Indian Public Health Standards (IPHS) for 101 to 100 bedded District Hospitals
Item
- Title
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Indian Public Health Standards (IPHS)
for
101 to 100 bedded District Hospitals
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HEALTH FOR MANY MORE A STUDY OF THE ACCOUNTABILITY
OF THE CATHOLIC HOSPITAL
ASSOCIATION OF INDIA
Fr. Joseph Melettukochyil CST
MA in Health Management, Planning and Policy
September 1993
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This dissertation has been submitted in partial fulfilment of the
requirements for award of the Master of Arts in Health Management,
Planning and Policy. The examiners cannot, however, be held
responsible for the views expressed, nor the factual accuracy of the
contents.
I
Director of Postgraduate Courses
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CONTENTS
Contents
Page i
Foreword
Page ii
List of Figures
Page iv
INTRODUCTION
Page 1
FEEDBACK ON THE CATHOLIC
HOSPITAL ASSOCIATION OF
INDIA
Page 4
CHAPTER 2:
THEORY OF ORGANISATIONS
Page 13
CHAPTER 3:
THE CATHOLIC HOSPITAL
ASSOCIATION OF INDIA AND
THE CONTEXTUAL FACTORS
Page 33
CHAPTER 1:
CHAPTER 4:
THE ORGANISATIONAL STRUCTURE
OF THE CATHOLIC HOSPITAL
Page 48
ASSOCIATION OF INDIA
CHAPTER 5:
A NEW STRUCTURE FOR THE
CATHOLIC HOSPITAL
ASSOCIATION OF INDIA
Page 62
Page 74
CONCLUSION
BIBLIOGRAPHY
APPENDIX 1
THE CATHOLIC HOSPITAL
ASSOCIATION OF INDIA
STATE WISE DISTRIBUTION OF
MEMBER INSTITUTIONS
APPENDIX 2
STATE - UNION TERRITORY WISE
DISTRIBUTION OF CHAI MEMBERS
APPENDIX 3
BED-WISE ANALYSIS OF
MEMBER INSTITUTIONS OF CHAI
i
LIST OF FIGURES
PAGE
FIGURE
2.1
Flat Structure with 4 levels
24
2.2
Tall Structure with 7 levels
24
2.3
Functional Organisational Structure of the
Royal Commonwealth Society for the Blind
27
2.4
Divisional Organisational Structure, Save the Children Fund
28
2.5
Federal Structure, Workers Education Association
29
2.6
Matrix Structure, Christian Aid
31
4.1
Current Organisational Chart of CHAI
56
5.1
The proposed Organisational Chart
68
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FOREWORD
This dissertation is the result of an interest to understand the theoretical background
of organisational structure and management. As a social activist, I was happy and
content to work with people at grass roots level to organise and empower them and
to participate in their liberative struggles.
In every step we took, though
challenging, the organised power of the people was the support and strength and
But, when I was invited to take up a
their love and affection was heartening.
management post in the national office of the Catholic Hospital Association of India
(CHAI) in Hyderabad, it was altogether different. I realised the need to improve my
management skills. I was fortunate to get a chance to do the Health Management
course followed by a dissertation on the organisational structure and functioning of
the very organisation in which I am working.
My sincere thanks to all those who have helped me to do this course, especially to
Fr. John Vattamattom SVD, the Executive Director, and the Board members of
CHAI, as well as CEBEMO Holland and MISEREOR Germany for funding my
study. I am very grateful to Dr. Thelma Narayan, Dr. Ravi Narayan and Dr. C M
Francis for helping me with various resource materials, especially with the
information from the "Golden Jubilee Evaluation Study".
My special thanks to Dr. Ann Matthias for guiding me in this dissertation. I really
appreciate the interest she showed in this work. I also wish to express my sincere
thanks to all the members of the International Division of the Nuffield Institute for
iii
Health as well as to the staff of the Information Resource Centre. I am also grateful
to the staff of CHAI for supporting me with necessary information to complete my
work. I hope that this study will be another step towards achieving CHAI’s goal of
"Health for Many More".
iv
INTRODUCTION
The Catholic Hospital Association of India (CHAI), a Non-Governmental
Organisation actively involved in promoting health and health care services, is
completing 50 years of service in 1993.
On the occasion of its Golden Jubilee, an attempt has been made to evaluate the
various activities, programmes and profiles, and its contribution in the field of health
and health care in India during the last fifty years. The Evaluation team which has
published a "Discussion Document for further study and Action" (Narayan T, 1992)
points out various issues which CHAI has to address while planning its future. One
such issue was the "accountability of CHAI". The Discussion Document states that
the membership of CHAI has raised several questions regarding the accountability
of CHAI to its members, to its founders, to the people and to its own goals and
vision.
Accordingly, the Discussion Document has linked the concept of
accountability to:
a
management of funds and accounts
b
living out its objectives and vision in all its activities and in its internal
functioning, quality and effectiveness of service.
Now, the question is how to gauge the accountability of the Catholic Hospital
Association of India which is a service providing non-profitable organisation?
Studies suggest that organisation audit is possible in those organisations that adopt
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and functioning. This audit can be done by measuring the input and output of a
system with feedback as the mechanism for achieving a dynamic equilibrium. This
approach encourages the management to define what it is trying to achieve, to make
the best use of available physical and human resources, to measure the outcome of
services and use this information to redefine the original task (Buckley G, 1990).
Developing an understanding of the way in which the organisation functions
enhances the possibility of implementing changes within it. It is futile to audit
specific aspects of practice if change cannot be implemented. In a system approach,
specific aspects of organisations, like budgeting and accounting, decision making
process, communication systems, leadership styles all these can be audited by using
the feedback systems (opus cit).
The feedback from the members of CHAI reveals that the present management
profile of CHAI is not relevant to its present size and the services it provides and
they expect a better management style for better accountability and improved quality
of service (Narayan T, 1992)
1.1
AIM OF THE STUDY
The present study is an attempt to review the internal organisational structure of
CHAI based on the scientific theories of organisations and principles of
management. It also intends to understand the causes of membership dissatisfaction
and to recommend suggestions to improve the quality of its structure to make it
more effective and accountable to its members and to its objectives.
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management. It also intends to understand the causes of membership dissatisfaction
and to recommend suggestions to improve the quality of its structure to make it
more effective and accountable to its members and to its objectives.
It is believed that if accountability can be brought into the organisational structure
of CHAI, accountability in the management of funds and accounts will naturally
follow.
As CHAI is one of the largest Non-Governmental Organisation (NGO) in the field
of health and health services in India, its organisation structure is examined from the
perspective of a Non-Governmental Organisation.
1.2
METHODOLOGY
Chapter One is a review of the "Discussion Document for further Study and Action”
prepared by the ’’CHAI Golden Jubilee Evaluation Team”. Chapter Two examines
the theories of organisation to understand the structure and functioning of CHAI.
Chapter Three looks at the various contingency factors that have affected the life
and the profile of the Catholic Hospital Association of India. Chapter Four analyses
the present organisation structure of CHAI. Chapter Five proposes a new structure
for CHAI. In the Conclusion, necessary recommendations to effect the proposed
changes are suggested.
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CHAPTER 1:
FEEDBACK
ON
THE
CATHOLIC
HOSPITAL
ASSOCIATION OF INDIA
One of the bold steps the Catholic Hospital Association of India has taken in
connection with its Golden Jubilee was to initiate an evaluation of its life and profile
during the past half century. This evaluation was entrusted to a team known for its
expertise, commitment and vision. They were also helped by an advisory committee
who reviewed the progress of the study from time to time. During the course of the
evaluation, 62.3% of the membership of CHAI (1,415 institutions) have shared
information and given feedback and suggestions on various aspects of CHAI.
Another forty people from outside CHAI participated in a Policy Delphi Method to
identify trends in the socio-political and economic spheres in India and their impact
on the health status of the population in the country.
1.1
FEEDBACK FROM MEMBERSHIP OF CHAI
The Golden Jubilee Evaluation Study Team has gathered feedback on CHAI from
its members, Executive Board, representatives of regional units as well as from the
staff of CHAI. The feedback on CHAI from its membership was mainly on:
1
The strength of CHAI
2
The weakness of CHAI
3
The expectations of its members from CHAI
4
On the future thrusts of CHAI.
4
While 62.3% of the members who responded to the questions on the strength of
CHAI have made many positive comments regarding CHAI, another 55% of the
members have given suggestions towards the future thrusts of CHAI. This study
mainly concentrates on the weaknesses of CHAI and on the expectations of its
members.
Looking at this feedback especially on the "weakness of CHAI" and
"expectations of the members from CHAI", reveals the main areas CHAI has to
focus on to achieve its objectives.
1.1.1
Feedback on the weaknesses of CHAI
From the feedback, the study team has identified 15 weakness of CHAI:
”1
Poor interaction between CHAI and its members, poor personal contact and
communication, and sense of alienation felt by members.
2
Inadequate focus on rural based members and their activities
3
It does not fulfil the needs of its members and does not look into their
problems.
4
CHAI programmes are not accessible to many members in terms of cost and
their location, especially for the smaller ones.
5
Poor functioning of the regional and State units. The centre does not take
much interest in them.
6
Services offered are meagre and inadequate.
7
The administration and functioning is not efficient.
8
CHAI is not practical in its approach.
5
9
Concentration on bigger hospitals.
10
Discrimination between members in its service.
11
Too much centralisation of power.
12
Charging for ’’Health Action" to small/poor institutions.
13
Lack of initiative of members in activities of CHAI.
14
Lack of professionalism,
It is run as a religious association.
Lack of
qualified personnel in the medical/health field.
15
It does not stand for its objectives", (Narayan T, 1992).
A closer look at the feedback on the weakness may help to categorise them into the
following three main areas:
1
CHAI does not stand for its objectives (15)1. Is it because:
a
Poor interaction between CHAI and its members (1)
b
Inadequate focus on the rural based members and their activities (2)
c
It does not fulfil the needs of its members and does not look into
their problems (3)
d
Charging for "Health Action" to small/poor institutions (12).
Are these issues mentioned above related to the objectives of CHAI at any stage of
its history and do they lead to the conclusion that CHAI is not standing for its
objectives?
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Numbers in brackets correspond to the numbers in the above list on
weaknesses
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2
CHAI is not practical in its approach (8). Is it because:
a
CHAI programmes are not accessible to its members (4)
b
Concentration on bigger hospitals (9)
c
Discrimination between members (10)
Are these issues related to the diversity of the membership of CHAI? What is the
type of CHAI’s membership? Why do they feel alienated from their association?
These questions may help to look at the direction CHAI has taken in the course of
history.
3
Too much centralisation of power (11) Is it due to:
a
Poor functioning of regional and state units (5)
b
The administration and functioning is not efficient (7)
c
Lack of initiatives of members in the activities of CHAI (13)
d
Lack of professionalism. It runs as a religious association. Lack of
qualified personnel in the medical/health field (14).
This feedback seems to raise questions regarding the structure and profile of CHAI
and there seems to be a need for an analysis of these areas.
The feedback on the weakness and CHAI mainly refers to its objectives and its
structure and functioning.
A reflection on this feedback will help to define the
objective and analyse whether its structure and functioning are efficient to achieve
its goals and objectives.
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1.1.2
”1
Feedback on the expectations of members from CHAI
Better interaction between CHAI and members through visits, more
personalised correspondence.
2
Financial assistance.
3
Guidance and support to member institutions, especially smaller ones.
4
Training programmes at the State level, preferably using regional languages.
5
Medical aid (supply of medicines) on a regular basis.
6
CHAI to focus on rural areas.
7
Provision of information to improve health work.
8
Courses/seminars on labour laws, social analysis.
9
Production of health education material in local languages.
10
CHAI should be ready to help members out of their problems.
11
CHAI to arrange for doctors who are efficient and service minded to work
in member institutions.
12
Support to/promotion of community health programmes.
13
Promotion of low cost drugless therapy.
14
Strengthening of regional units.
15
Training for community health workers”, (Narayan T, 1992).
69% of the members who responded to the questions on their expectations from
CHAI categorically say what they expect from their Association. This also helps
to re examine whether the services provided by CHAI are relevant to the needs and
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expectations of its members. This also points to whether CHAI is upholding the
interest of its member or whether the objectives of CHAI need to be redefined to
cope with the expectations of CHAI. The feedback on the expectations reveals:
The focus of CHAI:
a
CHAI should focus on rural areas (6)2
b
Promotion of Community Health programme (12)
c
Promotion of low cost drugless therapy (13)
d
Training of Community Health Workers (15).
The Role of CHAI as Guide and Support
a
CHAI should be a guide and support to member institutions,
especially to smaller ones (3)
b
Better interaction between CHAI and members through visits, more
personalised correspondence. (1)
c
Training programmes at the State level, preferably using regional
languages. (4)
d
Courses/seminars on labour laws, social analysis. (8)
e
Provision of information to improve health work. (7)
The Role of CHAI as Problem Solver
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a
CHAI must be ready to help the members out of their problems (10)
b
Financial assistance (2)
Numbers in brackets correspond to the numbers in the above list on the
expectations of members from CHAI
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c
Medical Aid (5)
d
CHAI to arrange for doctors who are efficient and service minded to
work in member institutions (11)
The mode of operation
a
Strengthening of Regional units (14)
b
Training programmes at state level, preferably using regional
languages (4)
c
Production of health education materials in local languages (9).
This feedback definitely tells that members of CHAI expect their Association to be
a guide and support to them mainly in their programmes and activities and in their
problems. Main orientations here seems to be in Community Health in the rural
areas which needs support in various ways including the proximity of the
Association through regional units.
1.2
FEEDBACK FROM POLICY DELPHI METHOD
The evaluation study team used a Policy Delphi method with a group of forty
panellists from various fields of activities and different disciplines to identify trends
in the socio-political and economic spheres in India and their impact on health status
of the population of the country. In the second round of their feedback, Delphi
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panellists have identified several organisational aspects and mechanisms that could
be strengthened or introduced by CHAI to enable effective functioning (Narayan T,
1993).
All these factors indicate the need for analysing the organisational structure of
CHAI.
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1.3
STRATEGIES FOR THE FUTURE
The Discussion Document has also identified twenty key issues for the consideration
of the Board, the Executives and the Association in planning future strategies for the
coming decade and beyond (Narayan T, 1992) One of the issues identified is the
accountability of CHAI. At a closer look at all the other issues identified by the
team, it was found that almost fifteen out of twenty issues were very closely related
to the issue of the accountability of CHAI to its members, to the objectives and to
the Catholic Community in India.
1.4
CONCLUSION
The feedback on CHAI should help the Association to redefine its objectives and
restructure its functioning to make the best use of the available human and physical
resources. There has been extensive and far reaching changes in the socio-political
situations in the country since the origin of CHAI. An organisation started during
the colonial period might have changed its objectives and direction to collaborate
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CHAPTER 2:
THEORY OF ORGANISATIONS
From the survey conducted among the members of the Catholic Hospital Association
of India a number of issues and problems the members face in their relations with
the association were identified.
Most of these issues seem to be related to the
management and administration of the organisation. To understand these issues in
the correct perspective, one may have to analyse the organisational structure of
CHAI and examine how these issues are related to the objectives of CHAI and its
organisational functioning. This chapter is an attempt to examine the organisational
theories and organisation structures in general. These theories will
’’help one to explain the past which in turn help to understand the present
and thus to predict the future which leads to more influence over future
events and less disturbance from the unexpected” (Handy c 1985).
Bernard (1983) defines organisations as
’’systems of consciously coordinated activities or forces of two or more
persons - to accomplish a common purpose”.
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Morgan (1990) says that
"Organisations develop out of a conscious decision on the part of an
individual or group to achieve certain goals through the bringing together in
a disciplined fashion of human and material resources”.
Despite a long history of organisations, research into the structure and functioning
of them is of the recent past. Most theories of the organisation originated with
industrialisation in the 19th century.
2.1
CLASSICAL OR TRADITIONAL SCHOOL
One of the early theories on organisation comes form the Classical School. It was
one of the first systematic attempts to develop a theory on organisations.
This
theory proposed a formal structure for organisations to improve efficiency. This is
associated with F W Taylor (1855-1917). The machine theory, as it is called, or the
scientific management of Taylor focused on the advantages of division of labour
both among and between managers and workers and also introduced a scientific
’’work measurement” of daily task and a study of optimal way of doing a task.
Within the same broad orientation, writers such as Fayol (1941-1925), L F Wiwick
and L Gallick concentrated on formulating a series of management principles
concerned with authority, specialisation, span of control and obligations (Collins
1992). All these studies related to organisation and management have been aimed
at increasing profit through the improvement of efficiency (Weisboard, M 1978).
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The structural approach also relied on the writings of Max Weber (1864-1920) on
bureaucracy.
Weber presented bureaucracy as a special form of rationality and
efficiency. Weber identified the dimensions of bureaucracy which included the clear
definition of duties and responsibilities, hierarchical authority, the importance of
official rules, impersonality, selection of candidates on merit, etc.
For Weber,
bureaucracy is the highly efficient system of administration characterised by clarity,
reliability, precision, stringent discipline, unity of command, strict subordination,
calculability and continuity. Following Weber, Taylor and Fayol presented some
fundamental basis to the structural approach to organisational efficiency.
They
suggest that:
a
organisations exist to achieve defined goals
b
problems in organisation are caused by faulty structure
c
organisations operate best when employees can rely on clear and established
rules, when specialisation of work is developed and finally when
coordination and control are set out through the exercise of hierarchical
authority and impersonal rules.
The structural approach places too much important on organisational structure for
efficiency.
When structure is well defined it has a significant but limited
contribution to organisational effectiveness, Child (1984). It has failed to consider
the persons working within the structure.
It also lacks environmental variables,
interpersonal relations and informal organisations which can also bring efficiency
and effectiveness into the organisations.
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HUMAN RELATIONS SCHOOL/BEHAVIOURAL SCHOOL
In reaction to the impersonalised bureaucratic view of organisational management,
pioneers of the Human Relations School studied the problems of organisations from
the viewpoint of human relations or behaviours of people within the organisations.
Pioneers in this area were Mayo, Koethilisbergen and Dickson. Their research has
proved that worker performance could be favourably influenced by social factors in
the work environment and changes in the attitudes of supervisors (Pugh, 1971).
They also showed that people do not pursue financial ends blindly nor can their
behaviours be predicted and governed in the way Taylor and others assumed. Mayo
and others having studied the role of individuals, informal groups and intergroup
relationships within the organisations, developed a number of important concepts:
a
people are not only motivated by financial factors but by a variety of social
and psychological factors as well,
b
an organisation is a social system as well as technical/economic system,
c
informal work groups have important roles in determining the attitudes and
performances of individuals,
d
management requires social skills as well as technical ones,
e
traditional "authoritarian" leadership patterns should be modified substantially
to consider psychological and social factors,
f
participation in work organisation, planning and policy formulation is an
important element in organisations.
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This means establishing effective communications between the various levels in the
hierarchy to ensure a free flow of information.
Following Mayo’s pioneering works study of people and their behaviour mainly the
motivating factors began to dominate the study. Thus we have Maslow’s basic need
theory, or self actualising man and McGregor’s Theory X and Theory Y, and
Herbut’s Motivation-Hygiene theories and the expectancy theory of Vroom etc. All
have contributed to the understanding of human factors at work yet none of them
provides a complete answer. Consideration of the various theories and assumptions
on which a manager subscribes will colour his views about the way to manage and
the ways to deal with people.
2.3
SYSTEM THEORY/CONTINGENCY APPROACH
Modern researchers on organisation theories have built upon the Classical and
Human Relations thoughts, and provide a more comprehensive view of behaviours
in organisations.
System Theory is one such approach.
It sees organisations as
complex social systems that interact with their environment and which must respond
to numerous interdependent variables such as people, tasks, technology, environment
and structure, (Perrow, 1972). While earlier approaches considered their variables
in isolation, system theorists study the relationship between several of them. Their
writings suggest that there is no one best way of designing organisations but because
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of change and volatility the best way dependent (contingent) upon prevailing
conditions (Silverman, 1970). Thus the contingency approach has developed out of
System’s thinking.
The term ’’contingency approach" was first used by Lawrence and Losch (1969).
They examined the operations of a number of firms to assess the effect on the tasks
and attitudes of managers in various functions operating with different structures and
environments. The first model developed by Levinson (1972) integrated methods
of psychology, sociology and system theory in order to discover "points and nodes"
of dysfunction of an organisation as a living system in constant change in an active
relationship with the environment. According to them, an organisation itself does
not have purposes; organisation’s purposes come from the people who integrate it.
As the organisation becomes more complex in its components, more complex
purposes arise.
2.3.1
Integration and coordination
The main emphasis of this approach is on differentiation and integration.
An
organisation tends to be divided according to the task it performs. These divisions
become integrated by specialists who find their own criteria for rewards, control
procedures, structure and reporting relations. Integration is defined as the quality
of state of collaboration among division to achieve goals and objectives of an
organisation.
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2.3.2
Method of integration
Integration in an organisation mainly takes place through centralisation or
decentralisation.
Centralisation implies that standardisation of common procedures centrally
administered.
Decentralisation implies that power is dispersed among its members and its units.
Decentralisation can be vertical or horizontal.
Vertical decentralisation when power is vested in the Chief Executive at the
strategic apex and he delegates it to the lower levels down in the vertical hierarchy.
Horizontal decentralisation is referred to the extent non-managers control decision
making process.
The power may remain with the line managers or with people
outside the line structure. Here it is assumed that formal power can rest with people
who are empowered to elect managers to the strategic apex which is the policy
making body. In this case, power goes to everyone by virtue of his membership.
Decentralisation is complete when power is vested with people. This is democracy
and everyone participates in decision making.
Participative and democratic
management lead to increased responsibility and accountability (Mintzberg, 1983).
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■
’’The structure of the organisation is the sum total of the ways in which its
labour is divided into distinct tasks and then its coordination achieved among
these tasks" (Mintzberg, 1985).
Lack of a proper design and structure result in low morale and low motivation,
delayed decision making, lack of coordination and high cost (Child, 1984).
2.4.1
How to design a structure?
One of the ways of designing an organisation may be based on the specialisation of
the organisation.
Specialisation is concerned with the division of labour.
This
means that various tasks and activities needed to meet the objectives of the
organisation should be suitably grouped and divided up.
This is done through
departmentation. People of a department are able to concentrate on a particular task
or group of related tasks and develop proficiency, knowledge and expertise. This
will increase the efficiency of the organisation. Specialisation can be based on the
services or functions; problems or needs of the particular geographical area or by
a mixture of both.
Organisations choose structures which will make them efficient to function in
particular circumstances with their special objectives.
This reinforces the
contingency view of the organisation. An effective organisation is the one which
has an appropriate structure and a culture. Appropriateness is determined by various
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Top Management
Departmental Management
Section Heads
Clerks/General
Personnel
FIGURE 2.1 FLAT STRUCTURE WITH 4 LEVELS
(SOURCE: LOCKETT M & SPEAR R, (1980))
Top Management
Divisional Management
Departmental Management
Section/Project Heads
Senior Supervisors
Supervisors
Clerks/
General
Personnel
FIGURE 2.2 TALL STRUCTURE WITH 7 LEVELS
(SOURCE: LOCKETT M & SPEAR R, (1980))
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Matrix Structure
In the Matrix Structure, project teams each with a designated manager, are combined
with a conventional functional structure. Project teams are multi-disciplinary and
are formed to achieve a specific goal or task. The project leaders liaise with the
functional heads for service and the functional heads provide technical expertise and
facilities and give structure to the organisation.
The project manager also has a
direct or line relationship with his supervisor, usually the Chief Executive.
The
Matrix form attempts to combine the efficiency and stability of the more
conventional departmental and functional form with the flexibility and directness of
a project based approach. It is a compromise between the traditional functional
organisation and a full scale programme based approach. Some of the Voluntary
organisations follow the Matrix structure.
2.5
STRUCTURE OF VOLUNTARY ORGANISATIONS
Following contingency theories and the system approach many voluntary and Non-
Governmental Organisations have designed their structures taking into consideration
the objective of the organisations, the type of function and services they render, the
geographical situation, the operational environment, etc.
When analysing the
structure of voluntary and Non-Governmental Organisations, researchers have
identified that some of them have followed a functional structure based on their
specialisation of their services while others, following the principle of
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decentralisation, have accepted a divisional or Federal structure. Those NGOs that
are more project-based have followed Matrix structures in their management
(Wilson, 1991).
2.5.1
Functional
Tasks are divided into separate departments or sections based on the functions
performed. They are arranged in a hierarchical way that facilitates communication
and information flow and submits to managerial level and this to Chief Executive.
This is a Functional structure. Functional committees which are coordinating the
functions of subcommittees.
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Executive Director
Deputy Director
Director
Appeals Department
K’-----Finance
Manager
r
Head
quarter
Appeals
n
Director
Overseas
Services
Communication
Manager
I
Analyst
1
r
Donation
Processing
Unit
Accounts
Department
Regional
Appeals
Organisation
Computer
Facility
r
Communication
Department
Head
quarter
Overseas
Department
Consultants/
Regional
offices
Overseas
FIGURE 2.3 REF: WILSON (1991) FUNCTIONAL ORGANISATIONAL
STRUCTURE OF ROYAL COMMONWEALTH SOCIETY FOR THE BLIND.
2.5.2
Divisional Structure
This structure allows different division of the organisation in different geographical
areas or for different types of clients. Each division operates relatively
27
independently but coordinated and controlled by the head office from where
functional services which are lacking in the division are provided, eg Save the
Children Fund.
President and Council
Executive Committee
Director
T
Administ
Trading
Company
ration
Department
UK
Division
Overseas
Div sion
Six Regions
__ Asia
Branches
__Africa
“1—
—
Personnel
Department
Finance
Department
—I
Public
Affairs
Department
■
__ Americas/Pacific
FIGURE 2.4 WILSON (1991): DIVISIONAL ORGANISATIONAL STRUCTURE,
SAVE THE CHILDREN FUND
■
2.5.3
Federal Structure
■
■
Each unit is more independent and autonomous in this structure. They are formally
part of the same organisation, with the same ideology, vision and objectives.
Control and unity are achieved through the same objective and vision.
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But
Federalism and decentralisation are different. In decentralised structures the control
of the centre is extended through delegation to the periphery. In internal structure,
the centre does only those tasks which the parts cannot or do not want to do. The
centre does not command or direct these parts but it coordinates, facilitates and
enables.
The basic belief in subsidiarity - a higher order body should not do
anything which a lower-order body could do perfectly well - is necessary for the
success of federalism (Handy, 1988).
National _
Conference
*
National
Committee
National
Office
Staff
District
District
Voluntary
branches
Fu 1-time
Staff
Voluntary
Branches
Part-time
Staff
Full-time
Staff
Part-time
Staff
FIGURE 2.5 WILSON (1991), FEDERAL STRUCTURE, WORKERS
EDUCATION ASSOCIATION
Federalism is suggested by many as a good model for NGOs as the federal units can
reflect their own priorities in their activities but under the umbrella of the central
organisation. The centre will be able to influence, encourage and suggest to the
units and allow freedom to be different.
29
easy to channel resources and energies where they are needed most without affecting
other branches or divisions. Divisions can be planned according to the geographical
area or the need for specialisation. But there can be conflicts when head office tries
to interfere with policy control and tries to coordinate the division.
2.5.4
Matrix or Project-based Structure
Researchers suggest that matrix structure is the ideal one for the operation of
project-based NGOs because it is organised around specific projects rather than a
hierarchy or divisionalisation (Wilson, 1991). The Matrix is made of any formal
hierarchy on one side and a project leadership on the other side. This is a very
flexible and adaptable structure.
30
Board
Executive Committee
Executive Director/Deputy Director
aC
Aid
i
Education
Communication
r inance
71-rundraising
Africa
Asia
Latin America
UK/Ireland
FIGURE 2.6 WILSON (1991): A MATRIX STRUCTURE
CHRISTIAN AID
The main problem with regard to this structure is the control and the dual authority.
This can lead to discrimination and
The dual authority creates ambiguity.
preferential treatment especially when there is scarcity of resources.
The project group works as a team with less status differentials and with more
internal freedom. The group’s objectives are given through the project. This is
more motivating and rewarding. Direct supervision is not necessary as the clients
31
Studies show that many voluntary organisation operate a semi-matrix structure with
two lines of authority (Wilson, 1991). Many organisations have a dual structure in
which regional offices are accountable to both headquarters and local membership
committees (Booke, 1984). The usual trend in NGOs is for Functional structures.
Because of the pressure between decentralisation and centralisation many NGOs find
it difficult to accept matrix structures.
2.6
CONCLUSION
The effectiveness of an organisation is caused by various factors such as its goals
and objectives, the type of work, the environment in which it operates and the
communication system that is practised.
Because of these contingent factors,
organisations are like living organisms under constant change and growth.
As
organisations grow more complex, more complex purposes arise and efficiency or
success is determined by how these various factors are coordinated or integrated.
An organisation chooses its structure to effect this integration and make it effective
in the particular situations to achieve its special objectives.
32
CHAPTER 3
THE CATHOLIC HOSPITAL ASSOCIATION OF INDIA
AND THE CONTEXTUAL FACTORS
From the discussions on the theories of organisation in the previous chapter, it was
concluded that organisations adapt various structures to achieve their goals and
objectives. An effective organisation is the one which has an appropriate structure
and culture (Handy, 19-90). Appropriateness is determined by a variety of factors
such as the history, growth and size of the organisation, its operating environment,
the goals and objectives for which it exists and the technologies used for
coordination and communication (Wilson, 1991), This chapter is an attempt to see
how far these contingency factors have contributed to the present structure of the
Catholic Hospital Association of India as a Non-Governmental Organisation. The
last part of this chapter will try to see the relations between the present structure of
CHAI and the feedback from its membership on its functioning.
3.1
CONTEXTUAL FACTORS
3.1.1
Size
The studies on NGOs have shown that many of the Non-Governmental Voluntary
Organisation have originated as mutual support groups. People working in the same
profession or service come together for support, encouragement or advice.
They
required minimum organisational structure; at the most they need a secretary or a
coordinator to convene the meetings or send out a circular.
33
It seems that these
support groups slowly start to take up certain services for their members. At this
stage, some kind of organisational set up begins to take shape, the number of the
people joining the group also determines its size. Many of the larger NGOs have
started as small support groups.
specialisation
When the number of services increase, the
expands and the requirement for more formal coordination
mechanisms and control systems are introduced and thus the formal structure
emerges. As the size changes, the culture in the organisation too changes from an
informal club culture to more formal role cultures. Communication, systems and
procedures become more formalised (Handy, 1988).
3.1.2
Age and History of the Organisation
An organisation’s structure is related to where the organisation is in its life-cycle
(Kimberly and Miles, 1980, quoted by Wilson, 1991). In the early stages of the
organisation it is likely to reflect the preferences of the founder or founders. The
organisation is their complete focus and they do most of the jobs and set the climate
and culture (Wilson, 1991).
During maturity, NGOs need more strategic and
management direction and it is now that the structure begins to take shape as
functions and tasks, and departments are defined.
When new objectives are
introduced, that may require new direction, new managing levels, and new skills as
growth leads to complex nature (Subramanian, 1988).
34
3.1.3
Operating Environment
The socio-political and geographic situations also determine how an organisation
integrates itself or differentiates.
The greater the complexity of the operating
environment of the NGO, the greater the need for highly differentiated
organisational structures. When a large organisation faces various demands from
different types of clientele, it is appropriate to adapt differentiated organisational
structures with special subunits to cope with those demands (Handy, 1990).
3.1.4
Goals and Objectives
NGOs may take up additional advocacy or campaigning role and act as a pressure
group to campaign and advocate a vision or ideology. At this stage, departments
and specialization are no longer sufficient to control the diversity of the problems
and an organisation has to decentralise its works through regional units (Handy,
1985). Researchers generally agree that given a strategy of growth, the structural
form of the organisation will in due course have to match the strategy it is
pressuring (Wilson, 1991). When service providing agencies take up campaigning,
problems begin. Service providing and advocacy are two tasks under one umbrella
and the organisation has to be decentralised or restructured to meet the challenges.
35
3.1.5
Technology
Depending on the size and volume of service, geographical differences and the areas
of specialisation, technology used to coordinate in an organisation differs.
technology is mainly used for communication and information sharing. In small
organisations, postal services or telephone facilities may serve the purpose if that is
dependable or available. In bigger organisations with larger membership, circulars
or newsletters may be used for information sharing.
Within the organisation
coordination and integration can be achieved through computers and other
communicative systems like telephone and intercoms, meetings, interviews, notices,
etc.
3.2
CHAI AND THE CONTEXTUAL FACTORS
To understand the present organisation structure and the management style of CHAI,
one may have to see how these multiple factors interplay in the various stages of
CHAI’s growth.
3.2.1
History and size of CHAI
The Catholic Hospital Association was formed by a group of 16 Catholic nuns in
1943.
All of them were medical professionals working in different part of the
country. They came together as a support group. During the first 15 years, there
was no formal structure for CHAI. Over the years, the number of church related
36
medical and health institutions and consequently the membership of CHAI grew.
Now CHAI has a membership of over 2,000 health care institutions including big
hospitals, small dispensaries and social service societies (see Appendices 1-3). This
diversity of membership is united in their commitment to health care ministry. In
1957 when its first full-time Executive Director took charge, CHAI began to enter
into its second phase of growth. Attention focused more to provide services to its
members. For the first time, it got a permanent office and new departments were
started for membership, projects, publications, employment and later central
purchasing service, etc. In most of the voluntary organisations, there is an evolution
from mutual support groups to a service providing stage, later taking an advocacy
or campaigning role (Handy, 1988).
CHAI entered into this third stage when it accepted community heath as one of the
objectives in 1978. A new department of community health was started in 1981 to
advocate the vision and philosophy of community health.
3.2.2
Operational Environment of CHAI
When CHAI was started in 1943, the health situation of India was very poor. The
medical care of the colonial government was mainly for the settlers and their
employees.
Those facilities existed mainly in cities or in towns.
This selected
intervention during the colonial period resulted in the foundation of Western
medicine in India. This included training centres for health personnel, basic research
in tropical diseases, and a health service system for the country. But simultaneously
37
it has also caused incalculable damage to the health tradition of India and the
indigenous system of medicine. The basic holistic outlook of people on health was
eroded and was replaced by the Drug-Disease-Doctor orientation.
Colonial
exploitation also let to the severe environmental destruction causing many new
diseases.
According to the National Planning Commission Sub-committee on
Health, the distribution of mortality rate among children in 1942 was as follows:
under 1 year
24.3%
1-5 years
18.7%
5-10 years
5.5%
Total 10 years
48.5%
(Mukhopadhyay A, 1992).
The socio-political and economic situation of India was so degraded that half of
India’s children died before the age of 10. For every 1,000 live births, 20 mothers
lost their lives. Malaria counted for 100 million every year, out of which 1 million
died. The epidemics and famines took a heavy toll, mainly women and children
were the victims. This was the background in which missionaries started health care
institutions.
During the first half of this century there were 93 Catholic health
institutions in India, of which 14 were established before 1900 (Narayan T, 1992).
After the independence in 1947, when the Government of India made a clarion call
to the voluntary organisations to participate in the nation building process, the
Catholic church in India responded to it by building more hospitals and dispensaries
38
and more personnel joining the health care ministry. Thus the number of the health
related institutions grew and the membership of CHAI. But the membership was
very scattered all over the country. In those part of the country where the Christian
presence was more, there number of medical institutions also grew. A hospital or
dispensary was considered as a basic unit of a Christian Community together with
school and the church.
The Bhore Committee set up in 1943 by the colonial
government and Sokhey Committee established after the Independence set the
foundation for the new health policy of India which advocated comprehensive rural
health care services through the concept of Primary Health Care.
In 1952, the
Government of India started the process of establishing PHC’s in various parts of
the country. The Catholic church supplemented the process by establishing more
dispensaries in rural and tribal areas especially where government programmes were
lacking. But the approach was predominantly curative and medical.
Goals and objectives of CHAI
3.2.3
The first motto of the association was "Union is strength". During the first 14 years,
the main focus of CHAI was on:
1
promotion and upholding of ethical values in medical care,
2
fostering the professional education for health personnel,
3
issues related to the professional management of hospitals.
39
The emphasis during the 2nd phase was:
1
providing assistance to members to meet their needs for medicines
and equipment by developing linkages with various agencies, donors
and governments,
2
providing continuous education to its members through journals,
seminars and the annual convention (Narayan, T., 1992).
The Synod of Bishops in Rome in 1971 called for
"Action on behalf of injustice and participation in the transformation of the
world" (Vattamattom J, 1984).
In 1972, the Catholic Bishops Conference of India (CBCI) stated that
"the church should actively involve itself in removing concrete cases of
injustices happening in the society in which it exists" (opus cit, 1984).
Following the Alma Ata declaration when the Government of India accepted the
goal of "Health for All by 2000 AD", the Catholic Bishops Conference of India
exhorted the Catholic community
40
"We want our health services to take Primary Health Care to the masses,
particularly in the rural areas and urban slums.
Catholic hospitals and
dispensaries should stress the preventive and promotive aspects of health
care” (opus cit, 1984).
Thus the teaching of the Catholic church and health policy of India prompted CHAI
to accept the concept of community health. In 1983 CBCI again exhorted for an
analysis of the society with tools of social sciences and in the light of faith and
asked to promote community health on a priority basis (opus cit, 1984).
CHAI entered into its 3rd phase in its life cycle when in 1978 it included
community health as one of the main objectives.
During the last 15 years, this
thrust continued to permeate all aspects of its life.
The Catholic Hospital Association of India adopted for itself the goal of "Health for
Many More” (a modification of the Alma Ata goal of "Health for All by 2000 AD"),
with a special emphasis and focus on the poor. The concept of community health
was understood as
it
a process of enabling people to exercise collectively their responsibilities to
maintain their health and to demand health as their right” (Vattamattom, J
1984).
41
This new vision demanded the paradigm shift in the health care approaches of its
members. The community health department was initiated in 1981 to advocate this
vision.
3.2.4
Technology and communication
To keep the scattered membership united was the main aim of the Association. So
they started an in-house bulletin in 1944 called "Catholic Hospital". In 1957, the
bulletin was renamed "Medical Service".
In the third phase of its growth, the
bulletin was converted into a regular commercial magazine ("Health Action") to
promote the vision of community health to a wider public.
The members were
asked to subscribe to the magazine which many did and many could not. Since
"Health Action" was meant for a wider public, it could no more carry the regular
information to is members. This caused a break in the flow of communication to
its members. This situation continues since 1988.
Within the office, more technological innovations took place - more telephone
connections, intercoms, telex, fab, etc were installed, and computer services were
made available to all the departments.
42
CATHOLIC HOSPITAL ASSOCIATION OF INDIA,
3.3
A GROWING NGO
The multiple factors that have affected its size, membership, growth, operational
environments and the technology have changed the Catholic Hospital Association
of India into a third generation NGO.
"As NGOs grow in sophistication regarding the nature of development and
the potential for their own roles, many undertake, increasingly effective
strategies involving longer time perspective, broadened definition of the
development problems, increased attention to the issue of public policy and
a shift from exclusively operational to more catalytic roles", (David Korten,
1987).
In the growth of NGOs, Korten categorises them into three generations:
Generation 1
NGOs of this category are mainly engaged in welfare, charity and relief to the poor.
43
Generation 2
This includes NGOs that are engaged in the development style projects in areas of
preventive health, improved farming, etc. Stress on local self reliance was the main
shift.
Generation 3
In this stage, NGOs focus their attention on facilitating sustainable changes on a
regional or national basis. In this stage, the NGO will play a more catalytic role
than a service delivery role, facilitating services by other organisations by linkages
and networking on a sustainable basis, (Korten, D, 1987). A similar view is shared
by Sethi (1978) and Meera Chattergee (1988).
If one can accept these arguments, CHAI has to be considered as a third generation
NGO with its multiple roles of advocacy, linkages, networking and trying to bring
sustainable changes in the field of health. This is clear from the various activities
undertaken by the Community Health Department, which included:
Training and orientation,
Research and documentation,
Promotion of rural and urban country health,
Promotion of regional resource teams,
44
Project planning and evaluation,
Linkages and networks and
Issue based campaigns.
The 50 years of CHAI’s growth has shown 3 different stages in its life.
The
different socio-political environment in which CHAI grew demanded different
organisational structures. Depending on the focus an organisation gives during each
phase, it develops its own organisational structure and culture.
The phase of expansion or consolidation is a crucial phase for any NGO
(Subramanian, A, 1988) and it may face many challenges at this stage. Expansion
is the logic of the market and therefore marks the business enterprise.
If the
organisation does not grow, it is destroyed (ibid).
Changes in services and increase in size means changes in personnel.
specialised personnel has to be recruited and managed.
More
This will mean a more
impersonal system of internal administration. The first question is whether the NGO
will maintain its proximity and responsiveness to the people it serves. NGOs by
nature are closer to the people and more flexible and adaptable. But as they grow
in size and as the bureaucratic system develops, it alienates from the people. The
organisation turns its focus from the people to its own functioning and management.
Size demands standardisation and therefore administrative bureaucracy is inevitable.
This precisely makes it alienated from the community (ibid). At this stage it is
45
necessary to combine systematisation and standardisation with proximity and
responsiveness to the people. A highly developed strategic competence becomes
essential at this stage (Korten, D, 1987) to keep the members close to the
organisation.
3.3.1
Growth and relationship with members
From the perspective of growth, if one looks at the feedback on CHAI from its
member institution it is easy to understand why 45% of the people who responded
to the questions on weakness felt that
"there is poor interaction between CHAI and its members, poor personal
contact and communication and a sense of alienation", (Narayan, T, 1992).
The reasons for this are also clear in the feedback. They say that
"CHAI is not practical in its approach; there is too much centralisation of
power", (Narayan, T, 1992).
All other answers to the questions on feedback follow from these basic problems.
Again 69% of the members responding to the question of the expectations of the
members, expect
46
"better interaction between CHAI and its members through visits and more
personalised correspondence", (Narayan, T, 1992).
It very much shows that they want to remain united to CHAI and expect support in
their activities, especially in rural areas.
62% of members answering the questions on the strength of CHAI approved its
vision on community health, "Health Action" magazine, its option for poor and
many of its actions that support the vision. They strongly feel that
"it is a hand to hold on", (Narayan, T, 1992).
3.5
CONCLUSION
The feedback from the member institutions of CHAI clearly tells that the current
structure is not sufficient for the present size and the roles of the organisation. As
organisations grow in size and change their roles, the structure and method of
functioning are to be revised to avoid problems as well as to facilitate the smooth
functioning. The feedback from the field calls for a review of the present structure
and the current roles of CHAI.
47
CHAPTER 4:
THE
ORGANISATIONAL
STRUCTURE
OF
THE
CATHOLIC HOSPITAL ASSOCIATION OF INDIA
The situational factors discussed in the previous chapter are only one side of the
organisation structure. The other side is the method of -integration or coordination
that exists within the organisation at various levels. These methods of integration
are the design parameters that give shape to an organisation structure. The basic
design parameters are centralisation and decentralisation.
"In designing an organisation structure both situational factors and design
parameters should be clustered to create configurations", (Mintzberg, 1983).
The method of integration within organisations indicates the source of power and
the flow of communications and information in the organisation.
This chapter
examines the structure of CHAI to review the source of its power and the type of
integration as well as the flow of communication within the various levels of its
structure including its membership, diocesan and regional units, its elected executive
board and the central office.
Since CHAI is representing the healing ministry of the Catholic church in India, it
seems appropriate to review also its relation with the Indian Catholic church.
represented by the Catholic Bishops Conference of India (CBCI).
48
4.1
POLITICAL STRUCTURE
The present structure of CHAI includes a strategic apex which is the Executive
Board of the Association and an operational unit in the central office. There are
also regional and diocesan units established according to the bye-laws of the CHAI
1961. For a proper understanding of the Association one may have to examine the
process of integration that takes place within the Association. As a policy making
body, the Executive Board is an important unit of integration.
4.1.1
The executive board
The memorandum of the Association of CHAI (1961) states that
"the powers and duties of this Association shall be vested in and exercised
by an Executive Board".
As a policy making body the:
"Executive Board shall be responsible for all activities of the Association and
its office of all categories", (Memo, 1961).
49
It is the Executive Board that initiates policies and projects and safeguards the
memorandum of Association of the Organisation. The Executive Board consists of
nine members elected by the members of the Association during the annual general
body meeting of its members.
’’Every constituent member has the right to appoint a delegate to attend and
vote at meetings of the Association on its behalf’ (Bye-laws 1961, Article
III).
The elected members form the Executive Board of CHAI.
They are the policy
making body and they also guide the central office in the implementation of policies
and programmes. Hence election to the board is an important factor in the process
of integration in CHAI. The Executive Board functions through board meetings.
They also appoint the Executive Director who looks after the regular activities of
the Association. The Executive Director is the link between the Executive Board
and the operational unit. He is assisted by other offices and staff as necessary.
4.1.2
Drawbacks of the present election system
The members of the Executive Board are elected by the members of the Association
during the annual general body which is convened during the annual convention.
50
"Election of all members to the Executive Board of the Association shall take
place at a previously announced meeting held during an annual convention
of the Association”, (Bye-laws, 1961, Art VIII).
According to the rules of the Association, the quorum for the business meeting is
fixed as one half of the members registered at an annual convention. In practice this
has many drawbacks:
Elections are annual but conventions biannual
Every alternative year annual conventions are conducted on a large scale with
exhibitions and seminars.
These exhibitions are on health and health-related
technological developments, new equipment for hospitals and other related item like
vehicles, computers and office and hospital furniture, etc.
These larger scale
conventions are conducted in major cities and they attract a good number of
participants. Since such conventions are very expensive, they are conducted only
on alternative years. When there is no exhibition, the number of the annual general
body varies depending on the programme arranged in connection with it.
For
example, the Bombay convention in 1990 attracted about 600 participants out of
2200 members. In 1991 a meeting of the sister-doctors was arranged in connection
with the annual general body meeting and the participants were mostly sister
doctors. The total number of participants were only about 100. The survey by the
0
os \
51
A;
evaluation team has shown that only 32.4% or 132 member institutions have
participated in the annual conventions in the past 5 years, that is the annual average
is 6.5% (Narayan T, 1992).
Regional imbalances
Conventions are conducted annually in different parts of the country. Participation
in the convention depends on the location of the convention in the country and the
size of the membership in that particular part of the country.
For example, if
conventions are conducted in any southern state, it attracts more participants than
when it is conducted in northern parts of the country. As travelling long distances
is very expensive and time consuming, participation will be restricted form the
particular regions.
It seems that the present method of election does nor guarantee a proper
representation of the membership of the Association in the Executive Board. In
some years, there is over-representation by one region on the Board, while other
regions are not at all represented for many years.
In 1991/2, out of nine board
members three of them were from one state while many other states had no
representation at all.
process.
This regional imbalance can affect the decision making
It is also very much against the principle of equity and community
participation advocated by the community health vision of CHAI.
52
A floating electorate
The present electorate is not permanent but almost a floating one.
There is no
consistent participation in elections. Depending on the theme of the convention and
the location, participation by the members varies. This causes not only regional
imbalances but also increases the possibility of unequal participation by certain
categories of membership, eg doctors, nurses, administrators, social workers. All
these factors reduce the responsibility and accountability of the elected Board
members as they may not meet the same electorate during the next three years of
their tenure. This also reduces the authority of the board members as the source of
power which is the membership (General Body) is a floating and unstable one.
Conventions are mostly attended by bigger institutions. But the membership pattern
of CHAI shows that 70% of the member institutions are smaller institutions. When
elections are conducted during conventions, bigger hospitals get representation in the
governing board.
Lack of reporting system
The elected board members have no system of reporting back to the electorate
regarding the activities of the association.
Ultimately there is no flow of
information and communication which is necessary for the integration of the
Association.
53
4.1.3
Diocesan and Regional units
When a large organisation faces various demands from different types of clientele,
it is appropriate to adapt differentiated organisational structures with sub-units to
cope with these demands (Handy, 1990). According to the Bye-laws of CHAI,
1961, regional units are supposed to establish their sub-units in the dioceses. The
2,500 member institutions of CHAI are scattered in the 125 Catholic dioceses of
India.
Members of each diocese form a diocesan unit.
Membership includes
hospitals, dispensaries and clinics, and social service societies of the diocese. At
present, diocesan units do not exist in many dioceses.
The Bye-laws of CHAI 1961 state the need for establishing regional units to take
CHAI policies to local situations.
Regional units were planned based on
geographical limits mainly depending on the size of the membership in a state or
group of states. The purpose of these regional units as envisaged in the Bye-laws
are:
1
To bring the Association’s acts and policies more effectively to its members.
2
To implement these policies with due regard for local conditions.
3
To study local Government policies and its effects on the general health
policy of the Association and share that information with others.
But there were only limited success in decentralising the organisation through
regional units. At present there are only 6 regional units. Attempts were made to
54
form such units ever since the Silver Jubilee of CHAI in 1968 with varying success
(Narayan T, 1992). The lack of success in establishing and sustaining regional units
may be due to:
1
Regional units were seen only as executors of the policies made at the centre.
2
They had no part in the policy making process of the Association.
3
Most of the regional units were initiated by the central office without
initiating a process to establish diocesan units.
This meant that the
sustainability of these regional units depended on the central office.
4
The regional units were separate legal bodies registered in each region. The
only link with the central office was a letter of approval by the President of
CHAI.
5
It seems that the relationship between CHAI and the Catholic Bishops’
Conference of India (CBCI) was not strong enough to support the regional
and diocesan units.
4.2
THE NATIONAL OFFICE OF CHAI
In Chapter One it was discussed that NGOs following the contingency approach,
design their organisation structure taking into consideration the objectives of the
organisation, the type of functions and services they render, and other contextual
factors affecting the organisation. Looking at the present organisational chart of
55
ORGANISATIONAL STRUCTURE OF CHAI
GENERAL BODY
CONSTITUENT MEMBERS
ASSOCIATE MEMBERS
EXECUTIVE BOARD
(ELECTIVE)
PRESIDENT,
[
SECRETARY,
2 VICE-PRESIDENTS,
TREASURER
4 COUNi’CILLORS
EXECUTIVE
'E DIRECTOR
(APPOINTIVE)
ASSISTANT EXECUTIVE DIRECTOR
(APPOINTIVE)
admi: TSTRATOR
(APPOINTIVE)
f-------
PROJECTS
!---- -- 1--GOLDEN
CHAI
JUBILEE
FARM
PROJECT
PROJECT
MEMBER
SHIP
--------- ,
CENTRAL DRUG
TESTING LAB
PROJECT*
I
“7---
ELECTRO
NIC DATA
PROCESS
ING
CONTINU
ING MED.
EDUCA
TION
------- ,---ZONAL OFFICE, DELHI
DEPARTMENTS
HAFA
HEALTH ACCESSORIES
FOR ALL
HEALTH
ACTION
“1—
FINANCE
AND
ACCOUNTS
—1--GENERAL
ADMINIS
TRATION
DOCUMEN
TATION
COMMUNITY
HEALTH
---- !--CENTRAL
PURCHAS
ING
SERVICE
r
T
1
RURAL
HEALTH
URBAN
HEALTH
RESEARCH*
I--
OTHER
PUBLICATIONS
PASTORAL
CARE
I
LOW COST
COMMUNI
CATION
MEDIA
*PLANNING STAGE ONLY
FIGURE 4.1 THE CURRENT ORGANISATIONAL CHART OF CATHOLIC HOSPITAL ASSOCIATION OF INDIA (SOURCE: CHAI DOCUMENTATION CENTRE, 1992)
56
CHAI, one may notice that various tasks of the organisations are differentiated into
separate departments or sections on the basis of functions and services. They are
arranged in some form of hierarchy with information and communication flowing
from various departments to managerial and executive apex.
Hence this can be
identified as a purely functional structure. Regarding the internal functioning of
CHAI the discussion report states that the staff of CHAI have raised questions about
lack of clarity regarding goals and objectives, high turnover of staff, levels of
confusion regarding roles, inadequate understanding and interrelationship between
departments, (Narayan T, 1992). An analysis of the structure reveals the following
facts:
Development has been ad hoc
In the course of the 50 years of its history, CHAI from time to time has taken upon
itself various tasks and has added one department to another in its structure. As the
functions and department increased, middle line managers were also brought in to
coordinate these activities of the departments.
Hence the present structure has
evolved as a result of its growth. Unlike the Royal Commonwealth Society for the
Blind, there was no policy decision to follow a particular structure, (Wilson, 1991).
No specification regarding reporting systems
In the structure of CHAI, there is no specification regarding who reports to whom.
There are a number of departments and sections under the same management. This
57
can cause confusion among staff regarding their roles. This also causes confusion
among middle-line management regarding control and coordination.
Such a
situation can cause lack of clarity as to what is expected of people and how their
performance is assessed. This can create problems among middle-line management.
Studies on the structure of organisations show that the growth in size tends to lead
to more specialisation and an increase in the number of levels. This will lead to
increased bureaucratization and communication problems and delay in decision
making and eventually the morale of the organisation will decrease (Child, 1984).
Ineffective use of senior executives
When there are too many departments, even senior executives may also be forced
to supervise and coordinate day to day activities. This may seriously detract them
from the time and attention they have to give to long term policy and to dealing
with external matters of a strategic nature, (Child, 1984). On the other hand, it can
also lead to ineffective supervision.
Problems regarding supervision and coordination
As can be noticed from the organisational chart, some of the departments are service
providers while others are mere administrative departments.
departments of a specialised functions.
There are also
Departments dealing with specialised
programmes may require less supervision and more internal freedom while purely
58
administrative departments may need direct supervision and close coordination.
These double standards may lead to sharp divisions between the administrative staff
and the specialists, (Subramanian, 1988).
Delay to execute collective decisions
The feedback on CHAI shows that there is a time lag between certain collective
decision and their implementation. This raises questions regarding the priority of
programmes and projects undertaken by CHAI as well as its accountability to the
people in whose name funds are received (Narayan T, 1992).
4.3
CATHOLIC HOSPITAL ASSOCIATION OF INDIA AND THE
CATHOLIC BISHOPS CONFERENCE OF INDIA
By the very fact that the entire Catholic health care institutions and personnel are
united under the umbrella of the Catholic Hospital Association of India, it is also
accountable to the church in India represented by the Catholic Bishops Conference
of India (CBCI).
The byelaws of CHAI (1961) have taken this aspect into
consideration and have given considerable importance to the relations between CHAI
and CBCI, when it says that
"The Ecclesiastical Advisor of the Association shall be that member of the
hierarchy whom the Catholic Bishops Conference of India shall elect or
appoint to guild the policies of the Association" (Art V).
59
Again in Art VII Sect I, it is said that
’’the Association will esteem as a favour the privilege of the Ecclesiastical
Advisor and other special officers and invite them to attend meetings of the
Association as deemed appropriate".
The need for a good relation between CHAI and CBCI is very explicit in the
byelaws.
However, there is no specific mention about how this relation can be
established and maintained. For example, how often the Advisor will be invited to
attend the Executive Board meeting or his role in the Association’s functioning is
not mentioned. A proper relation between these two bodies could also be used to
promote the accountability of the Catholic Hospital Association of India. CHAI and
its members will have more scope in creating awareness among the Catholic
community of believers on health issues through parishes as well as through schools
and colleges run by the church. This will increase the involvement of community
in the activities of CHAI which in turn can improve the ’community capability’ in
health management (Narayan T, 1992).
4.4
CONCLUSION
A review of the organisational structure of the Catholic Hospital Association of
India has shown that both its strategic apex and operational units require changes
to make the association more effective to achieve its goals and objectives.
To
achieve a better democratic participation of its members in the election process,
60
CHAI has to devise an effective method which will assure meaningful participation
by the electorate and guarantee more responsibility and accountability to the elected
members. In theory there seems to exist horizontal decentralisation but in practice
it does not seem to guarantee the democracy of the decentralisation to its
membership.
The operational unit in the central office also has to remedy the drawbacks to
overcome or to avoid problems discussed above.
Efficiency of the organisation
depends on how the process of integration and coordination takes place among
various departments. The Association may have to follow new strategies to design
a meaningful structure which will guarantee democratic participation of its members
in decision making and an adequate flow of information to them from its operational
unit. A better relation with the church in India also will promote the accountability
of the Association.
61
CHAPTER 5:
A NEW STRUCTURE FOR THE CATHOLIC HOSPITAL
ASSOCIATION OF INDIA
Examination of the present structure of CHAI reveals that both its political and
organisational units need to be redesigned to make it more effective to achieve its
goals and objectives. The result of the survey also shows that the membership of
CHAI expects a better management for CHAI that will ensure an improved
relationship between them and its central office. This chapter is an attempt to look
for an alternative structure to address the present weaknesses.
The strategic apex of CHAI, the Executive Board, should be a democratic and
participative decision making body that will ensure increased responsibility and
accountability.
This may be possible through building up strong regional and
diocesan units with vertical and horizontal decentralisation of powers. Studies show
that when NGOs take up advocacy and campaign, departments and specialisations
are no longer sufficient to control the diversity of the problems, and an organisation
has to decentralise its works through regional units (Handy, 1985).
5.1
THE POLITICAL STRUCTURE
The proposal is to make the regional and diocesan units participate in the decision
making process through vertical and horizontal decentralisation of powers. 45% of
the members who replied to the question on the weaknesses of CHAI stated about
62
the poor functioning of regional units and another 69% expect that CHAI should
strengthen the regional units (Narayan, T, 1992). It seems that those expectations
of the members could be satisfied by:
1
Initiating diocesan units in each diocese.
2
Establishing regional units with power to elect representatives to the
Executive Board of CHAI.
3
Establishing a Liaison Committee (General Body) of the representatives of
the regional units who will elect the office bearers of CHAI.
4
Establishing a better relationship between CHAI and the Catholic Bishops
Conference of India.
5.1.1
Diocesan units
The proposal is to initiate diocesan units in each diocese. The members of CHAI
within a diocese will form a Diocesan unit. Each diocesan unit can function with
a minimum structure. A convenor elected by the members of the unit will be the
co-ordinator of the unit and will also act as a link between diocesan unit and
regional unit/central office. These diocesan units will try to implement the health
policies of the church with the guidelines of CHAI under the leadership of the
Bishop of the particular diocese. As the basic units of CHAI, these diocesan units
will take the policies and programmes of CHAI to the community around them.
This will bring the people and the membership closer to CHAI. This will also allow
flow of communication between central office and Regional unit/diocesan units.
63
5.1.2
Regional units
The proposal is to revitalise the existing regional units and initiate units in those
regions where at present there is no unit. All the diocesan units within a state from
a regional unit. If a state does not have sufficient diocesan units to form a state
unit, a group of states can join together to form a regional unit. Regional units are
the link between central office and the diocesan units. Each regional office will
have its structure to function which will also include a regional office.
It is proposed that the members of the region in their annual general body elects an
Executive Board and the office bearers for the region. The Executive Board consists
of the Regional Presidents, two Vice-Presidents, Treasurer and Secretary (all office
bearers) and form councillors.
The terms of the Executive Board will be three
years. But when the new board is set up and internal ballot of the board should be
held so that three of the members will stand only for one year, another three only
for two years and three for a full three years. Thereafter all members will serve for
three years. Each regional unit will try to adapt the policies and programmes of
CHAI within the socio-cultural situations of the region.
They will also try to
collaborate with their respective state governments in the health programmes. One
of the Bishops of the Region will be an advisor to the regional unit who will also
preside over the annual general body of the Regional Unit. The Annual General
Body will conduct election to the Board as well as approving the annual budget and
64
accounts of the unit. The presidents of the regional units will be responsible to the
national unit and will have to work under the guidelines of the central office. Thus
each regional unit will be the operational arm of the national unit.
5.1.3
The General Body (Liaison Committee)
The Liaison Committee which will form the annual general body of CHAI will
consist of the office bearers of each regional unit, ie the President and vice
President, Secretary and Treasurer. There may be also other members coopted by
the Executive Board. The President of the CBCI Commission for health will be the
ex-officio President of the General Body. This body will elect the office bearers of
CHAI and discuss policy guidelines as well as approve accounts and budgets of the
Association. The office bearers of CHAI include the National President, two vice
Presidents, Secretary and Treasurer and are elected from the Presidents of the
Regional Units. The remaining four Presidents of the regional units will be the
councillors in the Executive Board.
5.1.4
Executive Board of CHAI
The Presidents of the nine regional units will form the Executive Board of CHAI,
and office bearers of CHAI are elected from them. They will be the ultimate policy
making body responsible for the over all affairs of the Association.
They will
appoint the Executive Director and any other officers needed to assist the Executive
65
Director to manage the day-to-day affairs of the organisation. The term of the office
bearers of CHAI will be three years but care should be taken to keep the continuity
in the Board. Elections to the board may be conducted in such a way that each year
three out of nine will retire and three new people will come in. When the new
board is set up an internal ballot of the new board will be held so that three of the
members will stand for only one year, three for two years and three for the full three
years. Thereafter all members will serve for three years.
5.1.5
Executive Director
He will be the overall manager of the central office and link between central office
and the General Body and Executive Board. He will present the annual reports to
the Annual General Body and periodical report to the Executive Board.
The
Executive Director will represent the Association in all forums and bodies in
connection with the work of the Association.
5.2
NATIONAL OFFICE OF CHAI
Studies on organisations structure show that there is no best way of designing an
organisation, mainly because of the contextual variables that influence each
organisation differently. But most of the proponents of the contingency approach
think that certain important factors such as division of labour, coordination, span of
control and information systems are key to the process of integration. In proposing
66
a new design for CHAI’s National Office, attempts have been made to consider
these elements of management to overcome the weaknesses of the present structure
discussed in the previous chapter.
In the new structure it is proposed that the National Office of CHAI in Hydrabad
should consist of various departments as shown in the organisational chart.
Executive Director of CHAI is the overall coordinating person and manager of the
office.
He is assisted by an Assistant Executive Director and other middle line
managers which include the Administrator, Divisional Manager and the Head of the
Community Health Department. They coordinate various departments under them.
Middle line managers are coordinated by the Assistant Executive Director who in
turn reports to the Executive Director.
The Administrator looks after those
departments that are more of an administrative nature. The Divisional Manager
coordinates the regional units, zonal office and other special projects. Head of the
Community Health department co-ordinates all programmes of the department. All
these sections work together to achieve the goal of CHAI and improve the quality
of service.
67
ORGANISATION STRUCTURE OF CHAI
EXECUTIVE BOARD
EXECUTIVE DIRECTOR
ASSISTANT EXECUTIVE DIRECTOR
1
DIVISIONAL MANAGER
ADMINISTRATOR
I------------ 1-------ADMINIS CENTRAL
TRATION
PURCHAS
ING
------- !----------
1-------
FINANCE
MEMBER
SHIP
EDP
------ 1
PROFESS
IONAL
TRAINING
COMMUNITY HEALTH
(HEAD OF TH^Z DEPARTMENT)
TRAINING
1
PASTORAL CONTINUED
CARE
MEDICAL
EDUCATION
RURAL
I-------RESEARCH
DOCUMENTATION
---- 1---
URBAN
--------- 1
ALTERN
ATIVE
SYSTEMS
1------------------------ 1
ACCOUNTS FUND
RAISING
(FARM)
SPECIAL
PROJECTS
REGIONAL PUBLICATION
UNITS AND
ZONAL
OFFICE
FIGURE 5.1 THE PROPOSED ORGANISATIONAL STRUCTURE OF CHAI
68
COMMUNICATION
AND
NETWORKING
WITH OTHER
RESEARCH
GROUPS
The new design takes care of the following points:
Division of work
Departments are divided based on the type of services the organisation is rendering
to its members.
Some of the works in the central office of CHAI are merely
administrative while other departments are more functional and specialised in nature.
This will help each department to become specialised in their particular field of
activity.
Reporting
Information is one of the important means of control in an organisation.
It is
important that each person in the organisation knows to whom he or she has to
report. This will help communication and flow of information which facilitates
decision making. This also takes care of the principle of unity of command which
recommend one person, one boss. Hence all the administrative departments report
to the administrator who reports to the Assistant Director and the Assistant Director
to the Executive Director. There will be 6 people reporting to the Administrator
who will coordinate the departments
Coordination
The type of work determines the type of coordination. While certain departments
may need direct supervision, others need only mutual adjustment, standardisation of
process, outputs or skills. Combining all these under the same management can
result in management problems and inter-group conflicts within the organisation
69
(Handy, 1988).
Head of the Community Health Department and the divisional
manager reports to the Assistant Executive Director who coordinates those
departments and reports to the Executive Director.
Span of Control
If the span of control is too wide, the supervisor may spend more time in
supervising and coordinating and may not get sufficient time for decision making,
training and support. Depending on the type of work, the span of control can be
wide or small. Hence all the administrative departments in the new structure are
managed by the administrator. This also allows more time for senior executives to
look into more specialised and strategic areas of the organisation.
Culture
Depending on the nature of the work, culture of a group within the department or
section varies, ie, the type of work determines the type of culture in a section. For
example, the publication division which has to bring out a magazine every month
on a stipulated date may develop a task culture while a community health
department involved in training, may develop a personal or team culture.
Combining different cultures in the same organisation also can result in intergroup
conflicts and management problems.
"Many of the ills of organisations stem from imposing an inappropriate
structure on a particular culture to thrive in an inappropriate climate” (Handy,
1984).
70
The above consideration leads to another proposal for a divisional approach for
certain type of work. Specialised divisions like publications could be a separate
division with more independence. The survey shows that 95.5% of the members felt
that the "Health Action" Magazine is relevant to their work and 92.7% members
receive them regularly. When there is a strong clientele to judge the quality of the
product and when the output is standardised, direct supervision will only increase
bureaucracy and delay in the work. Hence publications can be a separate division.
It can be even attached to a regional unit of CHAI which may also vitalise that
regional unit. They will be controlled by the policy of the organisation and the
allotted budget.
BENEFITS AND CONSTRAINTS OF THE NEW STRUCTURE
5.3
Benefits
The new structure proposed for CHAI has the following benefits:
1
The policies, programmes and vision of the Catholic Hospital Association of
India can reach down to the grass root level through the decentralised
system.
2
More active participation of the members in the decision making process of
CHAI is envisaged.
3
Regional imbalances are taken care of.
71
4
More involvement and better relation with the Catholic Bishops Conference
of India.
5
Better flow of communication between CHAI, CBCI and the members of
CHAI.
6
Operational unit is sufficiently decentralised so that senior executives get
more time for strategic matters of the organisation.
7
New division of work allows more scope for specialisation and better service
to the members.
8
This will bring CHAI closer to its members.
9
Better relations and more democratic participation in decision making
generates better accountability in the organisation.
Constraints
The proposed structure also has certain constraints which have to be considered:
1
Decentralisation and divisionalisation are costly and CHAI will have to look
for new sources of funding.
2
This also requires more personnel to manage regional units from the
voluntary sector.
3
As the diocesan directors of social work are also members of CHAI, there
is a possibility of their dominance in the election over majority of the health
personnel who are women.
72
5.4
CONCLUSION
An attempt has been made in this chapter to propose a new structure for the
Catholic Hospital Association of India that might improve the process of integration
between various level of the Association. Decentralisations proposed in the election
and the decision making process is supposed to improve the participation of its
members in the activities of CHAI as well as to facilitate a better flow of
communication between the central office and various levels of the Association.
The proposed structure also aims at a better relation between CHAI and the Bishops
Conference of India.
The operational structure proposed above might remedy
certain drawbacks of the present system discussed in the previous chapter and make
it more effective to work towards the objectives of CHAI. Finally this new structure
is supposed to bring more accountability to various units and CHAI as a whole.
73
CONCLUSION
The Catholic Hospital Association of India was established fifty years ago as a
mutual support group for the health personnel of the Catholic church scattered in the
Indian subcontinent.
During the last fifty years, it grew into one of the largest
health and health care services at a national level. During the last couple of decades
the concept of health and health care approaches have undergone drastic changes all
over the world. These phenomena have also influenced an evolution in the vision
and objectives of CHAI. From a mere support group for medical personnel it has
become a staunch proponent of community health vision and ideology.
Following the Alma Ata declaration when the Government of India accepted the
goal of ’’Health for All by 2000 AD”, CHAI welcomed this concept and adopted it
for itself as "Health for Many More” (Narayan R, 1988). This meant a paradigm
shift in the health care models of over 2,000 member institutions of CHAI. During
the course of the last 15 years, the membership of CHAI has generally come to grips
with the new vision and community health and has undertaken various programmes
and projects to promote the same.
The growth in size as well as the evolution in its vision and objectives has also
brought with it many problems in the Association. The feedback of the evaluation
study sowed that CHAI has to give urgent attention to certain areas of its life and
activities to address some of the issues identified by the evaluation team.
74
The analysis of the issue of the "Accountability of CHAI" has shown that there is
a dichotomy between its vision and its structure. The community health vision of
CHAI is based on the principle of decentralisation, community participation and
equity while these basic ideas were accepted in its vision, these were not absorbed
into its structure specially in its decision making process.
This dichotomy has
caused dissatisfaction and alienation of its members from the organisation.
Having looked into these issues from a theoretical point of view, it has been found
that CHAI follows a contingency approach in its organisation’s structure and
functioning.
In a systems approach, it is possible to overcome these issues by
redesigning the present structure and improving the functioning of various systems
within the structure. One of the suggestions is to decentralise the decision-making
process, that the strategic apex which is the Governing Board of CHAI that it may
have more democratic participation.
This will also improve the flow of communication within the various levels of the
organisation that will bring the members of CHAI closer to each other and to the
organisation itself.
Following are some of the suggestions to improve the
functioning of the organisation and the quality of its services:
1
Establish Regional and Diocesan units
2
Delink election and convention
75
3
Make necessary amendments in the bye-laws to allow
a
Regional units to elect their representatives to the Governing Board
of CHAI and to the Liaison Committee
b
The presidents of Regional units to form the Governing board of
CHAI
c
Regional units to elect their representatives to form a Liaison
Committee which will replace the Annual General body of CHAI
d
The Liaison Committee to elect the office bearers of CHAI
e
The Governing Board to coopt experts from various fields to the
Liaison Committee which will also act as a think-tank for CHAI
f
The Chairman of CBCI Commission for Health to be the ex-officio
President of the Liaison Committee.
4
The Liaison Committee will discuss and advise on policies and programmes
and will have the power to approve the budgets and accounts of the
Association.
5
The Governing Board of CHAI should be the policy making body which will
have the power to initiate and monitor policies and programmes.
6
It should ensure sufficient representation to women in the decision making
bodies as they form the backbone of the health care ministry in India.
7
The operational unit in the central office of CHAI needs to be redesigned to
allow better coordination and to avoid role conflicts.
8
As far as possible middle-line managers should be people with professional
training in Human Resource Management.
76
9
Every new staff member should be carefully initiated into the goals and
objectives of the organisation.
10
The Association should regularly publish a newsletter to inform its members
regarding the various activities of CHAI and its membership.
The policy making body of CHAI is requested to take notice of these
recommendations and to act upon them to make the Association more accountable
to its members, to its objectives and vision as well as to improve the quality of its
services.
77
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COMMUNITY HEALTH CEUL
326, V Main, 1 Block
Koramongala
Bangalore-560034
India
JAMMU 4
KASHMIR
APPENDIX 1
6
c-^
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RAJASTHAN
130
30
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62
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h
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HAVEU
3
ORISSA
82
V
t
S'
MAHARASHTRA-/ <S€C«-6^s
100
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ANDHRA
PRAD^SHz
243
•
/
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32
I
\
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r'
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L
164
5
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CATHOLIC HOSPITAL ASSOCIATION OF INDIA
STATE-WISE DISTRIBUTION OF MEMBER INSTITUTIONS
(Source: CHAI Documentation Centre)
APPENDIX 2
STATE-UNION TERRITORY WISE DISTRIBUTION OF CHAI MEMBERS
(Source: CHAI Documentation Centre)
HOSPITAL/
HEALTH
CENTRES
DIOCESAN
SOCIAL
SERVICE
SOCIETIES
ASSOC
IATES
225
8
10
3 ASSAM
50
3
53
4 BIHAR
165
4
160
5 GOA
30
6 GUJARAT
58
7 HARYANA
11
11
8 HIMACHAL PRADESH
3
3
9 JAMMU-KASHMIR
5
1
10 KARNATAKA
157
6
1
164
11 KERALA
398
18
6
422
12 MADHYA PRADESH
205
4
3
212
13 MAHARASHTRA
96
1
3
100
14 MANIPUR
21
1
15 MEGHALAYA
46
46
16 MIZORAM
4
4
17 NAGALAND
20
20
18 ORISSA
82
82
19 PUNJAB
28
28
20 RAJASTHAN
30
30
21 SIKKIM
1
1
STATES/UNION TERRITORIES
TOTAL
STATES
1 ANDHRA PRADESH
243
2 ARUNACHAL PRADESH
22 TAMIL NADU
365
1
2
32
3
62
6
22
13
5
383
3
23 TRIPURA
3
24 UTTAR PRADESH
123
7
130
25 WEST BENGAL
65
6
71
UNION TERRITORIES
1 ANDAMAN/NICOBAR
3
3
2 NAGAR HAVELI
3
3
3 DELHI
8
4 DAMAN & DIU
1
5 PONDICHERRY
2
1
1
4
2,208
74
35
2,317
TOTAL
1
9
1
APPENDIX 3
BED-WISE ANALYSIS OF MEMBER INSTITUTIONS
(Source: CHAI Documentation Centre)
CATEGORY
NUMBER OF
INSTITUTIONS
HEALTH CENTRES AND DISPENSARIES (0 TO 6 BEDS)
1,533
HOSPITALS WITH 7 TO 10 BEDS
149
HOSPITALS WITH 11 TO 25 BEDS
219
HOSPITALS WITH 26 TO 50 BEDS
141
HOSPITALS WITH 51 TO 75 BEDS
32
HOSPITALS WITH 76 TO 100 BEDS
31
HOSPITALS WITH 101 TO 150 BEDS
21
HOSPITALS WITH 151 TO 200 BEDS
17
HOSPITALS WITH 201 TO 250 BEDS
12
HOSPITALS WITH 251 TO 300 BEDS
4
HOSPITALS WITH 301 TO 350 BEDS
1
HOSPITALS WITH 351 TO 400 BEDS
1
HOSPITALS WITH 401 AND ABOVE BEDS
7
LEPROSY INSTITUTIONS
40
ASSOICATE MEMBERS
35
SOCIAL SERVICE SOCIETIES
74
TOTAL
2,317
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