fession.
De tels raisonnements ont rarement
conduit a des mesures serieuses a 1’encontre
des hopitaux universitaires. En fait, ces hopitaux ont garde, et parfois accru, leur impor
tance ecrasante. Ceci s’explique, en partie, par:
(i) le prestige de leurs medecins incluant les
professeurs d’universite qui detiennent le pouvoir medical, un pouvoir professionnel amplifie
par les medias et renforce par I’estime que leur
portent les elites,
(II) les activites de recherche clinique (les in
novations medicales sont testees dans et diffusees a partir des hopitaux universitaires),
(ill) le fait que les hopitaux universitaires sont
souvent le seul endroit ou les pauvres des
grandes villes peuvent trouver une quelconque
forme de soins.
C’est pourquoi si, d’un cote, les reproches formules a 1’encontre des hopitaux
universitaires sont fondes et si, de I’autre, les
hopitaux universitaires sont des institutions indestructibles, il convient de repenser leur role
99
La juste place des hopitaux universitaires dans les systemes de sante
dans les systemes de sante et de leur assigner
une place plus conforme a leur mission.
Quelle est la place des hopitaux
universitaires ?
Souvent le concept d’hopital universitaire
et celui d’hopital de dernier recours sont utilises
1’un pour 1’autre. Cette confusion n’est guere
surprenante puisque d’ordinaire les hopitaux
universitaires servent aussi de dernier recours.
Cependant ce n’est pas toujours le cas et assez
ffequemment la reciproque est fausse.
Pour eviter les inconvenients d’une telle
confusion, il conviendra d’utiliser, tout au long
de la reunion de Paris, une definition des hopitaux universitaires acceptee de tous les partici
pants. Voici une definition possible:
Un hopital universitaire est un hopital
(ou une partie d’hopital) ou des professeurs de
medecine et leurs equipes delivrent leur enseignement pratique.
Cette definition ne dit rien, intentionellement, quant
-a la complexite des soins (primaire/secondaire/tertiaire)
- a 1’appartenance (privee/publique)
- au financement (budget de 1’Etat, securite sociale, assurances privees, contributions personnelles)
Afin de decrire la place des hopitaux uni
versitaires, il sera commode de les approcher se
lon plusieurs axes:
Un axe historique
Comment les hopitaux universitaires se
sont-ils developpes? Cela explique-t-il leur caracteristiques ?
Un axe educationnel
Qu’enseigne-t-on dans ces hopitaux?
pendant combien de temps ?
Nombre et role des etudiants, des in
ternes et des residents ? Nombre et role des enseignants ?
Combien de medecins (generalistes/specialistes) sont diplomes chaque annee ? Qui de
100
cide de ce nombre? Quels sont les besoins du
pays?
Comment est organise 1’enseignement
des autres professionnels de sante ?
Qui paye la formation dans les hopitaux ?
(Ministere de la Sante, Ministere de 1’Education ? Autre ?)
Un axe en recherche medicale
Les hopitaux universitaires sont-ils le lieu
de la recherche, fondamentale ou clinique, un
endroit ou de nouvelles techniques sont developpees, testees et repandues ?
La recherche, telle qu’elle est pratiquee a
1’hdpital, participe-t-elle de fa^on significative au
progres medical ?
Un axe de soins
Quelles sortes de soins sont pratiques
(specialises, urgents...)?
Selon quel mode (hospitalisation classique, hopital de jour, soins ambulatoires, soins
a domicile...) ?
La qualite des soins est-elle meilleure a
1’hopital universitaire ? Cela peut-il se mesurer ?
Les hopitaux universitaires sont-ils des
centres de reference (c’est-a-dire des centres
auxquels les malades sont referes physiquement
et/ou des centres qui sont consideres comme une
reference au sens de standard pour des soins de
meilleure qualite) ?
Les soins specialises sont-ils directement
accessibles a tous ? Sinon, comment les malades
sont-ils selectionnes ?
Un axe juridique
Quel est le statut juridique des hopitaux
universitaires? Sont-ils publics ou prives? S’ils
sont prives sont-ils a but lucratif ou non ?
Y-a-t-il des lois qui regissent les rapports
entre les universites et les hopitaux universitaires ?
Quelle est la nature de leurs liens juridiques ?
Un axe economique
Quel est le poids des hopitaux universi
taires compares aux autres hopitaux (en termes
de nombre de lits, en termes de budget de fonctionnement) ?
<
Annexes
Quel le poids des hopitaux universitaires
compares au reste du systeme de sante ?
Le traitement d’une maladie donnee revient-il plus cher dans un hopital universitaire
qu’aillews ? Si oui, est-ce justifie par une gravite
particuliere ou simplement parce que 1’environnement universitaire est la cause de couts indus ?
Un axe social
Qui est admis ? Les malades viennent-ils
de loin de leur propre initiative ? Arrivent-ils generalement trop tard (non pas tant a cause de la
distance que pour ne pas avoir re?u les soins appropries aux niveaux primaire et secondaire ?
Les traitements sont-ils gratuits ou
payants, rembowses ou non ? en totalite ou partiellement ?
Les regies de facturation sont-elles les
memes pour tous ?
Y-a-t-il confusion entre les soins de sante
et les soins sociaux (par exemple: des lits d’hopitaux sont ils utilises comme orphelinats ou
lieux d’accueil pour les pauvres) ?
Quelle devrait etre leur juste place ?
La question n’est pas tant«Quelle est la
place des hopitaux universitaires?* mais bien
«quelle est leur juste place ?» ce qui implique
une certaine forme de jugement. Pour repondre
a cette question plus delicate 1’on utilisera les
memes axes d’approche: Pour chacun de ces
axes 1’on se demandera si la place actuelle est la
bonne (selon des criteres qui restent a elaborer)
et, si ce n’est pas le cas, dans quelle direction
faut-il faire evoluer cette place et quels moyens
utiliser pour ce faire.
Questions relatives a I’enseignement.
Les hopitaux universitaires jouent-ils le
role que le pays attend d’eux en tant que formateurs de professionnels de sante ?
En forment-ils trop ou trop peu ?
Leur foumissent-ils un savoir utile et suffisant ?
Qui devrait payer pour cet enseignement?
HP I
05254
Questions relatives a la recherche medicale.
Quels types de recherches devraient etre
faits dans les hopitaux universitaires. Ces types
de recherche devraient ils etre faits seulement
dans les hopitaux universitaires ?
Ces recherches devraient-elles etre financees separement des soins? Pourquoi? Est-ce
possible ?
Questions relatives aux soins medicaux.
Les hopitaux universitaires devraient-ils
n’etre que des hopitaux de reference ou devraient-ils foumir des soins de tous niveaux (y
compris les soins primaires) sous routes lews
formes (y compris les soins ambulatoire et les
soins a domicile) ? Devraient-ils foumir des soins
preventifs ?
Les soins dans les hopitaux universitaires
devraient-ils etre de meilleure qualite? Pourquoi ? Selon quels criteres ?
Questions juridiques.
La loi peut etre un moyen particuliere
ment interessant et efficace pour changer un sys
teme. Ainsi, par exemple, en France, c’est une
loi qui en 1958 a permis de moderniser les
grands hopitaux publics en leur imposant de
nouveaux liens avec les universites.
Questions economiques.
S’il s’avere que le traitement d’une maladie donnee coute effectivement plus cher s’il est
delivre dans un environnement universitaire, et
ce pour un resultat identique, il faudra rechercher soit comment reduire ce swcout, soit com
ment reduire le nombre des lits universitaires.
Dans quelle mesure ceci est-il envisageable ? Ya-t-il une limite inferieure au poids des hopitaux
universitaires par rapport aux autres hopitaux et
par rapport au reste du systeme de sante ? Si oui,
quelle est cette limite ?
Questions sociales.
Les hopitaux universitaires, a cause de
lews avantages (presence des professews) et de
lews inconvenients (conditions d’hebergement
souvent deplorables, presence d’etudiants inexperimentes) attirent particulierement a la fois les
La juste place des hopitaux universitaires dans les systemes de same
classes sociales privilegiees (qui ont les moyens
d’en surmonter les inconvenients) et les classes
pauvres qui n’ont pas d’autre choix que d’ac
cepter les inconvenients. Ceci peut conduire a
des situations plutot genantes tant du point de
vue moral que financier? Faut-il exclure cer
tains ? Comment attirer les classes moyennes ?
Quelle strategic ?
Quand toutes les questions ci-dessus au
ront ete discutees, certaines strategies devraient
apparaitre. Pour illustrer ce que de telles strate
gies pourraient etre, en voici deux exemples qui
sont a 1’oppose 1’une de 1’autre:
• Strategic n° 1:
Faire des hopitaux universitaires les hopitaux de reference ultime et rien d:'autre
Ce serait la tendance naturelle. Cette
strategie aurait probablement la preference des
professeurs de medecine particulierement interesses par les soins exceptionnels susceptibles
d’accroitre leur prestige. Elie serait bien en ac
cord avec le concept de soins gradues suppose
conduire a la meilleure utilisation des res-
sources limitees. Cette strategie, pour tentante
qu’elle soit, n’est pas sans danger pour les hdpitaux universitaires qui a la longue pourraient
ne plus avoir de contacts avec le reste du systeme de same si ce n’est a travers leurs prescripteurs.
*
• Strategie n° 2:
Diluer les hopitaux universitaires dans le
reste du systeme de same
Les universites developperaient des reseaux pour 1’enseignement clinique utilisant
toutes les composantes du systeme de sante. Ces
reseaux seraient flexibles. Leurs membres se
raient lies par conventions avec les universites.
De tels liens pourraient etre noues et denoues en
permanence en reponse a la demande educationnelle. Cette strategie pourrait bien a terme
signifier la fin des hopitaux universitaires en tant
que tels.
En fonction des situations locales, la juste
strategie pourrait fort bien se tenir quelque part
entre les deux extremes qui viennent d’etre evoquees. Bien sur, ces strategies ne sont que des
exemples. D’autres strategies, developpees selon
d’autres axes, pourront tres bien s’imposer au
cours des discussions.
4
102
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Autres references:
The role of Hospital at the First Referral Level for
Attaining Health For All. Institute of Hospital Ser
vices, Seoul, Seoul National University, 1990.
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La juste place des hopitaux universitaires dans les systemes de same
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Honore B. L’ Hopital et son projet d’entreprise:
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La place et le role de 1’hdpital en Afrique. Recueil
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Berthod-Wurmser M. La Sante en Europe, Pa
ris, La Documentation Fran^aise, 1994, 367 pages.
Services Hospitallers dans la Communaute Europeenne, Ed. CHCE, 1993, 512 pages.
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