HOSPITAL MANAGEMENT
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- HOSPITAL MANAGEMENT
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RF_M_3_SUDHA
H
HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)
AS A
SUPPORT TO THE STRATEGY
FOR
“HEALTH FOR ALL BY 2000 AD”
By
Dr. N. Seshagiri
Additional Secretary & Director General
and
Dr. Gautam Bose Additional Director
National Informatics Centre
Planning Commission
New Delhi
Presented at the
XXXI Annual Conference of the I.A.A.M.E., Bombay
on
January 28,1992
J
HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)
AS A SUPPORT TO THE STRATEGY FOR
“HEALTH FOR ALL BY 2000 AD”
1. Introduction
The Management Information System (MIS) varies according to the
set-up of the system and is always geared to the concept of
organisational needs, problem definition, design outline, detailed
system design, system integration and finally the implementation and
maintenance. This is true for Health and Family Welfare Sector too.
The Health in broader concept is holistic one and has many sub
systems. However, the “HEALTH FOR ALL” strategy forms the basis
of all the health activities in the country. Any health activity unless it is
linked with the concept of “HFA” cannot be viable and cannot have
optimal contribution towards the total health system.
In India the Multi-Purpose Workers (MPW) scheme was introduced in
70’s with an idea of integrating all the health care delivery activities
including promotive, preventive as well as curative services for
achieving the “HFA” goals. However, in actual practice it has been
observed that the grass root workers, both MPW male as well as
female including their supervisors, are mostly busy in fulfilling their
own targets for the various target oriented disease programmes
rather than to provide the total health care delivery to their assigned
population. In the process, some health activities get neglected and
certain segment of population, who are either not aware of the health
facilities or are refractile to the various health approaches, remain
uncovered.
It has been further observed that in the country, various health
sub-systems have their own information systems, some of which are
well developed and some are under developed. All of these are
independent systems and have no linkage amongst each other. All
the efforts till now geared towards synchronising and streamlining the
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various health information systems have not succeeded. The reasons
quoted are plenty but it is mainly due to the usual reluctance on the
part of an established system to give way to a newer and modern
concept of system integration. Hence, the onus now is on the
programme managers to contribute maximally towards the
development of an integrated, synchronised timely, action-oriented
information system for management of health activities at every tier
and not only for archival purposes.
An MIS should contain enough information about the programme
activities, quantify the outcome, identify the uncoverd areas and
bottlenecks as well as should help the workers of respective tiers to
arrive at a decision for appropriate action. In other words, the
information system should help in decision making, planning,
organising, executive and controlling processes which are not only
inter-dependent but are interactive. While designing this type of
information system, utmost care should be taken in choosing the
information parameters such that the routine information collection is
kept at its bare minimum so that the collection mechanism and the
grass root workers are not unnecessarily loaded. Rather every
information parameter before its inclusion in the system should be
first weighed against its actual utilisation.
2. Health Information in India: Present Status
The Health Information in India as it stands now is a fairly developed
one to serve the purpose of policy makers, strategy supervisors and
the programme implementors at higher levels. However, as already
indicated above, the system suffers from several ills viz. fragmented,
non-standard, ad-hoc information flow instead of user orientation etc.
Further, most of the information is for archival purposes, for use at a
deferred date, if any, at all.
In other words, the MPWs at subcentres are collecting and sending
the information to PHC because they are asked to do so. The same
holds good for PHC, district and state levels also. Under the
circumstances, the respective tiers are able to produce the data on
demand by higher authorities, but in the process, the data looses all
its requirement for converting it into a meaningful information for
action oriented use at the implementation levels. Thus, the basic
concept of decentralised planning and remedial action at appropriate
level gets defeated.
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The above picture is true throughout the country with slight variations
in the degree only, depending on the type and quality of general
administration and resources available for the health sector in a
particular state.
Structurally the information flow in the health set up is as below:-
Sub-Centre
PHC
(Field Suervisors)
District
(Programme Implementors)
State
(Programme Managers)
Centre
(Programme Managers)
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In the above data flow, several agencies/organisations are involved
which include CBHI, E&l Division and information cells of various
programmes at the central levels; equivalent of the same at the state
levels and respective programme officers at the district levels.
It may be pointed out that this holds good only for the rural areas as
most of the national health programmes are rural service oriented.
The Urban Health Information System is simply conspicuous by its
absence. Moreover, the quality and reliability of the data presently
being collected is very poor due to its low coverage and are not
comparable because of non-standardisation. In short, it can be said
that a true health profile of the country just not available, though
various approximations are always being made by extrapolating the
quality data and data available through special surveys/studies.
3.
Efforts Towards Integrated Health MIS
Since the weak points in the health information area were identified
as early as in 70s, an integrated Management Informa tion and
Evaluation System (MIES) for-health sector was devised by the CBHI
and was introduced in 1982; wherein it was visualised that all the
districts in the country would collect informaion from PHCs in an
integrated format and would send the report directly to the CBHI. It
was expected that the information would be computerised and output
tables would be provided to the programme managers at the various
levels. Unfortunately, the scheme did not take root for several reasons
and were identified in due course.
Based on the above experience and advancement in the field of
management information and also keeping in view the utmost need
of establishing MIS as a support to the HFA strategy, the Government
of India in consultation with the World Health Organisation (WHO) and
four participating states had devised a Health Management
Information System (HMIS) for the HFA strategy which was field tested
and reviewed.
In the review meeting of HMIS held in September 1989 in New Delhi,
it was unanimously observed that the devised information system is
a satisfactory one as well as feasible. The system was recommended
.4.
for implementation all over the country in a phased manner. However,
it was advised that the system should take advantage of the modern
Computer Communication Informatics Net work of Government of
India (NICNET) set-up by the National Informatics Centre (NIC). The
formats and information flow should be made computer compatible
so that data could be fed in the District Informatics Centres of NIC.
It may be noted that simultaneously several other
experiments/studies, by various professionals/institutions, were
going on in certain parts of our country on the same subject. To name
a few, Ballabgarh Project by AllMS, Bavala Experiment by
IIM-Ahmedabad, CMC Ludhiana Experiment, NATHI by CMC-Vellore
and IPPMIS Project by Kerala Government. Out of these, only the last
named one i.e. IPP-MIS Project approximates the HMIS Project of
GOI-WHO, supported by the participating states as far as its relevance
for application to the total population of the State/country.
4. NICNET
National Informatics Centre (NIC) provides Informatics services to the
Government of India at different levels such as Central/State
Government and District Administration. NIC has set up a nation-wide
Satellite based computer communication network called NICNET to
facilitate development of District Databases on important sectors of
economy and also to standardize and rationalise interactive
information exchange between the Districts and the States and then
to Centre, for decision support at all levels.
NICNET comprises of
0)
Large Main frame computers (NEC-S1000) at NIC Hq, New
Delhi and Regional Centres at Pune, Bhubaneshwar and
Hyderabad.
(ii)
ND-550 or equivalent super mini computers for providing
informatics services to the States.
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(iii) 386 PC-AT computer system at each district to provide serv
ices to the District Administration.
NICNET uses satellite based communication links through INSAT 1-0
for providing information flow among Districts, States and Centre. A
schematic diagram of NICNET is given in Fig.1.
5.
HMIS Version 2.0
In appreciation of the fact that conversion of the
manual system of the devised HMIS into a computer compatible
one required not only the technical expertise, but also proper
understanding of the various health information systems in operation,
a central team was constituted under instructions from the Union
Secretary (Health), comprising of experts from the allied fields. The
team not only studied the devised HMIS and other available
information systems but also made field visits to various HMIS and
non HMIS districts, Kerala State as well as project areas of other
experiments. The team also studied the feasibility of utilisation of
District-NIC set up and NICNET services for the purpose of HMIS.
During these visits elaborate discussions were held with grass root
workers, field supervisors, PHC, district and state level officers and
various other experts on the subject. Besides, exclusive meetings
were held separately with Central Programme Managers to ensure
that their interest did not suffer due to conversion of the system into
a computer- communication based one.
As a result of the above deliberations, the HMIS version 2.0 has been
developed and devised and has been now accepted by the Ministry
of Health & Family Welfare for its country-wide implementation.
HMIS Version 2.0 includes:-
0)
PHC Reporting Format
(ii)
District/Special Hospital Reporting Format.
(iii) Private Hospital/Nursing Home Reporting Format.
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(iv) Camps Information Format.
(v)
Manual for Instructions for PHC Computer.
(vi) Output reports at PHC,District,State & Central levels.
Besides the above, suggestive model formats for Subcentre Report
to PHC and Registers to be maintained at Subcentres are also
presented. It may be emphasised that Subcentre reports/registers
are only suggestive models and it would be entirely left to the States
to adopt these with or without modification or continue with their
existing system.
It may be observed that the HMIS Version 2.0 is not merely a computer
compatible format of earlier HMIS but its scope is much larger both
in concept as well as in structure. In the proposed system, the flow
of information is manual only upto the District level wherein the
information will be entered into the District Computers of NIC and
upward and downward flow of information from the District to the
apporopriate tiers will be made through NICNET by means of output
tables.
In HMIS Version 2.0, an effort has also been made to include, only
upto the district level, the hitherto neglected information component
from the urban, private and voluntary sector. Due precaution has also
been taken to filter the information at appropriate levels so that
desirable information can be disseminated at appropriate tiers. In
short, the proposed information structure is pyramidal rather than
cylindrical. An indicative diagram on Information Flow in HMIS ver. 2.0
is given in Fig. 2.
-2 2
6.
Logistics for Implementation of HMIS Version 2.0
in States/UTs
The HMIS Version 2.0 formats have been field tested, especially PHC
format, in four PHCs randomly selected in the remote areas of
Muzzafarnagar district of Uttar Pradesh and Sonepat district of
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Haryana. The field test results show that the formats are easily
comprehensible, especially with the aid of instruction manual which is
presently available in English only. The PHC Computer/Health
Assistant could follow the getup of the form and filled them correctly.
Hence, it is expected that by translating the format and the instruction
manual into the regional languages and with one/two days’ training to
the PHC Computer/Health Assistant and the District Information
Officer (DIO) of NIC, it will be feasible to introduce the system in the
States/UTs.
For the above purpose, it is proposed that each state should hold one
day training session for the District Chief/Designated Officer, Data
Entry person from the District Statistical Cell and District Computer
Centre Officer. For the comparatively small and medium sized states,
it will be possible to organise the training in the State Capital. This
training will be imparted by the officials of the Ministry of Health &
Family Welfare and Health Information Systems Division of NIC.
Subsequent to this, it would be possible for the trained district officials
to impart training to the PHC Computer/Health Assistant in their
respective District Hqs.
7.
Scope of HMIS Version 2.0 and Supplementary
Information for Individual Health Programmes
The scope of the proposed HMIS Version 2.0 is limited to the extent
that it will indicate the broad programme performance indicators and
morbidity & mortality pattern of the population at respective tiers. In
order words, it is the Health Intelligence and will reflect the Health
Profile of India at District, State and National levels and our progress
towards achieving HFA goals.
It may be worthwhile to mention that Programme Managers /
Implementators of various National Health Programmes may require
additional information besides those to be generated by the HMIS
Version 2.0 viz. financial/administrative information, micro level
programme indicators etc. It is envisaged that these would be
obtained by special methods, as are advocated by the individu al
programme authorities, either by surveys or sentinel centres etc. and
special periodic administrative reports.
0
-8-
INFORMATION FLOW IN HMIS (Ver. 2.0)
SUBCENTRE
(MPW^I & F)
►
DISTRICT HEALTH
AUTHORITY
PHC
(COM^UTOR)
DISTRICT
(STATISTICS CELL)
-PHC (CUNIC, LAB & STORES)
- DISTRICT/SPECIAL HOSPITAL
-PVT. HOSPITAL/ NURSING HOME
-PRIVATE PRACTITIONERS
-CAMPS INFORMATION
NIC
DISTRICT COMPUTER
N
**
N
E
T
(NIC <->
-STATE PROGRAMME MANAGERS
STATE ------ -STATE HEALTH SECRETARIAT
HEALTH AUTHORITY) -SBHI
N
c
N
E
E> •
T
-------------- CENTRE ----------(NIC < - > HEALTH AUTHORITY)
-CENTRAL PROGRAMME MANAGER
-HEALTH DEPARTMENT
- FAMILY WELFARE DEPARTMENT
-PLANNING COMMISSION
-CBHI
-NIHFW
DATA FLOW
Feedback
Figure 1
.J?
•4
4 i
I
I *
I
f
i MOTHERS
EARTH
HF
STATION
STATE SYSTEMS
NIC Hqs.
NEW DELHI
DISTRICT SYSTEMS
NICNET
A Nationwide Satellite Based
Computer-Communication Network
r
i
r
foreword by Dr. H. Mahler,
H 352-
Director General World Health Organization
There, are those who believe that hospitals and primary health care are incompatible
siib/ccts, aiyuiny that every dollar spent on a hospital is one lessfor primary health
care Hiis \t hool of ihoayht would have us enhance the position uj primary health
care at the direct expense of hospitals. There are still others who see hospitals as the
repository of the best that medical care has to offer and, as such, see it as a waste of
time and energy for hospitals to deal with other facets of health care. They would
keep primary health care separate, and not allow it to interfere with the life of a
hospital.
This conference was convened because wefelt the time was ripe to dispel the above
notions. Hospitals cannot be isolatedfrom primary health care - which is the key to
achieving health for all by the year 20(H). They are too powerful to be ignored; they
have knowledge and a functional capacity that must be tapped by primary health
care. They shape the public and professional image of health - an image which must
be radically altered if the "health for all” movement is to obtain universal support. In
my opening address I indicated that hospitals could become one of the main flag
bearers of this movement, but only.if they change their ways.
I believe the outcome of this conference represents a major step forward. The role of
hospitals in support ofprimary health care has been carefully explored, and the
conference conclusions provide a direction in which to aim: a basisfor guiding the
change.^required. I would draw particular attention to the important role given to
hospitals as well as medicalfaculties and other educational institutions in adapting
their curricula to the needs and challenge ofprimary health care. Unless there is a re
orientation of the education ofprofessionals, especially physicians, the conclusions of
this conference cannot be realised. This was brought out again and again in the
discussions; it is not new, but in the light of growing understanding of the concepts of
> : primary health care am! of its central place in national health development, it lakes
on particular importance today.
In this connection, 1 am especially gratified to see the unequivocal support given by
His Highness the Aga Khan to the outcome of this conference. With his support, a
major ally for the "health for all" movement has been gained. In shaping his health
services and educational institutions along the lines described, he will no doubt
provide an important example for others to follow.
Action speaks louder than words. The conference has set the stage for action with the
production of the present report. You are encouraged to use this report, to make it
available to others anil to participqje in whatever way you can in the implementation
of its conclusions.
•111J
CV liOSPL'iALS IN PLUi’iAliY HEALlil CAKE
)
oJ? ci c’itxTer*0neo sponsored by
Lio Apt Khan Foundation and Uic World ■'lealth Qi'ganisation
,■ ;
Novonibei* 19^1, Karachi, Pakistan
X
Major Conclusions of the Conference
2.
?
(v) ensure that the hospital meets its
referral and logistic support
responsibilities;
(vi) develop effective ways in which the
community can support and assist
in improving hospital services;
(vii) work with other sectors, non
governmental organisations and
community associates including
women’s groups active in the
catchment area;
The role of hospitals in primary health
care should be guided by co-ordinating
machinery which should be established
by national governments. Ihis
structure should be established al each
level of. administration (national,
regional,, local) and includes a
committee or council or board where
representatives from each part of the
health system (hospitals, health centres
and primary care workers) can sit with
representatives of the community to
deal with questionsconcetning policies,
management and resources.
3.
Hospitals should be associatedI with a
well defined catchment area within a
regionalised framework.
4.
Hospitals should have a department of
community health to mobilise interest,
expertise and direct interactions on one
side with the clinical services and on the
other with the communities in its
catchment area. The department
should. have a multi-disciplinary
composit'ion and foster and encourage
teamwork. The responsibilities of these
departments of community health
should include;^—
(i)
r
(iv) collahoralc with the community in
seeking relevant inlormalion <»n
health problems and appropriate
solutions;
Hospitals have an important role in
fostering anil encouraging the giowth
of primary health care — a role which in
some areas of the world they are already
pursuing. Little progress, however, can
be achieved without a strong and
unequivocal statement from political
leaders at all levels of their commitment
to primary health care. This
commitment must be unambiguous,
leaving the people and administrator in
no doubt that the political leadership of
the country, right up to and including
the very highest level, is committed to
primary health care — the key to
achieving health for all by the year
2000.
I.
support and encouragement to
primary health care programmes
in the hospital’s catchment area;
(ii) inservice training for reorientating
hospital health workers in order to
change the ‘hospital outlook’ to a
‘health perspective’;
(viii)idcntify gaps in ~lhe delivery of
primary health care services and
introduce appropriate innovat
ions;
(ix) stimulate and conduct relevant
health services research
i.- *- ------ which
focuses on practical issues to
achieve a progressive improve
ment of services.
5.
Health resources will have to be
increased to improve health systems,
including a dramatic increase in
primary health care services. Resources
for primary health care should be raised
by:—
(i)
(ii) using all health resources more
rationally;
\ j new sources of funds
(iii) e
generating
from international organisations
and community contributions;
j hospitals through
(iv) reorienting
departments for community health
so that an increasing proportion of
the hospital budget is spent on
supporting primary health care;
(v)
(iii) cooperate with the educators and
supervisors of primary health care
workers in the field to improve
training management and
administration;
increasing the proportion of the
overall health budget that is
allocated to primary health care.
improving the balance of health
personnel so that there are more
t^pcs and numbers of workers
available at the local and
inlet mediate levels of the health
system.
!
9
6.
f
7.
Medical faculties, as well as other
educational institutions for health
workers, should adapt their curricula to
focus on community health needs and,
where practical, develop and use
training material in the local language;
they have to introduce early and
continuous contact with primary health
care practice; they have to ensure
doctors and health care personnel are
more community oriented; they have to
participate regularly in primary health
care.research, teaching and service, not
ignoring management and administrat
ion.
a
The National Hospital Associations
and other relevant bodies should be
encouraged to collect, publicise and
circulate widely, local, nationally and
internationally,
noteworthy
innovations and developments of the
role of the hospital in primary health
care.
8.
The World Health Organisation and
other international, national,
professional and non-professional
bodies, should maintain a continuing
dialogue on the role of hospitals in
primary health care in order to ensure
that the potential positive role of
hospitals is understood and that past
antagonisms are converted to
collaboration.
«)
The Aga Khan foundation is in a
unique situation and should take a
leadciship role in illustrating how the
programme of a teaching hospital and
inedjeal college can be developed in full
support of primary health care.
10.
I'he report of t his conference should be
widely distributed to all member states
nt the World Health Organisation, to
editcatKinal institutions noolved in
health care and to, relevant non
governmental and funding agencies,
encouraging them to act upon the
conclusions contained therein.
*
56
Background paper on The Role of Hospitals
in Primary Health Care, prepared by the
World Health Organization.
Introduction
This paper is concerned with some selected,
critical issues in the future development of
the hospital as part of a national health care
system and within the primary health care
(PHC) approach to health. No attempt will
be made to be comprehensive with regard to
all types of hospitals and all aspects of PHC,
or their actual and potential relationships.
Neither is this paper explicitly concerned
with formal health service planning and the
more balanced use of resources between
different levels of health services. However,
many of the issues which will be discussed
have a significance which carries beyond
that of the tertiary care^iospital alone, as
well as being important to the better
utilization of scarce resources. The
discussion will be organized maihly around
the four themes of the Conference, as
follows:
T
1.
The role of hospitals in promoting and
using community participation in the
development of PHC;
2.
the role of hospitals in providing direct
support to primary health activities
(continuous education, supervision,
referral, supply, etc);
3.
the role of hospitals in orienting
physicians and other health
professionals towards primary health
care; and
4.
the role of hospitals in conducting and
supporting health services research.
The basic principles of primary heallh care
as a set of specific activities and PHC as an
approach to health development have been
widely discussed and by now are well know
to most health workers, as well as to many
others. The distinction between good (or
bad) health and good (or bad) health
services is an important one and
fundamental to the appropriate conception
and understanding of PHC. Properly
organized health care services have the
poh'llllill lol lllilklllg mi 11111 > i > 11 n 111
conliibution Io improved individual and
collective health status, but it will be only on
contribution of many. Other contrrbutions
will come from areas and developments not
commonly thought of as part of the health
scclor; lor example, agriculture, education,
transport, employment creation, greater
economic and social equity, etc. (the
intersectoral aspects of PHC). Still other
contributions will be made by organized
communities as well as by individuals and
their families to their own health care needs.
This will come in the form both of directly
health-related activities and greater
participation in the overall life of the wider
national community.
The International Conference on Primary
Health Care that was held in the Soviet
Union, at Alma-Ata, in 1978 issued a
Declaration which stated that primary
health care is the key to attaining health lor
all by the year 2000. The Alma-Ata
Conference described the health care aspects
of PHC as essential health care based on
practical, scientifically sound and socially
acceptable methods and technology, made
universally accessible to individuals and
families in the community through their full
participation and at a cost that the
community and the country can afford to .
maintain at every stage of their
development, in the spirit of self-reliance
and self-determination.
Primary health care reflects and evolves
from the economic conditions and socio
cultural and political characteristics of the
country and its communities. It addresses
the main health problems in the community,
at the first level of contact providing
promotive, preventive, curative, and
rehabilitative services accordingly. At this
level of first contact in the community it
includes at least education concerning
prevailing health problems and the methods
of preventing and controlling them;
promotion of food supply and proper
nutrition; an adequate supply of safe water
and basic sanitation; maternal and child
heallh care, including family planning;
immunization against the major infectious
diseases; prevention and control of locally
endemic diseases; appropriate treatment of
common diseases and injuries; and
provision of essential drugs.
From this it can be seen that the major thrust
of PHC is toward those who in the past have
had least access to adequate nutrition, clean
water, health care, etc. It is unfortunate that
this ‘thrust toward the periphery’ has been
taken by some as implying some sort of
opposition to the very existence of hospitals
and other mainly urban-based institutions.
This picture is not correct, as the PHC
approach involves the entire health system
incliiding honpiliih, from (lie univmily
leaching hospital to ‘front-line’ hospitals.
Although it is true that in many, if not most
countries sophisticated hospital
development has proceeded relatively more
rapidly than a proper overall balance in the
health cure system would dictate, the true
spirit of primary health care as adopted at
Alma-Ata sees hospitals as a tremendous
potential resource for support to PHC. Only
with the full support of hospitals and their
staffs, with their commitment to high quality
care, can PHC avoid the trap of becoming
‘second class medicine for second class
citizens’ Correspondingly, only by
becoming part of a national health care
system based upon the primary health care
approach to health can hospitals regain their
full relevance to society as a whole, and not
i
t
57
to much health care of any kind - except
possibly of the traditional type - and
certainly not that which is based upon a
costly high technology. Much formal health
care planning is based upon the dual
assumptions that all the population is to be
covered with particular services (e.g.
number of doctors per 1000 of population)
and that this coverage must be based upon
the most sophisticated of available
Because of the special position enjoyed by
technologies, even in the absence of proven
the leaders of medicine in most societies, it
relevance and positive impact. These
may be that the most important ; assumptions ignore the economic and
conliibuti'on to be made by them in the
political incapacity of the poor to purchase
snuggle to achieve ‘health for all by the year
much of their own high cost ca^e, and have
2000’ is a socio-political one. This
too little political infiuence to guarantee that
responsibility falls particularly heavily upon
governments make available to them
those medical leaders actively engaged in
sufficient health care resources so as to.cover
teaching, research and the utilization of the
ihcn basic health needs. It is here that
highest levels <>! ■ medical technology; ol
community involvement is most important:
course, this combination of activities is to be
the ability of the organized wider public to
found most particularly, but not only, in
infiuence decision - making at all levels in
those hospitals most actively engaged in
favour of policies directed toward the
leaching medical students. There is an
achievement of ‘health for all’.
urgent need for these and other leading
As has been staled, the modern hospital has
health institutions to be permeated with the
not developed in response to the major
challenging philosophy ol primary health
health needs and demands of the mass of the
care. However, care must be taken by those
population, and the possibility of positively
who do take up this difficult challenge
acting upon those needs and demands. One
because it will not decrease their scientific
basic reason, as discussed, has been the
responsibilities, as is feared by some, but
weakness of the poor: another has been the
rather will increase them, often in
external influences brought to bear upon the
unexpected ways.
hospital; external, that is, to mass health
needs and demands. The major such
external factor has been technology itself.
Undoubtedly, many of the technological
The Past Development of the Hospital
innovations of recent years have been
positive in terms of the number of people
In general, the hospital has developed as an
who have benefilted from them. It is equally
enclosed building associated largely with
certain that many of these technological
. curative activities performed for those
innovations have had only marginally
individuals who find their way to the
beneficial effects, while others have had no
institution. In particular during the last half
effect at all, and some have had positively
century or so, their development has not
negative ones.
come about as a direct response to the major
health needs and demands of the mass of the
The economic environment of current
population in any particular country, or of
health care systems provides some incentives
the possibility of acting upon those needs
and few discouragements to the adoption of
and demands. The more sophisticated the
the latest technology. Beginning with the
hospital, the greater the cost implications
subsidization of research and development,
and the wider the gap between their special
governments and industry provide relatively
capacities and. the population’s overall
unconstrained conditions for ‘buyers’ and
health needs and demands. T his gap came to
Tisers’ of health technologies. This situation
encompass the areas of leaching and
is further peipetuated by various pressures
research as well. Survey data from many
resulting, for instance, from marketing
countries show the limited catchment areas
campaigns, high public expectations
of so-called, national referral centres. In
concerning specialized medical care, the
Third World countries it is usual for 90 per
prevailing professional image of quality
cent of all in-patients in such "institutions to
medical care (in terms.of medical ‘centres of
be drawn from the city in which it is located.
excellence’), and even competitive
What are some of the major factors
aspirations for prestige*. All of these
explaining the development of hospitals in
contribute to relative, or absolute,
the way described?
overinvestment in costly medical care
facilities which are often misused, especially
To begin with, there is the restricted ability
by the relatively privileged few having easy
of the poor to fulfil their demands for needed
access to them.
health care. They are not in a position,
just to a relatively small minority of the
better-off. In fact, there is not as much
choice in all of this as may be imagined. T he
cost explosion in hospital cafe is such as' to
make impossible their present pattern of
development even wealthy countries,‘much
less poor ones. These issues will be discussed
in greater detail within the context of the
four themes of the Conference.
economically or politically, to enjoy access
The modern medical school and its teaching
hospital are the product of a symbiotic
relationship with industry which has
produced the scientific and technological
base on which the leaching hospital now
rests. This particular symbiotic relationship
substitutes for one between the hospital and
the whole population which would be based
upon mass health needs and demands. The
existing relationship between the hospital
and the producers of high technology
extends beyond the immediate uses of all
possible available technologies, to the
training of future medical practitioners, and «
to research efforts as well. Medical students
are trained to pursue a ‘technological
imperative’, to use any available technique
of intervention — sometimes even in the
absence of clearly proven effectiveness,
regardless of cost, if there is any possibility
at all of medical gain no matter how limited.
I
The problems connected with application of
(he ‘technological imperative’ are greatly
exaggerated in conditions of sharp resource
constraints. Thus, the external (to mass
health needs and demands) technological
factor is compounded in Third World
countries by another factor external to them:
that the latest technological innovations are
developed by, and in the first place for use in
the industrialized countries. The application
of the technological imperative in countries
spending annually as much as US $ 1,000 per
capita for health care creates sufficient
havoc there, but when applied in countries
spending one-tenth or one-hundredth or
even one-thousandth of that amount for
health care, the results are catastrophic!
The issues discussed above — the limited
influence of the poor, and the effects of
technology — have contributed to the
development of the hospital as an ‘enclosed
place’ catering almost exclusively to the
needs only of those relatively limited few
having access to it. The hospitals, and
especially the most select amongst them —
the university linked teaching institutions —
face inwards rather than outwards.
Consequently, they offer only very limited
support to other less sophisticated health
care institutions and usually no direct
support at all to communities and families,
except as sick individuals who may arrive at
the hospital.
The training activities of those hospitals
most actively engaged in teaching are largely
determined by the factors already discussed,
leaching is based upon the Technological
imperative’ and produces graduates having
both the inclination and capacity to practise
medicine mainly in the hospital setting.
There exists, in fact, a critical disjunction
between the needs of an appropriate health
services system and the medical training
institutions. Too few of the kinds of
/
58
personnel most needed are trained, while
relatively or absolutely too many of others
come into the medical market-place. It is
now the case that many countries, developed
and developing, arc facing a gross
oversupply of medical graduates, at least
relative to effective economic demand.
self-help. Indeed, the concern that
participation be real and accompanied by
true responsibility and authority leads to
consideration of the need for the community
to exercise appropriate social control of the
health services. Where this degree of
community participation has been achieved,
health personnel become better motivated
Hospitals, in particular teaching
and more able and effective in their joint
institutions, traditionally have played an
pursuit, with the community, of PI IC goals.
important role in conducting and
In such situations a rural community, for
supporting research. However, most of the
example, when involved in decision-making
research which is undertaken is of a bio
may give priority to such health-related
medical or clinical nature, often quite
concerns as clean water for drinking and
‘ narrow in its potential applicability. The f
water for crop irrigation rather than to
possibility of having sick patients serVe as a
personal health services. However, it is usual
source-of research data has facilitated the
that the community also demands some
conduct of such research within the hospital
form of immediate attention for disease and
setting. This factor, coupled with the
injury. Often broader health-related goals
availability of. high technology-based
cannot be pursued without assuring the
instruments, and the desire to do research at
personal health services clement and its
the internationally determined
appropriate back-up and referral, up to and
(industrialized countries, actually) frontiers
unhiding lhe leiliaiy van- mslilulion
ol knowledge have all contributed to a
It should be noted that in the case of national
research pattern which is not only not
institutions such as tertiary care hospitals,
relevant to mass health needs, but in the case
and especially those engaged in teaching, the
of most Third World countries limited in
relevant community which needs to be
output as well as often of poor quality. One
involved in participation is the wider
of the important bases for this poor quality
national one and not just the population
* work is located precisely in the effort to
living in the immediate neighbourhood of
reproduce the research being undertaken in
lhe hospital, although such a loca I
the industrialized countries.
population might be drawn into some
relevant participatory activities.
lhe Role of Hospitals in Promoting and
Using Community Participation in the
Development of PHC
Training and orientation of health workers
to support and appreciate full Community
participation is essential in most countries.
This should not be limited to the clear
connexions with clinical concerns, such as
self and family and community help with
rehabilitation, though these arc important
especially as entry points for more
traditionally trained personnel. It is also
important that health workers learn about
hazards in the workplaces of their countries
and how workers of all kinds are learning
and organizing or would like to learn and
organize to avoid such hazards. In a similar
way, they should learn what women’s
groups arc concerned about when it comes,
for example, to overly active medical
intervention in the birth process. Learning
about community organization and change
wi!} also help health workers to be better
able to foster broad health promotive and
preventive efforts. Such learning cannot be
based on theory alone, it must take place as
apart of direct exposure to the real problems
of the community.
While there is no single model for
participation — because of political,
economic and other country differences —
the fullest possible level of authentic
community participation should be
encouraged in health policy and decision
making as well as in community and family
The problem of maintaining active
community involvement beyond the first
stage of enthusiasm is a significant one. If
the system rests on community decision
making and control the problem may not be
so large a one, as the real action wiH'bc at this
level. If so. then it is only when participation
Reorientation of the Hospital Towards the
PHC Approach to Health
I
The discussion, here will focus upon the
potential for future changes, in the context
of the four interrelated themes with which
this Conference is concerned; namely, the
hospital’s role in promoting community
participation, providing direct support to
PHC activities, orienting health
professionals to PHC, and conducting and
supporting health services research. The
discussion is based upon the analysis,
offered above, of the development of
existing hospital systems, and teaching
institutions in particular. It also rests upon
the assumption, stated earlier, that “only by
becoming part of a national health care
system based upon the primary health care
approach to health can hospitals regain their
full relevance to society as a whole...’’
1.
is not accompanied by true (co-)
responsibility that communities lose
interest. This is one of several areas of
research that should be pursued in relation
to this sphere of concern.
2.
The Role of Hospitals in Providing
Direct Support to PHC Activities
(continuous education, supervision,
referral supply, etc)
Increasingly, hospitals are seen as a part,
usually the major part, of an overall health
care system. Acceptance of the PHC
approach implies not only the full
integration of the hospital with the overall
health c;ye system, but the reorganization of
the entire health system so as to provide
support dor primary health care activities.
This means that the health system as a whole
will have to accept the goal of making
esscnlial health care available to all The
muif •.pcLiah/vil needs <»l this calc will
influence the type of service that has to be
provided by the central levels of the health
system. The result should be stronger links
between the more centrally placed health
institutions and the peopleand communities
they arc intended to serve, usually through
the medium of health care facilities and
piogrammcs engaged in PHC activities al
the less specialized levels of the health care
system.
Thus, from its position of dominance, the
hospital is potentially the strongest ally
within the health care system for the
promotion of total population coverage
with essential health care, and the extension
of this minimum goal to that of‘health for
all by the year 2000’. The changes required
to achieve this desired end are far-reaching
in nature, but necessary if national health
development is to evolve in a socially
relevant direction. The continued isolation
of hospitals from the health needs that face
most people, especially the poorest,
represents an outstanding past failure of the
health system to rationalize its structure and
the use of available resources.
Some health systems have moved in the
desired direction of creating a more
comprehensive health care system for the
community, within which the role of the
hospital is linked fully with all other aspects
of health care including that of making
essential care available to all. In other
situations, individual hospitals have taken
the steps necessary to shape their activities to
.meet the wider needs of the community.
These experiences arc important. They
provide evidence that the prevailing model
of hospital functioning need not to be taken
as a universal norm. Alternative forms are
available from which valuable knowledge
can be gained, knowledge which can help
guide future developments.
59
false health information that is being so
Examples of hospitals functioning
successfully as parts of integrated health
widely propagated, whether through
service and manpower development systems ' ignorance or for ulterior motives.
can be found in a number of countries. In
V The Role of Hospitals in Orienting
one instance the Dean of the medical school
Physicians and Other Health
is not only the Director of the central
hospital, but the Director of the regional
Professionals Towards PHC
health service as well. The staff of the
Training is intimately linked with service
medical school is not only responsible fdr
arid research. Students absorb views and
servicing the hospital, but spend at least one
habits which will affect their behaviour over
day per week as well in associated health
a life-time of work. Too often, however,
centres; the reverse process, of health centre
teachers consider teaching as more of a
staff taking part in the service and teaching
distracting nuisance than anything else.
activities of the hospital, also takes place.
Frequently, they would prefer to get on with
Another example of such integration istobe
a piece of research, or high technology
found in a number of countries in which
based clinical work which, incidentally,
health services for urban and semi-urban
might be highly rewarding not only in some
:gions have been taken over by the training
scientific sense, but in a more immediate way
institutions responsible for the education of
as well. Even when research <?r private
physicians, nurses.and other categories of
practice docs not interfere with teaching,
health personnel.
pressing service demands frequently
Perhaps the most important specific role of
overwhelm the best of intentions on the part
hospitals in primary health care is the dayof a teacher of clinical medicine.
to-day support they can provide to the
Despite these many difficulties, the proper
various health activities being undertaken
training and retraining of health workers in
within communities, at other health units
the PHC' approach is both a powerful
and in cooperation with health promoting
motivating force and an essential activity for
activities of other sectors. It is in this
the accomplishment of PHC. The relative
relationship of providing active support that
distance from PHC of an exclusively
hospitals can most immediately influence
clinically oriented training, usually acquired
the quantity and quality of essential health
in hospitals, has already been indicated. The
care available to the population.
point has also been made that because
The proper functioning of a hospital system
hospitals constitute a major health resource
or any of its components is not only
in most countries, they need to be turned
dependent upon the adequacy of its
into centres of active health promotion and
resources. Of more importance is the
prevention with strong community guidance
relationship of the hospital to the prevailing
so that medical training itself can be
patterns of need for medical and health care.
reoriented to be based on PHC. All hospitals
A well endowed hospital, not effectively and
have al least some role to play as teaching
rully linked in a two-way system of referral
institutions.
and support to this need will not be able to
Training must be multidisciplinary and
use its resources to the fullest effect. In such
teach teamwork and appreciation of
a situation, it is not uncommon to find
community
participation rather than
highly qualified staff attending minor
exclusive medical control. Teamwork in
illnesses and high-cost beds and technology
many situations will necessarily extend to
being inappropriately utilized at the same
work with nurses, nurse practitioners, and
time as outpatient clinics are grossly
other types of health personnel. Most of
overcrowded. To avoid this, it is necessary to
such training should be on the job, at the
have a properly functioning system of
local level so that the student can see the
primary health care closely supported by all
place of more specialized and general
levels of the overall health care system.
knowledge in relation to local needs and
One way of entering the reorientation
tasks. Retraining might be used not only to
process discussed above would be by
reorient personnel towards PHC, but to
reviewing the scope and context of a hospital
expand the capabilities of PHC workers,
system’s activities (or those of a single
perhaps into broader development roles.
hospital) and relating them to the support of
There is- a clear need for continuing
particular PHC activities in specific areas
education to reinforce existing skills, and its
and in defined population groups. The
inclusion as part of the supervision process.
hospitals, and especially the most
All health workers need to be educators and
prestigious ones, could use their enormous
messengers of health, and their respective
human and technical resources to provide
training programmes should incorporate
the public wfth properly validated
these aspects.
information on health problems and
There is a great need for. new curriculum
appropriate methods and technology for
alternatives and appropriate teaching
solving them. The prestige of the leading
materials. The organ izat ion and
medical centres could serve to counteract the
management of large hospitals has also to be
reconsidered so as to reflect a wider
community based orientation. One major
issue to be resolved is the proper relationship
between a university-linked medical school
making use of a Ministry of Health hospital
for its clinical teaching, and the Ministry. In
some countries, this issue has been
approached by making the training
institutions responsible for the delivery of
both preventive and curative health services
within a specific region of the country. In
other situations. Ministries of Health carry
direct responsibilities both for the training
of health professionals and their later
employment. Obviously, the basis for
successful change goes beyond such
organizational means only, but these may be
useful entry points for other required
changes in these areas. Whether such
solutions might be widely applicable
remains to be seen.
4.
The Hole of I lospitals in Conducting and
Supporting Health Services Research
Health services research is concerned with
problems and questions which affect the
functioning of the health system as a whole.
Although it may include certain bio-medical
aspects of the treatment of disease, it mainly
addresses questions which if answered could
provide better insight into how best to
improve the overall effectiveness and
efficiency of the various parts making up the
health system including, of course, the
hospital itself. In the hospital context,
health services research should include both
activities which take place within the
hospital, as well as those which take place in
the communities in which the hospital is
directly involved. In fulfilling the latter role,
hospitals can provide valuable insight into
the design and development of local health
systems based upon the primary health care
approach. For example, how to design
maternity systems which can seek out those
most needing hospital-based delivery while
making it possible for other women to be
delivered safely at a community-based
maternity unit. Other examples of much
needed research which could be stimulated
— especially, but not only — from a hospital
engaged in teaching would be: the
relationships between primary health care
activities at the periphery and the wider
health care system; the relationships
between the health care system and other
sectors affecting health; the relationships
between the PHC approach and specific
disease control programmes; and, the
relationships between community
participation and the development of PHC
activities. Research which actively involves
health workers as well as members of the
community, i.c. participatory research, is
often required for the successful carrying out
of much of the research under discussion.
60
I he form of paiticipation is oflrn lhe most
effective way ol orienting health workers
towards PHC.
Within the hospital setting in particular, a
valuable service could be performed by
reassessing many of lhe health technologies
currently in use. Clinicians have been raised
in a technological environment which makes
it difficult for them to discern between that
which has passed through a rigorous lest of
scientific validation and that which has
gamed acceptance only through longcontinued practice or perhaps just
spectacular advertising claims. The list of
questions relating to efficacious and cost
efficient clinical practice which need to be
answered is long. Which surgical
interventions are really beneficial? Which
agnostic radiology is essential? Which
laboratory tests provide essential
information, and which only marginally
useful information?
Which radiotherapy in fact prolongs life?
Which drugs are effective and harmless?
Which electronic equipment for cardiac
patients is really life saving? l.normous
monetary savings could be made, not to
speak of the alleviation of human suffering if
simple tests could be discovered to predict,
for example, which patients would be really
likely to benefit from intensive coronary
t;irv Similarly, an rnonmms im lease in
> |li> K iiiy
'"iilil
I"
I»i«»»ii»Ih
lll•"lll
naining progiamines in which the hospital is
engaged. It is clear that the PIIC.approach
requires more, not less research and that it
be relevant to the most pressing mass health
problems.
5.
Keeping in mind the social goal ol
health for all by the year 2000, how will
hospitals evolve in the coming decades
in response to this goal, with particular
reference to basic functions,
organizational set up and staffing?
6.
What should be the interaction between
governments and hospitals to bring
about necessary changes?
Concluding remarks
Some suggestions have already been made as
to how hospitals— individual mstitutionsor
the entire system
might enter into the
process of reorienting themselves towards
primary health care activities and the PHC
approach. In connexion with this, the
following are some questions which can be
asked with regard to the four specific themes
of this Conference.
Orienting Physicians and Other Health
Professionals Towards PHC
1.
How can hospitals make the training of
health professionals more relevant to
the needs of the population, the new
role of the hospital, and the role of
professionals?
2.
How can hospitals promote favourable
changes in attitude and behaviour on
the part of health workers toward
teamwork and development of new
roles?
3.
How are these changes likely to directly
influence the functioning of hospitals?
4.
How can these changes be linked to
wider health service manpower
development eflorts in the context of
natlonul health care sliuctuiex and
institutions?
Community Participation
What are appropriate forms of
community participation in the health
sector in general and in hospitals in
particula r?
How can hospitals play a role in
stimulating effective forms of
participation?
I.
2.
What are the particular roles of non
governmental, private, cooperative and
oihci types of communities at the
,lit It u ni h v« h nt th' ht nllli '«‘i lui (r u
local and national government)?
3.
I'V
taUonah/mg the use ol expensive
radiological and laboratory equipment.
I low can health workers be encouraged
4.
appropriate
to accept and
i— stimulate
---To perform lhese functions would involve
forms
of
community
participation?
not only biomedical and bio-engineering
research, but also epidemiological,
5. How can appropriate forms of
economic, social, behavioural and health
participation in the health sector be
systems research. A combination of these
sustained in different types and levels of
facets of health research is required both to
communities?
identify and to generate health technology
that is scientifically sound and socially and
Direct Support to PHC Activities
economically acceptable, as well as to
discover the most efficient and effective
How can hospitals promote broader1.
ways of applying this technology, whether in
abased health policies at the national
the overall health care system or any of its^
level, including provision to the public
constituent parts including, of course, the
and decision-makers of appropriate
hospital.
health and health service related
information?
Beyond the health system, the leading
medical centres should be promoting
2. How can hospitals become more
research into the wider socio-economic
responsive to, and knowledgeable
dimensions of health. Research is required
about the health needs of a total
to discover ways of making it possible for
population living in a well-defined
people to develop more healthy.lifestytes, for
area?
influencing positively decisions affecting the
physical environment in which we live, and
so on.
Most hospitals in a position to conduct or
support research are also in a position to
promote it through problem-oriented
training programmes which include a
research component. A first step in the
promotion of heulth services research could
be its inclusion in the various education and
of logistic support, the improvement ol
two way referral systems, supervisory
and monitoring activities, etc?
3.
4.
How can a more efficient pattern of
health care activities be developed
withing the specific areas being
supported by hospitals?
How can hospitals positively influence
developments in other parts of the
health osystem, including the training„ of
auxiliary health personnet, the activities
of peripheral health units, the provision
Conducting and Supporting Health Services
Research
1.
Which outstanding problems in the
health system could most benefit from
research supported by hospitals?
2.
How can hospitals be actively involved
in health services research; and
especially at the lower levels of the
system?
3.
How can health services research be
included in training programmes
conducted by hospitals?
4.
How can participatory research be
organized and carried out?
5.
What is the hospital’s role in the
evaluation of cost effective health
technologies?
It has become almost trite to recognize the
existence in today’s world ol an interrelated
set of problems which together constitute a
global crisis. In one way or another, virtually
everyone now alive is feeling the effects of
that crisis. Of course, the poor and weak —
and especially chose in the Third World —
feeling them
them most
most painfully.
painfully. As
As aa
are feeling
■>
■f
.•ement of
pervisory
?
I goal of
, how will
g decades
^articular
nctions, .
ffing?
i between
to bring
r Health
raining of
•levant to
, the new
<c role of
avourable
aviour on
s toward
l of new
:o directly
lospitals?
linked to
an power
ontext of
ures and
consequence, and despite their weak
position, the poor are raising ever more
powerful demands for more just and
equitable social and economic relations,
both between and within countries,
communities and families. History seems to
teach that although the road to greater
justice and equity may be long, it does in fact
have an end.
The need to respond to the just demands of
the weak is no less great in the area of health
than elsewhere. In fact, it is in the field of
health that some of the most important
demands are being raised and where some of
the most important progress could be made.
A challenge has been offered to the leaders
of medical practice, teaching and research to
use their powerful political and technical
strengths in support of the great struggle to
achieve ‘health for all by the year 2000’. This
medical leadership, if imbued with the best
values of medicine as they have come down
through the centuries, could penetrate the
community — and especially the political
leadership of the national community —
with those values and the scientific strengths
that go with them. This could represent a
massive contribution to both justice and
good health which may, in fact, in their
wider social and community senses, be one
and the same thing.
i Services
kJ
is in the
lefit from
als?
involved
ch; and
Is of the
;carch be
gra ninics
earch be
e in the
? health
gnize the
errelated
istitute a
virtually
effects of
weak —
World —
y. As a
f
’
* ‘A-
STATEMENT BY DR H. MAHLER
DIRECTOR-GENERAL, WORLD HEALTH ORGANIZATION
for the
INTER-REGIONAL MEETING ON
STRENGTHENING DISTRICT HEALTH SYSTEMS
■
•
Harare, Zimbabwe, 3 August 1987
Excellencies, ladies and gentlemen,
1. I should like in the first place to thank the Government of Zimbabwe for hosting this
important inter-regional meeting which is the first of its kind devoted almost exclusively
to issues of health development in districts.
2. It is an honour for me to welcome all of you on behalf of the co-sponsors (Christian
Medical Commission, Danida, UNDP, UNICEF and USAID). It is very encouraging to note the
large number of participants, the majority of you representing your countries but, in
addition, many representing international and bilateral technical assistance agencies as
well as nongovernmental organizations and training and research Institutions. This serves
to underline the fact that the issue of strengthening district health systems is a matter
which all of us must support vigorously.
3. In every liberation struggle there comes a time to re-examine tactics, redefine
targets and take stock of the ability of the troops to achieve the final victory.
4. For experience shows, Mr Chairman, that the fight for freedom is long drawn out and
must be fought on many fronts.
5. Even where commitment to achieving the final objective is total, and where the moral
values underlying the struggle cannot be challenged, except by cynics, the very nature of
the struggle itself, the hard, grinding slog, year after year, and the difficulty to
demonstrate that the war is being won on every front despite the unmistakable pointers of
periodic gains - all of these whittle away at the determination to win.
6. It is my judgement that the struggle in which all of us here today are active
combatants - the struggle to liberate mankind from the burden of unnecessary ill health has reached that inevitable
phase when
*~ /
* i we must remobilize for the final push towards
Health for All.
I '
• 7. It is not by accident that I make these remarks here in Zimbabwe. I make them
• precisely because we are in Zimbabwe and because we can all be inspired by the example of
t1
« ^Aour hosts whose experience has demonstrated to the world that the long drawn out fight for
w
...
♦ A
' *■*
/^liberation can be won in the face of the established status quo and a constant undermining
«and misrepresentation of the moral basis for the struggle.
Tqn years since Alma-Ata
' '
' *•
- ‘
.
r
O1A
•L
During the last fifty/ years or so, individual countries and WHO have become
increasinglyr aware <of the deficiencies of the health strategies they have been employing.
These
sometimes
been based
-vjr-have
--- ----on erroneous
concepts. One concept is that associated
ittf the idea of ’centres of excellence’, whose effects - contrary to the rhetoric • manifestly fail to ’trickle down’ to the rest of the system. AAnother concept adopted in
communicable diseases byJ means of
,th# SQs and early 60s is the tackling- of single
time-l/mited ’vertical campaigns’, that were inordinately expensive and failed to tackle
the?wide grange of health1 needs felt by the people. Even the technocratic strategy of
basic.fteklth services of the late 60s and early 70s, proved to be an insufficient response
k ’•
*
•>»
page 2
to the problem, out
Out or
of tnese
these uissatisractlons
dissatisfactions with the past was born the concept of
primary health care, adopted by the World Health Assembly after the International
Conference on Primary Health Care at Alma-Ata in 1978, as the approach through which the
world’s major health problems can best be tackled in order to achieve the goal of Health
for All by the Year 2000.
9. So what shape are we in after ten years of struggle?
the final push, towards achieving our goal by AD 2000?
Are we fighting fit, ready for
4
10.. The Health for All concept has definitely spread rapidly to all countries as a health
conscience movement far beyond the expectations of those that were at the Alma-Ata
Conference.
11. BUT the worsening economic situation in recent years in most developing countries, and
the adjustment policies that have been instituted by many governments have adversely
affected health programmes to the extent that in some situations the challenge appears to
be slowing the deterioration.
12. Nevertheless, impressive progress has been made in improving health status as measured
by various indices such as infant mortality rate in practically all countries, BUT (why
must there always be a BUT?) some countries, and groups in need within all countries,
still lag far behind the acceptable.
13. Yes, political commitment in words to improving people’s health is high BUT the
allocation of resources still remains heavily in favour of urban, hospital-based medical
care.
14. Yes, coverage with immunization, drinking water, maternal and child health care is
steadily increasing BUT in a number of countries hunger and malnutrition are on the
increase because of inequitable food availability, rapid population growth and adjustment
policies which make no provision for protecting the poor and vulnerable.
15. Yes, literacy rates are improving BUT the literacy gap between the sexes is widening
at the very time when awareness of the critical importance to health of adult female
literacy is at an all time high.
16. Yes, progress has been made BUT some of the fundamental principles of primary health
care still remain mere rhetoric in too many countries, Take one of the pillars of primary
health care, namely that of intersectoral action, Here, the synergistic effect of better
nutrition, better sanitation, better education, better housing, as well as better
essential health care, is all too often forgotten in favour of a concentration on reducing
mortality from a few specific diseases. Take another pillar of primary health care,
namely community involvement. Here, quite insufficient progress has been made in enabling
people to take their health into their own hands. In all countries the nature of the
prevalent health problems is such that many essential activities can be undertaken by
ordinary people in their own homes; but in spite of the over-whelming evidence of the
need for health workers to inform people about what is important for their health and
impart to them skills they are capable of applying themselves, conventional
over-medicalisation remains an obstacle to health in many places. Indeed, in most
countries community participation means the execution by volunteers of tasks planned,
defined and directed by health workers and, at best, sanctioned by the local
administration.
•»
District health systems
17. Mr Chairman, in my opening sentence I referred to the need for a re-examination of
tactics, of the methods and procedures through which health for all strategies are being
implemented•
)
i
page 3
18. The recent evaluation of their national strategies by some 90 per cent of WHO’s Member
States, in addition to the facts I have just quoted, brought to light with dramatic and
sobering clarity one particular fact about our tactics which was already known to some
extent but which had failed to attract the attention it deserved. It is that the greatest
obstacle to achieving health for all is weakness in the planning, organization and
management of health systems, particularly at the district level.
19. Although the failure to fill the organizational gap at the intermediate level of
national health systems has much more serious consequences in the poorest, least developed
countries, its negative impact can also be felt in the developed countries where, all too
often, health systems remai’fi geared to reacting to patients when they turn up for medical
repair care rather than taking active measures to keep people healthy so that they turn up
as patients less often.
20. I make that point to strongly emphasize that the problemi we are required to face up
is the need to set in place health systems based on primary health care.
to, everywhere,
(
21. That said, it is those who can afford to suffer least who continue to suffer most
because of the inability to mobilize and coordinate, on a sustained basis, all the
potential health-enhacing resources which every nation has at its disposal. I refer to
all the institutions and individuals providing health care in a district, whether
governmental, social security, non-governmental, private, or traditional, as well as
ordinary people’s self-care in their communities and the health-related activities of
other socio-economic sectors.
22. It is this interacting complex of services and facilities from village health post to
hospital and of people from village leader to district education officer, from community
health worker to public health nurse, etc. which constitutes the district health system.
this
But the challenge is how to iturn
--- —
— district
-- 1- ' health system into one which is truly based
on rprimary health care so that it can function to full effect. Some tough decisions will
need to be taken, some key problems must be tackled because they simply will not go away.
23. In this respect the first fact to> be made clear is that the creation of strong
health care cannot and must not be left to the
district health systems based on primary
i
The
effectiveness
of
district
health systems will always depend on the
districts alone.
extent of support from the national level.
24. Most importantly this includes a fair and sustained allocation of resources. Thus
ensuring equity in health and health care between districts must be a major responsibility
of the national level. This clearly implies the need to tackle, head on, the issue of
resource allocation. It is a sad but unchallengeable fact that most countries have made
deplorably little headway in this regard. As always there are a few exceptions, one of
which is Zimbabwe, which has successfully redistributed a considerable proportion of the
funds previously allocated unfairly to two hospitals.
J'
25. The second challenge for the national level is decentralization.
decentralization, Central to this
■issue
delegation ul
of decision-making with respect to the use of
the resources that
issue
g
XbSUe is the
U11C ucxcgauAwii
Vf districts have at their disposal., This is right at the heart of political debate in many
district health systems will make an impact on
. * '> countries. Let us not pretend that
th
people’s ability to lead economically and socially productive lives if they only retain
the' role of post offices through which national authorities despatch directives to be
implemented normatively on a nation-wide basis, irrespective of the epidemiological and
operational variations which exist from district to district.
A
'let I* submit
that if we all take our collective goal of Health for All as seriously as we
_____
* say*we
do,
a
most
critical tactic which countries would do well to consider is to focus
say* we do,
1 -C m
* ztheir limited
resources locally on local problems through strong district health systems
based on primary health care.
1
<
«
*
P'
4
I
page 4
Mobilization of local resources
27. However, a change of tactic towards support for targetted local action can only bring
good results if all resources, funds, manpower, supplies and equipment are mobilized and
rationalized. This is a particularly important caveat at this time when national health
systems are chronically underfinanced and subject to gross inefficiencies in resource use.
*
•4
28. In many developing countries the ratio of health expenditure to gross national product
is not even constant, but declining, whilst the ravages of inflation and population growth
further erode the real expenditure on health per capita. In such a critical situation the
need to utilize every cent effectively becomes a critical necessity BUT, (there’s that
word again) precisely because of weak organization and lethargic management in districts
we see great wastage of available resources and a failure to mobilize and utilize
potential resources such as the efforts of people themselves on their own behalf.
29. Poor horizontal management of a broad range of primary health care programmes in
districts often co-exists with excellent vertical management of special programmes
resulting in loss of opportunities to do more with the available resources. The
concomitant inability to mobilize and rationalize the efforts and potentials of
non-governmental organizations, of community participation and of other health-related
sectors adds to these lost opportunities.
30. As if that were not enough, the impact on the morale of the front-line health workers
in their health stations, health centres and district hospitals provoked by chronic
neglect and poor conditions of service is such as to raise the question of whether or not
many district systems are making any contribution at all to the health and well-being of
the people for whom they are supposed to be responsible.
Fit to fight?
31. In many opening remarks I referred to the need to take stock of our ability to achieve
the final victory of Health for All. Are we fit to fight?
32. It seems to me that the answer is not a resounding Yes’. Some of us are doubtless
suffering from battle fatigue and it seems that all of us must do more, much more, to
improve the morale and the capabilities of our front-line troops.
iLuuele&s, I am convinced that we know a good deal about what to do. We know that
33. Nevertheless
we must <adopt the tactic of rehabilitating and building up our district health systems.
We know many of the obstacles which confront us in doing that, yet we also know something
about how to overcome them. We know where to mobilize and rationalize resources, however
meagre, for the struggle ahead. We recognize the paramount importance of motivating and
re-orienting all health workers, families and communities to primary health care.
34. For those many problems which still remain to be overcome let us be bold and adopt the
approach of learning-by-doing, through the systematic and practical application of health
systems research in districts.
35. Finally, and above all, let us all share our concrete experiences, as in this meeting,
for these may prove to be amongst the most precious resources at our disposal.
WHO support
36. Mr Chairman, ladies and gentlemen, your WHO remains steadfast in its commitment to
support you to build up strong district health systems based on primary health care.
L
r
J*
page 5
37. I humbly submit that your WHO has already created most of the necessary tools to
cooperate with countries to initiate and maintain district action programmes. However,
with the exception of a few countries, many of which are represented at this meeting, such
an action programme has not yet penetrated far beyond the central conceptualizing level.
We shall need to be able to do that, and to document the operational process in detail in
a few districts in each specific country setting.
I see four principal possibilities for WHO support.
*
*
38. First of all, I envisage a strengthening of WHO support for research and development
in selected districts as a means of finding practical solutions to difficult operational
problems. Linked to that is the pressing need of focusing WHO country budgets on health
systems research designed to boost development of district health systems.
2
39. Secondly, I envisage support for country-wide action for district development. This
might include technical support for the development of national strategies and plans of
action for district strengthening. It could also comprise support for improving the
planning, management and monitoring of operational procedures for districts, including
integration of individual programmes, training and reorientation of health personnel,
intersectoral action, selection of appropriate technologies.
40. Thirdly, I envisage information support to the promotion of district health systems
through learning material relating inter alia to training, leadership and team
development. Exchange of information about country experiences in developing strong
district health systems will form an important part of this information support.
41. Finally, I envisage WHO support through vigorous mobilization of additional human,
technical and financial resources for strengthening district health systems based on
primary health care. The presence at this meeting of representatives of important
multilateral and bilateral agencies and of a number of training and research institutions
is evidence of increasing interest in strengthening health infrastructure development in
districts as a means of boosting the effectiveness and efficiency of the Health for All
and primary health care implementation.
42. Mr Chairman, ladies and gentlemen, at this historical juncture of your WHO, I can
think of no better tactic of mobilizing for the struggle towards our goal of Health for
All than a declaration by all Member States of their intention to increasingly commit the
bulk of their national and external health resources to the establishment of strong
district health systems based on primary health care.
43. No words could match such a response to that nagging challenge which has pursued us
all since the Declaration of Alma-Ata, the challenge to put our money where our mouth is I
**********
4J
4
41
*
fl
4
DECLARATION OF HARARE ON STRENGTHENING DISTRICT HEALTH SYSTEMS
BASED ON PRIMARY HEALTH CARE
At our meeting here in Harare a mere twelve years before A.D. 2000, the
date set for achieving the goal of Health for All, we strongly reaffirm primary
health care as the means to achieve that goal.
Despite impressive progress in implementing primary health care in many
countries, weakness in planning, organization and management, particularly
in districts, represents one of the greatest obstacles impeding health
development. This fact emerged from an evaluation conducted by 90 percent
of WHO Member States.
We are convinced that effective intensification of primary health
care depends on comprehensive action based in well-organized district
health systems , as called for by the 1986 World Helth Assembly, j^ith increasing
concern to ensure equipty and the sustainability of the impact of accelerated
programmes on priority health problems, we are convinced that the district
provides the best opportunities for identifying the underserved and for integrating
all health interventions needed to improve the health of the entire population.
A district health system is taken to mean a more or less self-contained
segment of the national health system which comprises a well-defined population
living within a clearly defined administrative and geographical area, either rural
or urban and all institutions and sectors whose activities contribute to improved
health.
We believe that the community and all sectors, including the health sector,
B [s' •
need to come together for the effective strengthening of district health systems,
through vigorous implementation of the following points for action.
DEVELOP A DISTRICT PLANNING PROCESS to define objectives and set targets
in each district with emphasis on those families and communities most at
risk.
h
2
STRENGTHEN COMMUNITY INVOLVEMENT by creating appropriate
mechanisms for providing support and increasing self-reliance
by strengthening their knowledge and skills in solving their
own health and development problems.
*
PROMOTE INTERSECTORAL ACTION by creating mechanisms to give
health concerns higher priority on the agenda of district
development and helping each sector define their role in health
activities.
*
DEVELOP DISTRICT LEADERSHIP for primary health care through orientation,
training and continuing education of key individuals from all
walks of life.
*
MOBILIZE ALL POSSIBLE RESOURCES for heatlh development, exploring
further the role of financing through user-charges, social security
and pre-paid schemes, and making better use of resources available
from communities and non-governmental groups.
•k
ENSURE SUSTAINABILITY by integrating into the district health
system and improving the basic management skills of health personnel.
★
REDEFINE THE ROLE AND FUNCTIONING OF HOSPITALS within a district
as integral parts of the district health system.
•k
USE HEALTH SYSTEMS RESEARCH as a tool for solving problems of the
district health system, including financing and resource allocation
and to answer the need for health develpp^nt networks to conduct
situational analyses and field studies.
★
ADOPT NATIONAL POLICIES which provide for necessary support to districts
DECENTRALIZE financial management as appropriate to encourage
-- -
flexibility within districts in adapting national policies for
use according to local priorities.
*
resource
ENSURE EQUITY BETWEEN DISTRICTS by allocation of national resources
on the basis of need.
4
3
Although communities and nations will naturally take responsibility for
the above action, we would also:
ENCOURAGE THE MOBILIZATION OF INTERNATIONAL^ RESOURCES in support of the
implementation of district health systems based on primary health care, action
research and development, and exchange and dissemination of information.
National, regional and global collaboration in this effort^will avoid wasteful
duplication and ensure that support is provided for priority areas, Such support
should promote national capabilities.
3*)4-
CAHP-211.
’ Uournal of Christian Medical Association of India.
November 1973 pp. 468 - 472.
HOW MUCH OF A HOSPITALrS WORK COULD BE DONE BY PARAMEDICAL WORKERS?
Helen Gideon, MD
Christian Medical Commission,
World Council of Churches,
1211 Geneve 20, Switzerland.
(Paper from Bangalore Workshop conducted in April 1973 for
the Orientation of Medical Officers and Nursing Superintendents
for Community Health Care),
Summary
Analysis of 1032 outpatients and 681 inpatients for eight mission
hospitals in six states in India showed that 48% of outpatients and
44% of inpatients would probably not have needed to come to the
hospital if they had been treated or advised earlier by a paramedical
worker.
Material and Method
Hospitals sending delegates to a community health workshop were asked
to send a list of inpatients for one week and 1,000 consecutive first
attendance outpatients by age, sex and diagnosis. The object was to
get the participants of the workshop to analyse these data to get an
idea of what percentage of patients need not have been admitted to the
hospital if health education, advice, preventive care or simple treatment
could have been given to them earlier. Also, what percentage attendance
at OPDs was really necessary either for prevention or treatment.
It was decided that the patients be categorized into ’Preventive’ (p)
and ’Non-Preventable ’ (NP). Preventable, where admission and OPD
attendance could have been prevented if care had been given and accepted
earlier. Non-Preventable, where admission or OPD attendance was required
for treatment. Before this exercise could be given to the participants,
the workshop leaders did a ’test’ analysis. A careful look at the lists
soon made it clear that patients could not be divided into these two
categories. For instance, how would one categorize those who came for
FTND (full-term normal delivery) or ’New Born’? or cases marked NYD (not
yet diagnosed)? or those who came for tubectomy? Could a threatened
abortion, febile convulsion, eclampsia have been prevented? Unless a
decision could be made on such diagnosis, the analysis could not proceed.
Consideration had also to be given to the inconsistencies that were bound
to occur with each participant’s interpretation of what could be called
’P’ or ’NP’.
With this very real problem it was decided to have a third category which
was termed ’Special’. This category included all doubtful diagnoses,
FTND, new born, etc. Three leading physicians took the lists and marked
each patient ’P’, ’NP’ or ’S’,. Careful attention was paid not to
overweigh the preventable cases, For the OPD lists it was decided that
every fifth case out of 1,000 be' analysed, The following list serves
as an example of the classification in each category:
-2-
♦
-2-
INPATIENTS
Admission probably
unavoidable.
Admission avoidable,
had simple care been
given earlier
'P'
Obstetetrical and
other unclassifiable
diagnoses.
Upper Respiratory
Infection
Pull-term normal
delivery
Pneumonia
Septic Abortion
Abortion
Asthma & Bronchitis
Abscess
New Born
Heart Diseases
Parasites
Tubectomy
Pyelonephritis
Pulmonary Tuberculosis NYD
Diabetes mellitus
Amoebiasis
Delivery requiring
Caesarean or forceps
Typhoid Fever &
immunizable diseases.
Hansen's Diseases needing
admission
Antepartum Haemorrhage
Gastroenteritis
’NP’
Cancers
'S'
Accidents & Fractures
Malnutrition & anaemia
and related infections
OUTPATIENTS♦
Hospital outpatient
attendance, probably
unavoidable
’NP'
/.
Hospital outpatient
Obstetrical,
attendance, avoidable unclassifiable
had early community
care been given
'P'
’S'
Diabetes
Kwashiorkar,
Antenatal
Malnutrition &
associated infections
Cancers
Abrasions
Fractures
Anaemias & general weakness
Sterility
Myalgia
Hypertension
Gastroenteritis & Diarrhoea
Allergies
Hookworm & other Parasites
Epilepsy
Discharging Ear
Patients & Surgery
Urinary Infections
Check-up
Upper Respiratory Infection
Hyperacidity
Immunizable Diseases
Scabies•
-3-
- 3
The following table lists the hospitals from where data was obtained.
TABLE 1
Name, location and size of hospital; number of one-week inpatients;
number and percentage of patients analysed*
• ; J -.1
Beds *
No;
analysed.
No. not included
in analysis ’S1.
Admission
date*
No. of
patient s
(1 week)
1-8 Sept.
1972
138
68
70
Holdsworth Memorial
Hospital
Mysore City.
280
CSI Hospital
Bangalore
200
?
110
79
31
CSI Hospital
Woriur
Tiruohy 3
Tamilnadu.
52.< 11-17 Feb,.
1973
30
21
9
19-25 Mar.
19 73
52
30
22
Mohulpahari'Christian
Hospital
PO Mohulpahari
Bihar.
Holy Cross Hospital
Kottayam
Quilon
Kerala.
120
250
?
196
163
33
160
3-11 Feb.
1973
52
26
26
115
26 March
19 73
192
141
51
350
17-23 Feb.
1973
189
$
153
36
Total
959
681
278
Percentage
100
71
31
Creighton-Freeman
Christian Hospital
Mathura
Uttar Pradesh.
* Holy Family Hospital
Delhi.
** St.Joseph Hospital
Dindigul
Tamilnadu.
* One day only
** Not by age and sex, included only in totals
Participants worked in pairs, analysing the material by age, sex, ’preventable’,
’non-preventable’ and ’special’. As each pair completed the analysis, the
information was called out and recorded on a blackboard and percentages were
calculated.
The bed strength of these hospitals varies from 52 to 350 beds; the total number of
inpatients for one week for each hospital (except Holy Family, Delhi) was 959; 681
or 71% of these have been analysed.
-4-
4
TABLE 2
Analysis of 681 patients (by age and sex) admitted during one week for
conditions defined as ’preventable’ and ’non-preventable’ (’P’ and ’NP’).
2.1
UNDER-FIVES
Males
2.2
No.
%
No.
’P’
’NP’
19
11
63.3
36.7
16
6
Total
30
100.0
22
N>.
%
i ’NP’
18
19
48.6
51.4
'‘Total
37
100.0
$
72.7
27.3
35
17
32.7 j
100.0
52
100.0
Females
Total
No.
%
Nt.
%
No.
%
’P’
’NP’
34
28
54.8
45.2
61
66
48.0
52.0
95
94
50.0
50.0
Total
62
100.0
127
100.0 189
100.0
I
~7
67.3
15-44 YEARS
Males
;
45 + YEARS.
Total
No.
2.3
5-14 YEARS
2.4
Females
2.5
SWURY ANALYSIS
Irrespective of Age, Sex
No.
%
28
81
25.4
74.6
! ’P’
; ’NP’
301
380
44.0
56*0
Tetal 109
100.0
Total
681
100.0
’P’
1 ’NP’
No,*
J
__ I
* [
al^a«?lysiS inclu^es I53 patients of the Holy Family Hospital in Delhi and
191 of
~ ~ St.
\ J°seph’s in Dindigul*, as data from these hospitals were not
available by age and sex.
Notes
As a result of some corrections, these figures vary slightly from
the handouts at the workshop.
Summary of Table 2
Of 681 inpatients:
67.3% of patients under five years were preventable admissions
48.6%
50.0%
25.0%
I!
n
n
it
ii
5-14
15-44
over 45
It
t!
It
tt
»»
II
It
tl
•t
It
It
ft
44.0% of total patients 9 regardless of age, were preventable admissions.
These figures would have been considerably higher if more information had been
available in the diagnosis as was listed.
5
11 OUTPATIENTS.
Of the eight hospitals, only four sent lists of 1,00d conseiutive first
attendance outpatients by age and sex and diagnosis. Three hospitals sent
grouped diagnoses which were difficult to analyse. In all, it was possible to
analyse 4^331 outpatients; of these, every fifth case was considered. The
results were as follows:
TABLE 3
Analysis of selected 1,032 outpatients from hospitals by age and sex
and.by conditions defined as ’preventable’ and ’non-preventable’ (’?’ ad
(’P’ and ’NP’).
3.1
3,1
Females
Males
!____
! * p'
j 'NP’
Protal
No.
No.
J
No.
J
80.3
19.7
41
10
80.4
19.6
94
23
19.6
66
100.0
51
100*0
117
100.0
I'NP’
49
21
I Total
i
70
100.0
I
’P’
’NP’
i
Female
Total
J
No.
No.
70*0
30.0
I
15-44 YEARS
Male
I______
80.4
3.3
No.
’-P’
Total
53
13
5-14 YEARS
3.2
7
I
UNDER-FIVES
J
No.
131
132
49.9
50.1
92
155 '
37.3 223
62.7 287
43.7
S6.3
263
100.0
247
100.0 510
100.OC
j—'11
Total
45 +
3.4
YEARS
Jki
S1MMAr}*A^ALY§I^ top) _
No.
.p.
■ 'NP*
I Total
24
~ <4..
23.•
’NP'
~“495
537
4.701"
52.0
| Total*
1 ,032
100.0
61
105
100.0
* For one hospital, data by age and sex was not available.
have been included in the total.
Summary of Table 3
jC
These 60 patients
Of 1,032 outpatients:
80.3% of patients under five did not need hospital OPD care
it
If
ii
II
it
tt
II
70.0% ii
5-14 yrs
I!
ti
II
II
n
ii
If
ii
43.7%
15-45 yrs
tt
n
If
n
it
If
22.8% II
over 45 yrs ”
48.0% df total patients, regardless of age, need not have attended OPD.
-6-
-p'
■'U
w
6
CONCLUSION
j
These data should not mean that hospitals can be done away with. The
The
figures are presented with the hope that hospitals may find it possible to
reorganise their services, fso that
J’ 1 highly
’
‘
experienced
doctors, specialists,
and sisters are n«,t forced to waste
- - - their
-1----. .time
- -- j on work that can be done by
others.
If auxiliaries could be trained, given simple standing instructions on what
to treat, what drugs to use, what to refer, then almost half the hospital
work-load could be reduced. If auxiliaries Are not available, it may be po
1
possible to train and use school teachers or girls with a high school
F
education to work in their own villages, with supervision from the hospital V
staff.
Such reorganization will:
a)
give the doctors and specialists more time;
save hospital funds, facilities , beds, drugs and the time of the
supporting staff;
c)
develop responsible paramedical staff; ’
d)
make it possible to serve greater numbers of people, as time of
personnel and funds will become available;
e)
save family disruption caused by admissions that could be prevented;
f)
save the time spent at outpatients, whicli patients can use to earn a
livelihood.
The advantage listed seem obvious. At the same time one can visualize the
problems as ociated with reorganizing services, e.g., for a while the
hospital income will drop due to prevented admissions. It_ may
u be that
admissions will increase again as patients needing treatment are diagnosed
in the community. There will be problems of retraining the staff to fit
into the changed pattern of service. Problems such as these and many others
will arise, but if the value of reorganization is realized and accepted, the
challenge of change vzill not seem insurmountable.
June 19*73'
1
*********
5.
>
Reprinted by permission by The Co-ordinating Agency for Health Planning,
C-45, South Extension, Part II, New Delhi - 110049.
6
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7
to
0
n 3-6
COMMUNITY
326, V Mein i .
India
Dr. N. H. ANTIA
F.R C.S.
Despite a ten-fold increase in doctors
and hospitals beds since Independence and
a hundred fold increase in the production
of drugs, 80% of our people continue to
have no access to any meaningful form of
health care. Communicable diseases like
malaria, tuberculosis, filariasis, leprosy,
gastroenteritis, measles, tetanus, polio and
whooping cough, for which there are
cheap and effective preventive and/or
curative measures, continue to take their
toll and some appear to be on the
increase.
The response of the medical profe
ssion and their associates, the Pharma
ceutical industry, the health bureaucracy
and politicians, is a further increase of
medical colleges, increased drug produc
tion, more sophisticated urban hospitals,
and lately, more medical research. Is it
that our health policy makers are not
aware of the problems that face the
majority of our people, especially those
in the rural areas ? Or are their priorities
related chiefly to the problems of the
elite minority who have both money and
power and of which they are a party, I
believe it is a bit of both.
At independence India was fortunate
to have the Bhore Committee’s report
which even today remains an unrivalled
document, with a clear analysis of the
health problems of populous and predominatly rural countries with limited financial
resources and a detailed prescription for
its solution. It recommended a decen
tralized Primary Health Care approach
which would reach out to every village
with emphasis on prevention, health edu
cation and involvement of the people in
their own health care. This was adopted
by our government right from the First
Five year Plan. Why is it then that we
have ended up with a predominantly urban
based hospital-oriented curative service
(notwithstanding our 5,600 primary Health
Centres) while China which adopted the
Bhore Committee’s approach at a much
later date has already surpassed the
targets which we have now set for
2000 AD. The causes for our failure
have been critically analysed in the
recent ICMR./ICSSR report “Health
for All : An Alternative Strategy”. It
boils down to a lack of will to look
after the interest of the majority of our
poor whether it be in health, education
or any other field, and China and Sri
Lanka have demonstrated that even with
limited resources and available medical
technology it is entirely feasible to provide
good health to all, provided the will is
there.
The almost entire emphasis of our
medical profession right from the day that
the student enters the medical college is
on personalised curative services based on
the existing western model, a model whose
medical problems and financial cost can
only be appropriate for the elite minority
of our country.
Since there is no immediate hope of
changing this pattern of services despite
proclamations to the contrary, is there an
alternative which could serve the needs of
the have-nots ? Fortunately, our experi
ence with a 35,000 rural population over
a period of 10 years at Mandwa across
the harbour from Bombay reveals that
much can be achieved even under the
existing circumstances provided an entirely
new approach is utilized.
Instead of the usual medical approach
of classifying diseases and health problems
on the basis of anatomy or pathology,
let us classify the problems according to
the skills and facilities which are required
for their diagnosis prevention and treat
ment. It opens up an entirely new
approach to the problems of health and
disease. One realizes that by far the
commonest problems of prevention and
also of diagnosis and treatment are
of a very simple nature and can
be tackled readily and often most effec
tively by the people themselves. This may
’TH CELL
iem farfetched, but if you think over it,
lost of the episodes of illness that even
ou and your family experiences in the
ome consist of minor ailments such as
oiighs and colds, fevers, aches and pains,
uts and bruises, boils and loose stools,
hese have traditionally been looked
fter by the family and cured with simple
ledicines or even herbs even though they
re being rapidly medicalized. Many of
lese can be prevented by a commonsense
pproach such as dieting, resting, boiling
f drinking water and teaching clean
abits to the children and servants,
kithough they may rarely represent the
nset of a more serious disease one does
ot have to run to the doctor except if
le symptoms persist or aggregate, The
ast majority are self-healing in nature.
There is another group of diseases
/hich are also fairly common and cause
lot of morbidity if they are not adequa
cy treated, but are seldom fatal. These
re also equally easy to diagnose and
nese are extremely cheap yet very safe
nd effective remedies for them, which
:an be used by the people themselves if
nade available, Scabies, worms, boils,
diarrhoeas and conjunctivitis are some
examples.
The third group consists of diseases
which are today the greatest killers and
crippiers in our country but strange as
it may sound, are relatively easy to dia
gnose or at least to suspect, and for
which inexpensive, safe and effective
remedies are available which after confir
mation of diagnosis can be carried out
by a community health worker if the
treatment regimen and drugs are provided.
Not only is this cheaper, but it also
ensures early diagnosis and regularity of
treatment for these are functions which
require more cultural affinity than scientific
skills. Let me illustrate this with a few
diseases which pose the most major
national health problems and fall within
this category.
Despite consuming by far the largest
chunk of our health budget for years,
malaria has once again raised its ugly
head and poses a national hazard. Why
is it that after almost eliminating this
disease-it has returned with a vengeance?
We blame the mosquito and the parasite
but if you would peruse the Ph. D. thesis
of Col. Pranab Datta, on his remarkably
detailed and frank systems study of this
disease in Gurgaon district which is only
next door to the Ministry of Health in
Delhi, you will realize that the malaria
programme succeded only when a rigid
almost military approach was undertaken
in the past, tn the present circumstances
where there is an absence of accountabi
lity at all levels, the failure in national
programmes in health or other fields is
due almost entirely to the failure in
implementation, namely a human failure.
We must accept the unpleasant reality
that no programme, however well planned,
has any hope of success under the pre
vailing conditions.
In the above circumstances, suppose
we place our faith in our people and in
their own self-interest rather than in
their exploiters who have their own self
interest whether they be politicians,
bureaucrats or professionals, is there a
possibility of tackling this problem.
Strangely enough, despite research and
medical jargon the control of malaria
boils down to the elimination of the
mosquito vector and of the parasite in
the human. It basically consists of treating
all persons who have fever with rigors
with a single dose of a cheap and
effective drug called chloroquine after
taking a blood smear, which if positive
must be followed by a further short
course of pills. If there is a high rate of
malaria in an area, measures must be
taken to find and remove sources of
mosquito breeding and spraying house
with insecticide. These tasks do not
require either skills or facilities that are
beyond the capability of any villager if
they are taught, encouraged, and provided
the drugs, slides and insecticides. They
can use the spray guns which they use
for their crops. There would be no
problem of accountability like it is for
the army of malaria control staff, for the
mosquito bites and the fever provide
sufficient incentive to the villager but
not to remote health officers and
technicians
The incidence of tuberculosis a
disease which is responsible for 10%
of all deaths continues to increase
despite a National Tuberculosis pro
gramme, free supply of drugs and 5600
Primary Health Centres; and despite
our hospitals and every urban street and
now even villages overflowing with
doctors. The reason is not difficult to
understand. Just imagine yourself as a
landless labourer in a village with a
cough of more than a few weeks
duration, with low evening fever and
with loss of weight and appetite. You
will probably wait in the hope it will
get better and only when much worse
seek the help of a local doctor for the
Primary Health Centre is too far away
and because the paramedical workers is
as usual on leave, not available or has
no medicines. The figures of the National
Tuberculosis Institute at Bangalore tells
us that 80% of the time you will come
home undiagnosed with a bottle of
cough mixture and probably with a
vitamin injection in the bargain. It is
only when you are seriously ill and
unable to work that you will borrow
money and go to a larger urban medical
centre when you will be diagnosed as
suffering from advanced tuberculosis. If
you are fortunate to be referred to the
District Tuberculosis Centre you will be
provided with a free supply of strepto
mycin injection and INH tablets. Your
only recourse is to go to the local doctor
for the injections three times a week for
which you will have to pay him or her a
few rupees which you can ill afford. No
wonder once you feel belter after a few
injections you stop your treatment (which
comprises of 90 injections) till you have
a relapse and are dubbed as an irregular
patient who has become drug resistant.
In the meanwhile, you have spread the
disease to your children who are further
malnourished because of the expenses on
your illness. Despite the official figures
you can well imagine why only a small
minority of patients take regular treat
ment. Are we surprised that tuberculosis
is on the increase in our country. The
response of the health service providers
is to increase the staff and provide
newer and more expensive drugs when
there is no reason to believe that these
workers will work any more conscien
tiously or that the newer drugs will be
consumed more regularly.
Instead, suppose we teach a local
village woman some elementary principles
of health and illness and among her other
duties to suspect persons suffering from
cough, low fever, loss of weight and of
appetite and have them checked for
tuberculosis by a doctor ; then teach her
to keep a stock of streptomycin and INH
and give the injections. There is every
likelihood that there will be a marked
improvement in early diagnosis and regu
larity of treatment. She will keep a watch
for early signs of the disease in contacts
of the patient and explain to the patient
in her own way the need to keep away
from the children and to properly dispose
the sputum. In actual fact our experience
shows that this is exactly what happens
if you take this approach and only a few
people need to be referred for complica
tions to the doctor.
Let us take leprosy which we glibly
propose to eradicate in the next 17 years
The problem is’’the? same compunded by
the natural desire of a person not to go
to a special leprosy technician or leprosy
centre for treatment because of the social
stigma attached to this disease. The
disease is easy to suspect. A pale anaesthetic skin patch or thickening of the
facial skin and of a few nerves ; after
confirmation by a skin smear the treat
ment used to be the taking a tablet of
Daspone daily for a few years. Yet
Leprosy has been on the increase despite.
17 years of a National Leprosy Programme
based on siich a cheap yet remarkably
effective drug. Now we blame drug resi
stance as a result of irregular treatment
and wish to enforce a much more expen
sive and complicated multidrug regimen
which is to be implemented under medical
supervision only. The occasional compli
cations of the drugs are magnified and
the treatment taken away from the hand
of the people so that a larger leprosy
empire can be built with no guarantee
that it will deliver the goods any better
than in the past.
Yet in our experience, trained village
omen identify cases much earlier because
»ey move regularly in the village without
irrying the stigma of a leprosy worker,
hey ensure regularity of treatment and
sip in the process of rehabilitation in
te village itself.
The same problems apply to most of
ur major health problems like gastroentritis, tetanus, whooping cough, diphtheria,
measles, filariasis and guineaworm. Why
aen this reluctance to take the people
ito our confidence and teach them to be
s self-sufficient as possible? Why are we
o anxious to appropriate their own legiimate functions and prevent them from
poking after their own welfare when we
,ave clearly demonstrated over 3 decades
hat we are incapable of solving their
iroblems. Is it because this would threaten
he medical empires we have built on
mman suffering? Or are we afraid that
>nce health is ‘demystified’ people may
luestion all the other myths we have
reated to keep them in a state of perpetual
lependancy? Is it not better to frighten
hem with the sight of the awful conse
quences that result from the failure of
prevention and early detection so that we
may then build equally awful hospitals
in our beloved cities to deliver Primary
Health Care to the influential and ‘chit
cases’ and terminal care to the poor.
While there is undoubtedly a need for
hospital facilities can these not be chiefly
in the form of small general hospitals
within each taluka or even sections of
the towns. 90% of all referred problems
can be solved by such hospitals within
the community with adequate provision
of general medical and surgical staff and
facilities of an operation theatre, X-ray
and pathology. They would be cheaper,
more accessible and a part of the commu
nity. They could not possibly be as
impersonal and inhuman as the unmana
geable monstrosities we have spawned in
the cities and towns for the benefits of
the medical profession. Having created
these unnecessary and unworkable disease
palaces we now seek to devise methods
to manage the unmanagable. Even here
we seem to be so bewitched by the
western model that we ignore the most
important reasons why our hospitals do
not function : namely, the cultural pro
blems of the doctors, staff and patients.
We try to ape the western hospitals with
our oriental culture with the result that
our institutions aie only caricatures of
their western counterparts. They are
socially unclean, leave aside medical
asepsis ; we happily accept 40% infection
in our cold surgical operations and our
doctors and students including the pro
fessors of microbiology regularly suffer
from diarrohoea, dysentery and infectious
hepatitis from the unhygienic good which
is cooked under their vision 70% ot all
equipment is not functional at any given
time (Ramachandran report).
Yet we continue to build larger hos
pitals with the latest specialities and
gadgetry at enormous cost and take pride
in our intensive care, renal dialysis and
microsurgical units, as also in the CAT
scan while the institution goes to the
dogs.
In fact we are falling between two
stools ; we do not have pride nor do we
work within the strength of our own
culture which is built on intense interper
sonal relationship and works best in the
family ; village and at the most at the
taluka level ; impersonal organisation
which has been evolved in the West. We
spend on sophisticated equipment whose
chief value under the present conditions
lies in the prestige reflected on its pur
chaser and operator. Even if it works, it
generally serves only to prolong the life if
not the agony of the aged. This, while
we have no compunction in neglecting
hundreds of thousands of children suffering
from pneumonia who could be saved with
a few tablets of sulphonamides or provid
ing the knowledge of oral rehydration for
combating the greatest killer of our
children for if they survive they may
grow up to be our new generation who
may well break their bonds to liberate
themselves and their country.
(Delivered at the 2nd Conference on
Hospital Administration.)
-
HOSPITAL MANAGEMENT PROGRAMME - COIMBATORE PRODUCTIVITY COUNCIL,
COIMBATORE - MAY 7-11, 1979
administration of out-patient and in-patient departments - I
by
Major General B MAHADSVAN PVSM AVSM FAMS (Retd)*
1. General
The general principles of hospital administration
are the same as those qf, administration in any other field, the basic
difference being in the realm of humanitarianism and in the ideal
and spirit of service. In hospitals, one is dealing with sick people
with many behavioural abberations, who need kindness and sympathy.
Unlike business houses and factories, the end product of a hospital
is not production of bolts, nuts, cars and other goods, but the
production of service - to the people, by the people.
In the past, hospitals were meant only for the
treatment of the sick. The present day concept, scope and philosophy,
has undergone a radical change all over the world, both in developed
and developing countries. The hospital of today has been accepted as
a social entity and a focal point in Community Health activities.
The
in its first technical report on "Role of Hospitals in
Programmes of Community Health11 brought out as early as 1947> gave
a very comprehensive descriptive role, namely that ,fThe hospital is
an integral part of a social and medical organisation, the function
of which is to provide for the population complete health care, both
curative and preventive, and whose out patient service reach out
to the family and its home environment, the hospital is also a centre
for training of health workers and for bio-social research.
Therefore, the modern concept goes beyond the
conventional idea of a hospital being a repository for the treatment
of the sick and visualises it as one part of a comprehensive
integrated system of health services, both of preventive and curative
medicine and as an institution devoted not only to in-patient
treatment but also to render ambulatory domiciliary care for the
community, including control of communicable diseases. So, one should
view the hospital organisation as an essential part of the health
service of a country. This, I feel, should be a fundamental thinking.
Further the term hospital should be broadly used to include hospitals
of various gradations - teaching hospitals, metropolitan city hospitals,
polyclinics, district and taluq hospitals, primary health centres
and mobile hospitals. However, in this talk of mine, I am confining
my remarks to the requirements of a general hospital in a metropolitan
town.
Hospital form the most costly part of a health
service programme in a community. It is, therefore, sound from the
economic point of view to do everything feasible to keep patients
out of hospital by reviewing the reasonable demand for inpatient
treatment. The hospital should be the Centre of a net work of
clinics and services functioning within the community itself and
regarded as a projection of the hospital’s activity beyond its
own walls and extending into the homes and work places of the people.
♦Director of Rural Health Services and Training Progrannnes
St John’s Medical College & Hospital
Bangalore 560034
2
:2:
In recent years, the centre of gravity of
a hospital has been shifting more and more from wards to the out
patient departments. Much of the investigation and diagnostic
practices that formerly necessitated admission to a hospital can
now be carried out in a well equipped out-patient department with
a saving of expense and avoidance of the disruption of family life
that hospitalisation causes. This is one of the means of keeping
a patient out of hospital to which reference has already been ■
made by me.
If the following extramural services based
on a hospital are well organised, the cost of medical treatment
can be reduced and much suffering prevented in a community, both
from the disease and economic points of view/i-,^;,r.- . ...
.
v
•
Y’.'
a) Promotion of health and prevention of-'‘disease
through antenatal and postnatal clinics, industrial
health and school health services
b) Link up with the local health authorities in
epidemiological work - case finding and immunisation
procedures. The local Medical Officer of Health to be
given a staff status for integrating hospital -and
local health authority services
c) Integrated maternal and child health services - social
obstetrics and social paediatrics
d) Routine and periodical examination of community for
prevention of chronic diseases such as rheumatic group and
cardiovascular diseases
e) Early detection and treatment of psychiatric illness
through a good OPD mental health service
f) Health education of patients and relatives in wards and OPD
g) Efficient medico-social case work to ascertain
physical,emotional and social aspects of illness
including follox* up
h) A good nutrition and dietetic services extending to
homes of the people
i) Provide facilities for training of medical, nursing
and health workers of all grades
j) Provide opportunities for research both in and outside
the hospital
k) Establish a close link between General Practitioners
and hospital work with particular reference to
diagnostic, x-ray and library facilities. A General
Practice Unit could be conveniently established in the
OPD
l) Function as a referral hospital under the regional
hospital scheme
..3
m) Organise Clinico-Social Case Conferences where General
Practitioners and Health Officers are invited to participate
in the discussions.
Out Patient Department
’
■
'
•
:..A;
Hospital facilities and medical and para-medical
help are perhaps the most over worked resources in our country.
There is scope for better utilisation of existing resources by
application of modem management concepts and techniques in many
spheres of hospital activity. Many hospitals in India and abroad
have reaped rich benefits by such applications in diet planning,
materials control, better ward utilisation and long range financial
planning. OPDs particularly in government hospitals which provide
an interface with a large number of patients, offer an unique
opportunity for better service and enhancement of hospital image,
through application of modern management technique.
The out patient department is the point of contact
between the hospital and the community. Many patients gain.their
first impression of the hospital from the out-patient department,
and it is, therefore, important if the patient’s co-operatipn is to
be obtained, that this impression should be a favourable one.
Bverything should be done to create an atmosphere of friendliness
and welcome. Although the’ lay out of the departments, the architecture,
its furnishings and decor do play a role, it mainly depends upon the
attitude of all members of the hospital staff employed therein. For
most people it may be a first visit to the hospital which could be
a frightening experience unless there is an atmosphere of reassurance f
an absence of red tape and formalities. The OPD (including the
casualty department) is a hospital’s shop window. Therefore, the
reputation of a hospital can largely be made or marred by its
impression upon the patient in the first few minutes after his
arrival•
There aro three aspects of out-patient work which
need consideration.
(a) linergencies and accidents (casualty department)
(b) Unreferred patients : TIn underdeveloped
' ’
1_
countries, the
hospital represents the only available
-------j source of medical
care. The OPD is, therefore,
‘
over crowded with unreferred
patients* Appointments cannot
--------- be made, patients are mixed
together, an jattempt
“
to impose rules fails before
such a huge attendance.
Ai> wcie
a position
years ago
---- . This7uwas
a position
years
in developed countries as well but as community care
has developed, unreferred patients are few.
In^developing countries, it should be the local
health plan , to. establish
localdispensaries within towns,
.
---which are iadministratively
' ’
linked with the main hospital
but physically independent. Only patients requiring^
specialist attendance should be referred to the OPD
of
SUGh
clinics have proud
great value in many countries and metropolitan
owns. Unfortunately people are specialist and hospital
J-ndQd and flock to the hospital even for minor ailments
SI1:,"
a°“
■
lor sucn I liter* clinics and levies a charge fn-r
+■ n
not be^tot nCheme °f establishinS out reach clinics may &
not be totally successful.
:4:
(c) Referred patients : That is to say, those that have been
sent by a general practitioner or peripheral health clinic
to the OPD of a hospital for consultation by a specialist
or for special investigations (pathological or radiological).
The primary role of an OPD is to provide specialised
services and facilities, not normally available to the .
General Practitioner, thus enabling him to institute
ambulatory and domiciliary treatment which is ideal from
the points of view of economy, preventing disruption of family
life and making available hospital beds for treatment of
more urgent cases. The OPD should also serv6 the purpose
for selection of patients for whom in patient treatment is
necessary, either immediately, in acute cases or by
appointment system when a bed becomes available. The OPD
should also play the important role as stated earlier
for follow up of patients discharged from wards.
A good OPD should function as a poly-clinic. The conventional
oomponents of an OPD are:
a. Consulting area (standard
^stanuaru consulting suite)
suiie;
b. Treatment area
c. Passage and waiting area
d. Minor operating theatre with required annexes
e. Diagnostic services area - Radiology, Cardiology and
respiratory diseases, laboratories, EJSG, Dental,
chiropody, clinical photography, endoscopy, medical
physics, day patients and recovery
f. Physiotherapy and occupational therapy
g. Administration and general service areas - Reception,
Medical records. Medico Social Unit, Administrator’s
office, pharmacy
Certain essential areas of operation only will be dealt
with in this paper.
The structural requirements of an OPD are conditioned
by the functions of the several parts of the department, which
in turn, depend upon the social and cultural characteristics of
the population to be served. 1^. must be remembered that the OPD
is one of the growing points of a hospital. With increasing
knowledge and scientific explosions, the practice of medicine is
changing very rapidly. OPDs should be planned in such a manner
that they are capable of permitting the growth of new specialities
with an increasing range of diagnostic tests and ’working up’ procedures,
on ambulatory patients. Therefore, an OPD needs to be planned with
a measure of adaptability in its internal arrangements and a very
substantial capacity for growth.
A centralised OPD should preferably be built horizontally.
This pennits extensions or contractions when required and avoids
movements of patients going upstairs and wandering all over, creating
confusion for the hospital staff. It may be more economical to have
vertical buildings linking the OPD with the pattern of ward design.
Vertical buildings, although compact, depend for movements on lifts,
stairs and ramps. They have limited flexibility. The building whether
horizontal or vertical should lend itself to easy adaptation and
expansion.
5
:5f
Fragmentation of any part of a hospital leads to wastage
of staff. In an OPD, consultation among specialists is frequently
required and hence out patient clinics should be grouped together
in one department. The OPD should be near a public read to be
easily accessible to patients, as some of them may not be very mobile.
It should be near the x-ray, pharmacy and pathology departments. Only
in the case of dental suites, opthalmology and orthopaedic clinics, would
special accommodation be required with provision for equipment,
fluoroscopy etc.
'
.
e
.. ...
Large waiting halls have become a thing of the past.
Some kind pf entrance hall or concourse is needed in which out patients
may be received and registered and from which they may be directed
to a small waiting room or space serving the particular clinic they
are attending. These subsidiary waiting rooms arc necessary to prevent
the corridors outside the various consulting rooms from becoming crowded
with waiting patients, this impeding circulation of patients. The
effectiveness of an OPD can be measured in terms of:
•a. The total average waiting time for a patient from
the time he enters a hospital till the time he
leaves after medical attention
b. The total time spent by a doctor with the patient
for diagnosis, treatment and education on
preventive medicine
g.
No. of patients treated
d. Cost of offering the service and the revenue
generated if any
e. Extent ofpatient satisfaction
f. Effectiveness of medical care
In our country particularly in government hospitals, the
appointment system does not work due to many obvious reasons. The
patients arrive in a random manner and wait in a queue in different
places. As the patients arrive for registration etc., unless the
capacity of servicing through the three main areas ie., registration;
clinic and dispensary, is balanced with the arrival of patients,
queues will build up. The length of the queue and the average waiting
time per patient are dependent on the balancing of capacity with' the
demands imposed upon it. In the absence of an appointment system,
the arrival pattern of patients cannot be approximated to a poisson
distribution, which is necessary for the application of the Queueing
Theory. Hence other methods have to be employed for better allocation
of resources to reduce waiting time of patients. In one hospital* study,
it was observed that a male patient spends on an average 85 minutes
waiting at various stages (registration 55 minutes and at clinic 27
minutes) to get 2 minutes, of doctor time for the examination^ For
a patient attending the x-ray and laboratory> the waiting time' was
.
195 minutes. By modifying the starting time of rogistration/clinic/
dispensary, synchronising the doctor time, availability with patient
arrival pattern, and opening up of .another registration • counter,
a reduction in waiting time at various stages was achieved. The doctor
was able to give five minutes service time per patient. The waiting
time of patients, particularly at the registration, wa^ used for
health education*
: 6:
The causes of delay in service causing bottlenecks
in an OPD, has been well summarised in the Porritt
-J Report of U.K.
a. Faulty appointment system
b. Waiting for registration
c. Delay in finding old notes
d. Patients losing their way
e. Making appointments for subsequent visits
f. Making appointments for special investigations
g. Delay in special departments - x-ray, pathology etc.
h. Waiting in the dispensary
i. Insufficient internal communications
j. Insufficient clerical staff, particularly receptionists
and unit secretaries
k. Insufficient and faulty instruments
l. Unpunctuality of patients and doctors
m. Waiting on examination couches
n. Inadequate information from general practitioners. So far
as India is concerned, the following may bo added:
o. General illiteracy
p. Queuing for minor or imaginary ailments as an
excuse for getting sick leave
q. Lack of free general practice service
r. Shortage of hospitals
s. Shortage of medicine, nursing and other technical staff
t. Importunity of the clients
u. General lack of ’self-help* tendency.
£
Attempts have been made to meet the conflicting
requirements of various specialities by establishing a standard
consulting suite with slight modifications to suit individual
requirements, privacy of consultation is essential even in underdeveloped
countries. The practice of simultaneously examining several patients
and taking their histories in the same room, albeit behind screens,
is very undesirable for both patients and most specialities. Nuffield
studies advocate that the design of clinical suites should facilitate
consultation and examination in an unbroken sequence based on the
principle of interchangeability. A flexible and most economic
arrangement would be to have a series of intercommunicating consulting
rooms. A consultant conducting a clinic uses one, two three or more
consulting rooms according to the nature of work, his speed of
operation and the number of assistants he has. The consulting room
need be just adequate to contain a doctor’s table and chair, a
patient’s chair, an examination couch, an instrument trolly and a
lavatory basin. In one corner should be a curtain on a rail behind
which a patient can undress and dress. While, one patient is dressing,
the doctor writes his notes, then moves into the next consulting room
to deal with the second patient, and so on. Time and motion studies
conducted on this pattern of consulting rooms indicate no waste of
consultant’s or patient’s time. Standard consulting rooms of this
type can very adequately serve most specialities. In India a size
of 12’ x 14* may suffice per consulting room. For teaching purposes
a larger consulting room to provide 400 sq ft would be necessary.
However, for ear, nose and throat, opthalmological
and gynaecological work, some modifications could be made. From
the nursing point of view also, this intercommunicting system
is economical. Every 2 or 5 consulting rooms can be served with
a nurse’s bay fitted with a bay and reagents for urine testing,
a desk for patient’s records and either a small steriliser or a
space for holding packaged, sterile instruments from the central
supply department.
.7
:7:
The minor operating theatre in the OPD should be
a simple type, for dealing with minor surgical conditions with diagnostic
procedures such as cystoscopy and sigmoidoscopy. A recovery room with a
bed is needed for patients to rest in for a while, until the pain, shock
or effects of the anaesthetic have passed.
X-ray, pathological and electrocardiographic
facilities need to be provided for special investigations. Patients
requiring such investigations should again visit the hospital by
appointment with the special department. Otherwise the work of the
department could be completely disrupted by a trickle of outpatients at
all hours. For instance, x-ray examination involving, contrast media
particularly, need special appointment of the patient and need the
personal attention of the Radiologist. With certain specialised clinics,
it will be possible to make arrangements for x-ray examination at the
time the patient sees the consultant — a straight x-ray of the chest
for the chest physician or of a bone or joint for the orthopaedic
surgeon. The same applies to electrocardiography in an ad-hoc cardiac
clinic with a technician and the cardiologist may be able to see
the tracing with the patient’s notes, without delay. With regard to
pathological investigations, the specimen (blood, urine etc.,) can
usually be taken at the time of request but the result is not available
until the time of the patient*s next visit.
An OPD depends for its success on the quality of
its staff more than upon any other single factor. All the clinicians
including the most senior members of the medical and surgical staff,
should play their part in the clinics of the OPD. In a teaching
institution, the OPD
the most important teaching area from the
points of view of good clinical material and teaching medical students the
art of practising medicine in a comprehensive manner.
The nursing side of the OPD should be the responsibility
of a well qualified and experienced nurse^ whose primaiy function should
be to see that the work in the various clinics proceeds smoothly.
Another important member of the OPD is the Receptionist
who makes first contact with the patient. Patients and their relative
can be exasperating people,asking all kinds of silly questions, but
they are often ignorant and frightened people (particularly in an
underdeveloped country) who must be treated with patience, sympathy and
understanding. A Receptionist should possess charm and be courteous in
dealing with such people.
Facilities for refreshments (canteen) should be
available in the OPD. Every attempt should be made to undertake health
education of patients and their relatives during any waiting period
in the out-patient department.
On Askin
the Right Questions
From the Voluntary Health Association of India
A/T ANY a hospital is hard put
1 to define its philosophy.
It does not have one. If it does,
nothing clear is written down. It
is only the minds of some of the
older staff.
No hospital can afford to con
tinue with vague assumptions
about its mission Every hospital
needs to discuss and write its
philosophy in clear terms and
publicise it. Again, after some
years it must revise and rewrite this document.
IMany
voluntary health care institutions
------ 3
in India which flourished years
back, are now limping, barely
managing to survive. They have
outlived their original purposes
and have become irrelevant to
the time and the place.
• There is an idea prevailing that people need hospitals urgently. So
build the hospitals, cure the sick and improve the health af the people.
Nothing can be patently more absurd.
Yet another idea prevailing is that the services rendered by health
care institutions are intangible
‘'
You cannot ‘"really measure them’\
This is equally absurd. And suicidal. It has generated much wishful
thinking, planning and hoping.
These silly notions avoid embarrassments, skirt searching qi'c.>tions,
and difficult answers.
Such questions and answers demand clear thinking on the part of
men who manage voluntary health care institutions. •
and society on the whole is becoming more sick and needier.
“providing health care” is now
connected with the economic
Fundamentally, what does development and well being of
the community. It is in the light
“promoting health care” mean?
of this new and different answer
What is the definition of
to
the question “what is health”
health?
that there is a trend towards pre
If health is understood to be ventive and community health,
Our philosophy is to serve the mere removal of disease, the and holistic health. This answer
the poor”, or “promote health mistakes of the past will continue sccms t0 make more sense too.
care”, or “cure the sick and the to be repeated by health care
needy . Such statements are institutions. The health of the Who are our friends ?
inadequate. They conceal. They people will continue to be un
This is related to the question
do not enlighten.
satisfactory. But if health is “What is our mission?” Often the
defined and understood in the
There are many ways of serv context of the individual’s social, top administration intent on
ing the poor, promoting health economic, physical, mental and “pulling the institution through”,
care and curing the sick and the spiritual well-being, the answer is interprets friends to be funding
needy. In fact, that is what entirely different. The philosophy agencies a thousand and more
voluntary and government insti and mission of the health care kilometres away. This leads
tutions in India have been institution is then wider. The frequently to unnecessary and
attempting for many years. The health care administrator has a curious behaviour on the part of
poor are still poor, the health of total set of new and different hospital managements — like
the populace has not improved, decisions to take. The task of new buildings; new specialities;
additional, sophisticated equip30
Vohintary Action
■
nicnt; c flor I
census and i
(whereas if i
jng health,
to decrease
number of i
Fortunately
cies have a
the fact tha
are not bein
plete answer
a consequen
old ideas r
longer flowi
Sometime
thought to b
tals or com
the coim ti
an other rai
unnecessa ry
all “what
think, if we
the Joneses’
as compcti
organisatioi
The conquestion,
would be, t
people in tl
and near
friends. It
the services
If the pcoj
institution,
that commi
What do ou
The expc
us that or
questions
targets.
needs felt t
community,
hospital. I
priority, f
housing, Jo
seeds seem
needs. So
institution
health” anc
July-Augus
census and number of surgeries;
(whereas if the hospilal is promot
ing health, it should endeavour
to decrease OPD census and the
number of surgeries and so on).
Fortunately many funding agen
cies have alerted themselves to
the fact that the right questions
are not being asked, and incom
plete answers are often given. As
a consequence funds for the same
old ideas about health are no
longer flowing.
it is tnese needs which have to
be catered to first Health will
have to take a back scat.
Our answer to the question,
“What do our friends need?” will
therefore change the role of the
health care institution to one of
social and community develop
ment, of which health is only a
part.
What do our friends value ?
Hence among them there is a
trend toward, community health,
towards more participation of
people so that they assume res
ponsibility f r their own health;
and attempts to integrate health
with economic development and
welj-being. lt_ is thus only in
response to some of the timetested traditions of people, that
there is now a movement towards
using local herbs and medicines,
and a healthy respect for faith
healing. It is in response to the
economic status of the commu
nity that health institutions have
continuously to explore ways of
lowering the costs of health care.
What do the people in the
community value most in a hospi
Som .'times the “friends” are tal ? The people in the commu
thought to be neighbouring hospi nity value trust and equality.
I hy health
tals or comparable hospitals in They value participation. They
sure them’'.
the country. This leads to
value their tradition, culture and
iw:h wishful
The affluent expect routine
another range of curious and
time-honoured customs. Any insticurative care from the hospital.
unnecessary behaviour for after
The poor of the community
([ucylioitSi
all ‘ what will the neighbours
Nothing
perhaps
provokes
more
expect
wisdom and solace from
think, if we do not keep up with
the
people
who manage the insti
the
ire
of
a
community
than
to
the Joneses”. Imitation (as much
the part of
tution.
The
latter constitute the
as competition) among service see a posh hospital coming up
majori/y.
Hence
it makes sense
organisations is suicidal.
when the problems of the. poor
to respond accordingly.
The correct answer to the are more basic — malnutrition,
;arc“ is noW
question, “Who are our friends?” hunger and unemployment.
Questions for the Future
;e economic
would be, the community. The
well-being °f
No dynamic institution can
people in the community around
tution
in
a
poor
society
which
is in the light
rest content once the above
and near the hospital are its
Tcrcnt answer
friends. It is they who arc using respects these values of the questions are asked and, the
aat is health"
answers secured.
the services of the organisation. people will probably have more <correct
-------- d towards preIf the people do ndt need the success.
Every management needs to
ttunity health,
institution, it need not exist in
Nothing perhaps provokes plan for the future—both the
. This answer
that community.
more the ire of a community in immediate and the long-term.
re sense too.
the long run than to see a posh The effective administrator and
What do our friends need ?
IM!
hospital coming up, when the the effective governing board is
3s?
The experience of the past tells problems of the people are more constantly examining “What will
us
that our answers to these basic—malnutrition, hunger and
o the question
be our philosophy and mission?
Questions have missed their unemployment. Worse still is Who will be our friends in the
tion?” Often the
targets. Health is not one of the the management of the hospital future — in ths next two years,
on intent on,
needs felt by the people in the which lives in total isolation from five years and ten years ? What
ution through”,
community, the friends of the the real problems of the sur- will our friends need? What will
to be funding
sand and more i j hospital. Health is not a high rounding community and conti- they value?’' The answers of
; priority. Food, drinking water, nues to believe in the myth of today are only valid for a limited
y. This leads
housing, loan facilities and good
nncccssary and
promoting health care.
time. Tomorrow's answers and
seeds seem to be more urgent
ir on the part of
tomorrow's requirements will be
needs. So if the health care
’ements — l^c
However, some enlightened different. New knowledge and
institution intends “promoting health professionals have identi
new specialities’
new experiences imply changes in
health” and “serving the poor” fied the more correct answers.
histicated equip
philosophy and our ways of
^ly-August 1980
Voluniavy Acti°n
31
n'eiitly- So
ihe people.
!
Of? /
I!
i
i Kdoing things. Refusal to acknow
ledge change and experience of
the past forebodes the decay of
the voluntary health institution.
Figure 1.
Traditional health institution.
Risibility <
resp' •ories of pc
categ'
health ne
to the
The multi
tO'the nurse
sionly some ex;
also the respi
voluntary healt
promotion of
care.. The hist
an(i charity h
pendency and
expectations it
great deal of
through health
____________
Tree care and c
•1 i
'
ed dependency
■W
i healthy expecta
i.taL;
Conclusions
The business of management
is to ask certain questions of
vital iimportance to the institution. The absence of such
questioning, and the answers to
these questions if any, can make
or break an health care institution, especially a iVoluntary
’
institution since the latter has
only limited resources.
Enlightened ppeople concerned
with health have■“ been asking
such questions, At the same
time the intention has been to
learn from past performance and
past ideas in health.
J
— no defined territory
— care for all who come
— priority on curative
— a little extension work
— sophisticated and excellent
medical facilities
Figure 2.
— specialised service
— little effect on total health
— not owned by community
— high cost of service
— healer (doctor) centred
New role of the health institution.
unlearning is
Only then wou
self-responsibil
acceptable.
Our concept of health before
asking the right questions is
Portrayed in Figure j. Figure ,
gives the picture after the possible
right answers. The new answers
imply a social and developmental
role for the health care institution.
It is possible that our answers
are incomplete or even wrong.
That is unavoidable. New know
ledge and new experiences inevita
bly erode into our past structures
•_ndL01d Ways Of doin8 things- It
is the task of effective managements continuously to anticipate
and plan for change.
Our emphasis has been centr
ed around the voluntary health
care institution, The bias is
intentional.
The reasons are
historical.
It is the voluntary health sector
which has pioneered many new
approaches in health care in
32
— defined community
— vertical range of services
— banking
— cooperatives
— farm facilities
— drinking water
— animal husbandry
— nutrition education
— youth clubs
— women’s clubs
— training of community health
workers
— MCH under fives
—- TB and leprosy
India. Being non-governmental
in structure, it has shown more
flexibility
and
adaptability.
Commitment
is high
(but
often mis-channelled because
of lack of questioning or inade
quate answers). It can be expect-
— school health
cure for the seriously ill
— liaison with specialised hospitals
community participation
— more patient oriented
appropriate technology used
— low cost drugs and house remedies
used
— greater effectiveness on the total
health and awareness of a smaller
number of people; Jong term effect
greater chance of spreading health
awareness
— holistic health
ed therefore that it would be
easier for the voluntary health
agency to pioneer in
community
health and development,
holistic health.
and
All this docs
need for hospi
tive care. There
who will requi
ised and need
care. But h<
longer take <
Small hospita
support to the
The priority c<
Health St
Achi
bl '■
If we look •
tical indicato
sector, the
Independence
impressive,
medical collet
in the immed
encc era.
Th
With this pioneering goes the
centres and c
ary health c
were none
outlay on h
Voluntary Action
July-August
responsibility of training new
categories of people, appropriate
to the health needs of the coun
try. The multipurpose worker
and the nurse practitioner arc
only some examples. There is
also the responsibility of the
voluntary health agency in the
promotion ol low cost health
care. The history of free care
and charity has promoted dependency and raised unhealthy
expectations in the people. A
great deal of time and energy
through health education for
tl
ilth
lity
1
Free care and charity has promot
ed dependency and raised un
healthy expectations in the people.
unlearning is
involved here.
Only then would the concept of
self-responsibility seem
more
acceptable.
I
sly ill
lised hospitals
pation
ited
idogy used
d house remedies
ess on the total
,ness of a smaller
long term effect
>f spreading health
iat it would be
voluntary health
er in community
velopmcnt, aI,nd
"
nee ring g°eS
Voluntary Act’011
All this does not preclude the
need for hospital beds and cura
tive care. There will still be people
who will require to be hospital
ised and need specialised medical
care. But hospitals need no
longer take our prime energy.
Small hospitals are needed as a
support to the community effort.
The priority could be lower,
■bn
21 Health Status —Plans and
Achievements
: we look solely at the statiskcal indicators in the
health
^ctor, the achievement since
^dependence has no doubt been
^pressive. We now have 106
P^dical colleges in place of 30
'Mheiimmediate
’
■ post-Independera. There
~
are. 5,400
f, C health
L—..!.
''“ires and over 38,000 subsidi*ry health centres where there
^Cre none before. Our rupee
Mlay on health has gone up
4m‘4'AiiglJS( 1980
with every Plan. National pro
grammes on communicable dis
eases and population control
have been initiated. Smallpox has
been eradicated. There are 28,000
leprosy beds and almost 43,000
TB beds available. Millions have
been covered by the immunisa
tion programmes. 24 per cent of
the 120 million eligible couples
have been covered by the family
planning programme, and so on.
What the statistics fail to point
out is something most people
working in the health care field
sooner or later become aware.
The health budget has never
exceeded 5-6 per cent of the total
Plan outlay. Of this, a major
portion has been utilised in the
building up
of sophisticated
medical colleges and training
doctors. Ironically, in 1978, this
country had half as many regis
tered nurses as doctors.
Over 45 per cent of the popu
lation are below subsistence level.
More than two-thirds of the
population have no access to safe
drinking water or basic Mother
In
1978 this country had only
half as many registered
nurses as
doctors.
and Child Health Care program
mes. Child mortality at places
is as high as 150
per 1000.
Malnutrition is common among
adults. It is formidable among
children. The rate of population
growth continues to be 2.5 per
cent in spite of the family plan
ning programmes. Malaria is
staging a comeback even more
deadly than before. There are
no statistitics available to show
the number of tuberculosis cases
that are now resistant to first line
drugs owing to lack of follow up.
A cursory glance at the dis
eases treated at any general hospi
tal will show that the majority of
cases are preventible in nature.
The root of the disease lies in
poverty, malnutrition, environ
mental decay and ignorance. In
such a situation how can our
health resources be spent to pro
vide at least basic health care to
the people ? After years of grop
ing and experimentation, it seems
to be amply evident now that to
be effective a radically different
method must be adopted.
The major health provider of
the country has all along been
the Government. Each Srate has
formulated its policies under the
broad guidelines of the Central
Government. Cities have muni
cipal health systems over and
above government ones. Hos
pitals are provided by big employ
ers such as the railways, police,
plantations, large industries, etc.
for their own employees. Cities
also have the benefit of the
private practitioner.
The voluntary and charitable
institutions providing health care
constitutes a significant part of
the total. Tn 1970, it was esti
mated to be roughly 22 per cent
of the health care system.
The Growth of the Voluntary
Health Agency
The voluntary institutions were
usually started to fill a need that
no other organisation took heed
of. Most of them were built by
religious organisations. Dedicated
and committed people reached
out to serve the needy. They
became aware of the needs of
the people and the fact that many
people had no access to medical
33
-
-.
'M
1
ip-
care. Charitable voluntary health
centres and hospitals sprang up
to till the gap supported by religi
ous institutions. In the late 19th
and early 20th century, most ol
these were of Christian origin
supported by churches in India
and abroad. The lone missionary
who started the health care faci
lity soon spread the word of the
usefulness of such a hospital.
Friends abroad were eager to
help. Funds were received and
bigger and better hospitals were
set up. Compassionate donors
sent money, equipment and
i
drugs. Many trained doctors
and nurses came themselves to
contribute their skills towards
caring for the sick.
hospital grew. Even those who
could aftord some of the cost
wanted large concessions of free
treatment. The voluntary hospi
tal continued to fulfil these
expectations, with virtually total
dependence on the foreign fund
ing agencies. The patient, once
cured, returned to his village
home to drink contaminated
water and live in unhygienic
conditions, knowing that when
he fell sick again he could count
on the magnanimity of the chari
table hospital. No significant
impact was made on his health,
even.less on his health awareness.
their doors to the very peOp|
for whom they were built.
with maximum
Responsibility-
ficS8’
jhc Wellness f
Most of the hospitals that
survived did so because they
began to draw more and MOr5
a rich clientele. The paying ^ere are at lea
patient was more demanding, pensions relevar
Therefore it became necessary t0 I Jept of holistic he;
keep up with the sophistication
Nutritional
and the rapid specialisation in the ;
jng wellnes
medical field. The more sophisti
foods and a
cated the hospital, the more
j
inducing or
successful.
! —■ Physical fit
The Promotion of Wellness
I
Environme
Modern medicine has created a I _ Stress mar
set of beliefs, habits and value
The Suffocati
systems which are not strictly
Many More Problems
and th
health inducing. Firstly, tradition
This was only one problem. al modern medicine has concen
Somewhere
The sick came flocking to these There were many more. The trated more on the absence of
for
many peop
hospitals from near and far. As expatriate doctor usually ran the illness than on prevention and
ma
ny
who arc
the news spread of the skillful institution
single-handed. As promotion of a high level of
lanterns
in mic
and dedicated service, more long as it was of a small size, health and wellness.
God
He
is nc
came. So the hospital grew to and the inflow of funds conti
the
market.
The drugs prescribed by the
accommodate them. More funds nued, he managed well. He gave
and equipment arrived from jobs out to the local needy, who modern doctor are so «expensive
In practica
friends and churches abroad. could help him in running the that only the top 10 per• cent in
boredom, na
And so the voluntary hospitals hospital,. The result was that India can afford it. Many drugs
a general put
continued to grow.
all his time was spent in seeing cause more problems than they
The spiritui
the patients and managing the solve. This system of doctors
seldom talkc
In spite of the nobility of
and medicine has made the
institution.
tionwith h
thought which inspired the start
patient dependent on the healer,
mise of rn
ing of many hospitals and health
Problems began to surface in that is the doctor. Self-respon
made it e\
centres, this activity of medical the post-independence era. The sibility for one’s own health is
ask questio
care has turned out to be short expatriates started to return discouraged in several round
I what is the
sighted. The doctor was always home. The sources of funds, about ways. The sick person is
the world
overwhelmed with the number of which were more often received exempt from all role-obligations.
I
and their f
patients waiting to be treated. through personal contacts, began
need not work. He can go to
I of their re
He did not stop to examine the to dry up. There were insuffici bed, and others will care for him.
root cause of the disease and ent skills available within the Society does not hold the patient I tend to
1 looked.
help improve the hygiene factors. organisation either to provide the responsible for his illness, The
He had no time. Moreover, the high quality of medical care
care or
or patient must accept the need for
Jung ai
patient was never to take the to manage the institution.. Costs help, and is obliged to cooperate
have sli<
responsibility for his health. Over of service went up rapidly. Many
modern
with the source of help.
and above this, when the patient hospitals just shut down. Many
related t<
came and was not able to pay for others drastically reduced their
Our new concept of health
ing and
his care, he received it free. He charitable work and began to would not stop at the neutral
dreams ;
was even provided free food.
charge patients, thereby closing point of the illness-wellness
ing fron
continum. It attempts to go
As a result, the expectations
Our
further, to a state of high wcllfrom the charitable voluntary
July-A
Voluntary Action
34
3
-W-
J ff? :
‘L a
he very people
re built.
hospitals that
because they
lore and more
. The paying
c demanding,
me necessary to
? sophistication
dalisation in the
: more sophistial, the more
of Wellness
ic has created a
bits and value
•e not strictly
irstly, traditionie has concenthe absence of
prevention and
high level of
ss.
scribed by the
e so expensive
10 per cent in
t. Many drugs
ems than they
,em of doctors
has made the
on the healer,
)r. Self-responown health is
several roundsick person is
role-obligationsc. He can go to
dll care for him*
hold the patient
is illness. The
pt the need f°r
jed to cooperate
f help.
icept of health
at the neuttf1
.llness—wcllncSS
attempts to
e of high well‘
Voluntary Ad*011
ncss, with maximum emphasis on
self-responsibility.
health would therefore try to
tinum. Thc welmess pract
integrate the psychic and spiritual
cannot also treat illness”
urges in man. An i •
The Wellness Life Style
■ integration calls for role clarification. Qthe.
of the body, the mind and the
Self-responsibility is the first spirit would be a necessary wise medical practitioners and
step to a wellness life style. Partj of our journey towards high- other highly trained professionals
will suffer burnout resulting
There are at least four other love] wellness.
from
a superhuman effort to do
dimensions relevant to our conboth.
With this, the human touch
cept of holistic health.
and the spiritual aspects of man
— Nutritional awareness (eatIt is doubtful v/hether to
hospi-
would be restored to the healing
tals can change to holistic health
Ing welIness - promoting
foods and avoiding illness - process. The future of health and wellness education. They
care would be a return to the have been too
inducing ones)
much and too
roots of man.
long
concentrating
on fthe physi— Physical fitness
While not specifically oriented cal. The future scenario in health
— Environmental sensitivity
towards physical health, human- would therefore be many doctors,
~ Stress management.
■Stic psychology, the conscious- nurses, para-medicals, priests,
ncss-expanding movements and counsellors, etc. moving out of
The Suffocation of the Spirit
spiritual movements all recognise the hospitals to set up commu
and the Mind
that health is a by-product of nity healing centres. Here they
one
’s mental attitude. So holistic will work together as a team that
Somewhere along
:'
God died
health
requires techniques which will take more and more the
for many people,• There are still
heal
the
whole man, not just thc aspects of ashrams. They could
many who arc going around with
body.
This
also was known for begin with instruments/questionb-terns in mid-day in search of
naircs to assess one s stress level
God He ,s not to be found in
and
health level. These data
the market.
Holistic health requires techni
would form the basis for deter
In practical terms, this means ques which heal the whole man not mining a new life style. Once the
foredom, nausea, alienation and just the body.
person is decided and firm about
his new life style, then any neces
general purposelessness in life
‘ e spiritual life of man / many ages.
JKings,
’
priests, sary training would begin. Self
dOn? talked about in connec- prophets, fakirs,
, seers, tribal responsibility will be the basis
for change.
n«lth his health. The pro doctors, saints over the
years
se of modern medicine has knew the power (and used it)
As this shift toward self
ade it even unfashionable to of j
‘
psycho-spiritual
therapy in
responsibility grows, the need for
^stions about meaning - healing.
hospitals becomes much less, the
^hat- iis: the meaning of life and
the ,
cost of health care goes down
Wellness Education and
world and so on. Dreams
. drastically, and a high-level of
^Ltkeirr psychic
*- v“‘v vv»,
Health
Care
content in terms
wellness becomes within the reach
7 their relevance
Wellness education and health
—- to
-j man's health
of people. One of the most
tend to
get ignored or over- care should remain separate.
^oked.
They are two separate systems, wonderful advances of science
is the fact that psychologic
Wn§una Others fo,lo"ins him Doctors are becoming a new stress has been shown to depress
modern
that m"Ch °f thc genre of practitioners who work immune activity. Mobilisation
'flat /
d3' rleUroscs are alongside and complement educa of positive psychological attitudes
.Etonian’s search for mean- tors and other health field pro will restore the body's ability to
dreaand COntent in life- Our fessionals. J. W. Travis remarks : overcome invasive viruses and
It is my firm conviction that
. ’’is are messengers of meandestroy mutant cells.
Since
the
same person cannot practise
roni our unconscious.
tension diseases are the main
disciplines that are on different
°Ur new vision
of holistic ends of the illness—wellness con- cause of disease today, psycho
spiritual therapy is the onlv way
^^'August 1980
35
■
even to hope for healthy people.
As the benefits arc reaped, the
existing health care delivery
system will cease to exist as we
now know it.
Most probably, this new/old
approach will “take oil” faster
in the rural communities, using
schools, health centres, adult
education, cooperatives, etc. as
a medium. Since this constitutes
SO per cent of India’s population
it is a good place to begin. The
change will be slow and painful.
© Wide use of wellncss/worseness continum questionnaires to
assess and redesign a health
management programme to maintain health through a healthy
life style. This method can be
used by hospitals, clinics, health
centres, and by health personnel
wherever they are. Once the
method is taught to the public,
they can become “teachers” for
others as more and more people
learn how to take responsibility
for their health.
• The practice of holistic health
and wellness education in the
hospital,'healing centre would
• Doctors and health profes need new kinds of professionals
sionals have over the years shoul- in new areas such as:
dered the responsibility forindivi- (a) Nutritional awareness counduals health and cure. Now it is
selling.
their primary task to shift their (b) Meditation through yoga.
responsibility back to the indivi
dual through a patient and (c) Autogenic training.
(d) Acupuncture/acuprcssurc.
sustained educational process.
(e) Bio-feedback/biogenics.
• Individuals must be aware of
(f) Mechanical/clectronic pain
both the applications and limita
relievers.
tions of medicine. This can be
Faith healing,
done by health
health education
education in
in
regional languages, using adult
Psychosynthesis,
education classes, school health (i) Massage, Rolling, Feldcnkrais.
programmes, mahila samajams, (j) Jungian psychology : dreams,
youth clubs, etc. for wide dissemi
guided fantasy.
nation of knowledge.
(k) Dance/art therapy, Tai chi.
What does All This Mean
to India ?
0 Meditation as a means of
attaining Nirvana can be reinstated as an ancient practice, for
stress reduction and at-oneness
with nature.
• Developing a new life style
to incorporate proper exercise, a
balanced diet, adequate sleep
and a philosophy of life which
gives meaning to the uniqueness
of each person’s existence. This
meaning keeps the person alive
and productive in the use of his
creative potenAal.
restructuring of our tradition
approach to health. The coiu^'
nity would need a great deal
r.. .
1 °i
education and publicity abo^
the shift. Not a few obstacle
and problems will be faced.
Problems Not Insoluble
lnf<
T’!:
These problems are not insoluble. What we are envisioning
will be neither easy nor accom
plished immediately. It could
be a.process over the next ten
years—just as ten years back
there was a process to move
towards rural community health
care. It requires some prophets,
some teachers and some very
broad awareness.
Ap
He
c
Contact address:
The Director, VHA1
>?■
C-14 Community Centre
Safdarjang Development Area
New Delhi-110016.
Homoeopathy,
(m) Chiropractic.
(n) Clinical psychology using all
counselling methods.
(o) Depth psychology—use of in
tensive journal methods.
b
People would stay long enough
to be well along in their new
health life style so that they can
carry it on successfully in their
homes.
Our new concept of health
therefore requires a fundamental
36
Voluntary Action
2ESSSE3
July-Au^
M 3-9
VOLUNTARY HEALTH ASSOCIATION OF ITO IA (KARNATAKA)
RfiFORT ON THE WRKSHDP ON 1 INTERPERSONAL SKILLS IN HOSPITAL
AND HEALTH CARB ADMINISTRATION’
A Workshop on ’Intorperoonal Skills in Hospital and
Health Cars Administration* was organised by the Voluntary Health
Association of India (VHAl) Karnataka Branch on 22 Feb 1981 at
St Martha’s Ho api tai. Bangalore* The key resource personnel
for the Workshop consisted of Professor R L Kapur, Head of the
Dept of Community Psychiatry, National Institute of Mental Health
and Neuro Sciences (NIMHANft)? Bangalore and his active young
teas of Psychiatrists, Nurses and Psychiatric Social Workers*
Session I
After the opening r^narks by Dr Marie Ma scare nhas,
Secretary, VHAI (K), Professor Kapur gave a key note address in
which he highlighted the need for better interpersonal skills
in any health team and also listed out some of the common problems
which juniors and seniors in a heiraichy faced in their day to day
interactions. Professor Kapur stressed that the need for developing
interpersonnel skills in a hospital setting was mainly for the
sake of the patient who entered our hospitals and
health centres as a guest. Starting with the senior adalatretnra
in our institution, he listed out the following cannon situations
or nethods of functioning which were the cause of many pzvblme.
1. Administrators block suggestions by juniors like angry parents
responding to a naughty child
2. Ateiaistrata 15 delegate responsibility and allow free discnseion
but do not delegate the power to sake decisions taken, effective
J. Adninistratore follow an open door policy, acting the good
saaaritan role with juniors and leave 'Biddle Management' out
of the decision process
4. Administrators appear to give freedon in choice but are not
always open to all options and show their definite psferences.
2
Adifilnistr&tors often pass on the tack of decision
asking even on inportsint matter* to niddlo level managerseo
So that they can he node the ecapegoat for difficult or unpopular
decisions*
6» AdninistratorSconstitute comnitteesto study and suggest policy
deci cions but no action is taken on their deliberation*
7» Adninistrator* often expect acceptance of their idea* by
juniors a* a nark of their respect or a sign of their worth»
In such situation* crlticisB or differences of opinion are
seen a* personal criticism. This feature was particularly
culturo-baaod and peculiar to India*
Hating taken the administrator* to task, Professor Kapur
then listed out the common problems associated with juniors in a
interpersonal
heirarchy which were of equal importance in causing MBNpnMMMB
conflict and strained relationship in a health institution*
!• Juniors who accept decentralised rovers tat refuse to accept
the responsibility which goes with it*
2* Juniors who do not take their problems to seniors because of the
’such things are not done1 attitude (sone of the smaller
problem* aMd snail solution* and often the senior* can
solve it at an earlier stage* If it is kept bottled up it often
blows over into a such larger problen)
3* Juniors who develop a father-complex with their bosses* This
sort of emotional dependency is again peculiar to the Indian
situation*
Professor Kapur then dealt on the problem of interpersonal
conflict being projections of intsapersonal
problems of either
or both individuals* It was therefore very important for such
one of us to indulge in a certain amount of self-analysi* to
discover: What makes us angry? Who makes us angry? Why are we
angry? This realisation would help us to control our reactivity
in different situations and accepting the constraints of our
4
Session XII
After a very interesting hour of discussion the four
groups presented the salient features and conclusions of their
diecusaion at a plenary session chaired
Professor BM Verna,
Professor Saeritus, HIMHA1S.
dnong the many interesting perceptions/suggestions
that emerged from the group discussion were:
1* Importance of humanising relationships in an organisational
hoirarohy even if it means starting on simple steps such as
calling a person by a name he likes to be called
2« Importance of self analysia to undcretand one’s own coloured
percoptione of situations and people
?• Ono should gradually evolve^ into a role rather than try
and fit into a fixed notion of it
4> Liberalisation of hoirarchical relationships was necessary
but not at the cost of disciplft in the institution
5« Hoirarchical relationships should not bo carried over
outside office or after office hours*
6. Occasions for infernal group or team interactions like
having a neal together should bo increased in any organisation
7« Special nestings where all categories of staff could assnablo
and air their problens should bo held regularly* Sono
institutions call these ’preventive’ neotings or ’grumble* or
’grievance1* meetings*
8* One of the biggest problmas in interpersonal relationship in
our organisations was the factor of role rigidity, which is
culturally induced, strengthened by community rewards and
expectations, related to a need for security and a result of
a rigid dmarcation of responsibilities in a heirarchy, This often
•y'
results in an individual reacting in a rigid ctdtical ntwits in
5
•very situation*
fallowing the group reports there was a lot of interest
generated in the so calleslconcept of Ygrumble1 meetings* Issues
such as
1.
who should be present?
ii« what action is to be taken? and
iii♦Does/Should this bypass middle management?
wore raised and enthusiastically discussed* The consensus was that
a*
All sections of an organisation should be inwolTod in such nestings;
b*
The meetings should take place in decentralised mailer units
so that good group interaction could take place
o* To balance negativity and positivity such meetings should discuss
pro bl ess as well as good points in each institution* The idea of
SWOT sessions was very much appreciated ie»t a discussion on
STRBHGTHS, WKAKMESSES, OPPORTUNITIES AND THRSATS to every institution*
Professor Tenia then summed up the plenary session by
taking on overview of the interpersonal problems in health institution
and stating that
a* In our health institutions the quality of healing has begun to suffer
because the quantity of technical know-how had increased but the
quantity of participatory experience especially between doctor
patient was getting reduced*
b* It is important that interpersonal skill development must be at
the basic operative level and not at the level of pure intellectual
understanding
c* All meetings, ward rounds, conferences in an health institution should
be a mutually enriching experience for all concerned
d* Bvery organisational problem should be understood in relation to the
individual body-mind relationship
Ve know that in the human organism tension can bo nature produced*
ambition produced and even doctor produced* These tensions
based on past experiences captivates the present resulting in a
6
6
double elavexy of *actiGipatoxy precaution1 • This is true not
only of internal physiology but also interpersonal relationships*
f* For better interpersonal relationships the human being must
undergo a growth process and it is very important that in the
brief period of his contact with a health toam or organisation thio
process is helped on and not stunted*
«•
In every hoi rarchi cal organisation there must be a continuous
processor delegation of the ’pcwer-responcibility and experience’
triad to juniors for the overall growth of th® organisation*
h* Svory organisation must move from a heirarchical leadership
representing emulative power to a situation of toanwork and
mutual enrichment(representing free flowing power of human
creativity*
Session IV
In the afternoon after lunch there vas an interesting
role playing session in vid ch the following participated:
Hospital Administrator of St Bartha’s Hospital: Mr CD Sunders
ii* Consultant, Dr Ko shy
iii*Staff Yurse
ir* Junior Doctor, Dr Angelina
Helper: Salome
▼i* Patient: Dr Sylvia Dabu
The problem presented to the group was a common
situation in the ward. A Consultant prescribes an ev’ergency drug for
a seriously ill patient and on the rounds next day discovers that
this has not been administered to the patient. The group played
their roles very realistically and since each member of the team
blamed the other for the problems and all this was done forgetting
the need of the patient-*-the role playing was followed by a very lively
discussion*
The session was chaired by Dr Channabasavanna, Medical
Superintendent, UMBANS<
The main consensus that emerged in the
discussion led by Dr Kalyanasundaram was:
* * * **7
4
7
1. The patient is the centre of all our activity in a hospital
or health centre. Hence his needs, must be supreme over
Institutional or personal needs of the health team*
2« In every crieiB each nember of the health team must
the
patient in view and must be encouraged to use his initiative
er creativity—no re than what is expected by role definition.
5. A post or a job has sone built-in role linitations but these
do not apply to the person who plays that role, iiach of us
should use the role Unitation but not get under it. In nonents of
crieiB, our cmtivity should buret out of this limitation.
.-.-4
■
4* In a health team evexy member is equally important. Kb member,
not even the doctor by virtue of his education or social status
should feel like ’boss* and play a superior role. In fact he should
use every opportunity to strengthen the team concept by decentralising
responsibility and power and encouraging initiative.
5. In tiie Indian situation* due to the culturally strong family
bonds* health teas members in India should encourage and explore
the possibility of family mecaber© of a p^ient being more involved
with the nursing care and managenent of patients as well as
seeing their help during crisis situations.
6» As a side light of the role playing there was some discussion
on the importance of havirg a standardised list of drugs in every
hospital pharmacy and of ensuring that all the staff of the hospital
prescribed frost this list for the sake of hospital efficiency,
economy and good patient care.
The Workshop was very much appreciated and it ended with
Dr Marie Mascaranhas proposing a vote of thanks to Professor Kapur
and hl. t«u for being euch an excellent resource on such an important
pxoble. in hospitals and health care institutions.
I
h| 3^0
/
QUALITY
ASSURANCE
OF
HOSi ITAL
CAUE
by
Dr. Mario C. de Souza
Deputy Hospital Administrator
St. John’s liedical College Hospital
Bangalore
(Prepared for presentation at the 1 989 National Hospital Convention
of the Indian Hospital Association to be held at the Lady Hardinge
Medical College, New Delhi on 11—12 November 1989. Adjudged as the
Best Essay submitted for the Essay Competition 1989 conducted by the
Indian Hospital Association.)
I.
INTROPLCTIOK
hedical care is one field where perhaps the consumer is relativelx .ignorant about what is good for him. Decision-making is therefore
wholly relegated to the provider, who, practically is free to do as
he pleases. Vested interests prevailing in certain situations, and
due to utter negligence at other occasions, the decision-making
power that the provider enjoys is at times abused to his own financial
advantage leading Ivan Illi ch to asseverate in the opening chapter
of his book ’Limits of hedicine’: ’’The disabling impact of professional
control over medicine has reached the proportions of an epidemic.....
the epidemic of iatrogenesis”.
A_
Further, to make natters worse, in contrast to an industrial
situation where output can be easily expressed in terns of units,
there is no, ^clear
tof~ puJ;imt_j^j^
In
this context, the fascination which exists with high technology care
leads one to associate the esoteric practices of modern medicine with
quality care, ^nd since the application of such technology is
generally expensive, both providers and consumers are apt to link
costs with quality and view the two as synonymous. Not surprisingly
therefore professionals are heard to deliberate that, ”a choice must
be made between good patient care and high costs on one hand, and
poor quality care and low costs on the other.” High technology forprofit enterprises further justify their philosophy by arguing that,
”... the purpose of our centre is to save the patient’s life and not
his money.” Dut
^ut analogies such as these are fallacious for they deny
the very concept of pro du ctiyity and assume that the only way to
provide better patient care is to abandon all economy measures and
practice extravagence.
Quality assurance of hospital care attempts to resolve just the
above issues. It aims at establishing quality control programmes to
evaluate and monitor the quality of care and to ensure that care.[of^
is provided at a I^easonablj^^cpjst. • Quality
assurance is not synonymous with use of sophisticated procedures,
super-specialization and adoption of superfluous invasive technology.
It does not advocate excellence at all costs. Instead, quality
assurance necessitates that institutions and health professionals
render care in a most efficient, offective and economical manner.
This entails a cost-benefit exercise to define strategies for optimum
utilization of resources, focus on cost-effective methods, and
introduction of systematic on—going quality control programmes to
continuously monitoi- and improve the quality of care rendered and
the overall productivity of the hospital.
• ••2
2
II. THE
PKjJoElVl1
IN
INDIA
Looking in general at the functioning of Indian hospitals, it
car. be said that systematic and comprehensive quality assurance
programmes are virtually non-existent. Some major centres of
learning do have some appraisal activities such as periodical publi
cation of statistics relating to patient-load, mortality and morbidity,
clinical conferences, clinico-pathological reviews, mortality
meetings, and enquiry into major incidents of negligence. These
however, are generally limited to the technical aspects. Termed
Medical Audit or ,Heer_?-Leview, the focus is on a retrospective analysis
of medical records and statistics to ascertain the accuracy of
diagnosis and treatment regimen. Rarely are the associated problems
of hospitalization looked into. Thus, what problems^ were c-ncounte?- . d
.luring._the
s. .s.tajj. v/ere. the.. inves_ti£ation _aM.
-9K6- 9X
.yA-dAg.> Al-A the patient jqenegi <
io._ the .benefits., etc., arc questions never
asked. The patient is generally at the mercy of the hospital/doctor
and is required to pay for every procedure done, irrespective of the
need for the same or the inefficiency with which it was administered.
There is no system laid out to ensure that a routine patient visiting
the hospital is given a reasonable standard of care consistent with
the hospital's objectives and resources. It is therefore not infre
quently that one hears of incidents of gross negligence: the healthy
eye that was wrongly extracted, the unconscious patient who fell off
the cot and sustained a pelvic fracture because the cot lacked side
railings, the patient who succumbed during a coronary angiography
which was unfortunately carried out on the wrong individual, the
knife-happy surgeon who has built castles out of the xjroceeds of
unindicated tonsillectomies, the case of a patient never, recovering
from anaesthesia given by a drunken anaesthesiologist, a kidney being
removed during caesarian section, and many other such 'stories'. .The
traditional 'wall ..of. Ailence' that exists around every operation
theatre effectively filters off most of the incidents of malpractice,
but as an insider into the functioning of hospitals, I<may aver that
had we in India a more well-informed populace and a speedier system
of dispensing justice, settlement of malpractice cases would have
been a major concern for hospital administrators and doctors.
HI. HOW . ..IS.....Q^UALriY.. ASSURA1 ff-
PHACTICISED . IN
lLQ§pri\AL?
Appraisal of quality of care involves assessment of:
- quality of teqlwical_care
- quality of ari-of^care
To institute a system of quality assurance, every hospital is
required to set up a Quality Assurance Cormittee which meets
periodically and reviews the quality of care delivered in relation
to previously determined standards. Such appraisal is to be con
ducted. with reference to three sets of variables:
1.
Variables:
The hospital management and medical professionals must agree
on what is the minimum infrastructure required for making avail
able a particular service. There must be clarity regarding the
er
building r&quireuientsy type of equipment needed, environmental
' characteristics of the hospital, and the hSunber of each cate
gory . of ..staff required for rendering care to the patient. The
committee should lay down the minimum qualifications required
for each category of medical, nursing and paramedical staff and
should define the type of organisation necessary in the hospital
for effective delivery of patient care. The setting, up of
different departments, the need for different coordinators, the
days and timings during which each department should be open to
render service and determining the size of each department keep
ing in mind the overall hospital ■ objectives come. ..under the pur
view of quality assurance committee. The committee should alsi
approve on an annual basis the budget to be made available for
patient care, activities. Appraisal of structural variables
therefore involves determining the extent to which these
recommendations have been complied with. Thus* at least annua •iy,
the hospital'management or the quality assurance committee sho Id
conduct a variance analysis to note the difference between act- ials
and standards, this being easily possible if the standards are
expressed in quantifiable terms.
.2
£^9AsJ^acto^rs:
The committee , should specifjr the type of cases that are to
be accepted for investigation/treat'ment based on the hospital’s
resources. It should also lay down the standing instructions
to be.xollowed for routine patient care, the nursing regimen to
bo adopted, the manner of documentation of. patient information
and the hospital records th.at are to be maintained for ensuring
effective delivery of care. The committee, either directly or
by setting up the following sub-committecs, should look into the
following specific aspocts of treatment:
(a)
Tissue Utilization Sub-committee, to screen:
- unindicated surgeries
- normal tissues removed/amputated
- correlation of pre and post operative diagnosis
surgical complications
- deaths arising out of or during surgery/anaesthesia.
(b)
Therapeutics Sub-committee, to review:
- non-ethical prescribing practices
■
- irrational use of antibiotics
- use of irrational drug combinations, banned drugs
- non-adherence to drugs listed in hospital formulary.
- unindicated transfusions.
- iatrogenic complications arising out of IV and blood
transfusions.
(c)
Infection Control Sub-committee , to study and recommend
strategies for control of;
— nosocomial infection in different departments
• ••4
4
- iatrogenic infection sustained by patients
— routine procedures to be followed to control cross
infection in the Operation Theatre, Wards, Laboratories,
Blood bank and Treatment Rooms
* sterilization procedures, preparation of packs by the
Central Sterile Supply Department.
(d)
HH£?j^_Audlt Sub-committee, to enquire into:
- non-conformance to recommended nursing regimens
- inappropriate/excessive ^se of consumables, disposables
and supplies
- incidents arising out of poor nursing care - fall from
cot, bed-sores, patient burns, etc.
3.
4. •
quality of care through outcome measures
strictly involves examination of indices relating to the out
put of the hospital and to the patient’s final condition.
However, there is yet nojjl^ar^^
of hospital
^ut
Diverse definitions exist though noTTTf tl^hav7
been validated through economic cost-functions. Hospital output
has been aefmod in terms of patient days, sum of weighted
services, episodes of illness, end results or desired health
levels expected of the specific hospitalisation, etc. In view
that exists, hospitals traditionally appraise
heir output through use of surrogate factors vdiich theoretily are known tohave some relation to output: length of
stay, review of pcrfonnance/efficiency of particular services
teg. cost anaiysis Of each disease treated, cost-benefit ratios
°L.speclflc services rendered, etc.), review of performance/
efficiency of the providers (eg: performance appraisal of
doctors, performance evaluation of a department through appraisal
oy objectives, practicioner-profiles such as patient-department
urnover ratio, analysis of length of stay department/.doctor
wiseJ, review of performance of the hospital relative to that of
other hospitals (length of stay speciality-wise, mortality rate
speciality-wise, disease-wise cost of treatment, ratio of
expenditure on investigations to the patient's hospital bill
dlsease-wise), review of the overall satisfaction of the patient
with the quality of care rendered as recorded at the time of
discharge.
1.
Hg.j4.QQ-l He cor ds:
form easily accessible, medical records are perhaps the most
useful source of information on quality of care rendered. The
.5
I
5
hospital management must therefore ensure that the records are
maintained in a AcgiJ>le, complete, and factual manner and that
they accurately summarise the events that have occurred during
the hospitalization of the patient, v/ith the increasing use
of problem oriented medical records (POMR) and recording of
progress notes through the use of SOAP (subjective complaints,
objective findings, doctor’s assessment and j>lan of action)
and with the recent application of computers for medical rec ord
indices and for patient data-base computerised information
systems, the patient’s case-file can be a powerful tool for
the concurrent and retrospective review of the process factor,s
of hospital care.
2.
Inci de_nt Itoview:
During a patient’s hospitalization several incidents may
occur which have a bearing on the treatment and the patient’s
final recovery. These ’critical’ incidents may bo of the follow
ing nature: delayed at tendance*'by a physician, incorrect
medication, burns arising out of faulty physiotherapy, assault
on a patient by an employoe/outsider, wrong patient being
subjected to an investigative/surgical procedure or a right
patient being subjected to a wrong procedure, death in a corri
dor with no physician/nurse accompanying the patient, etc.
^sj^^^ment involves maintaining a record of such critical
incidents and analysing them for their nature, frequency, time
and place of occurrence, personnel involved, and listing of
their causative factors. Corrective action can -then be taken
to reduce the frequency and seriousness of such incidents that
cause risk to the patient’s well-being. Risk management can
go a long way in improving the work standards of a hospital
and in the overall improvement of quality of care rendered.
3.
Hospital- Information JSyjtem:
An on-line real-time data-base computerized system can be
of immense value in generating a management information system
for appraisal of quality of care, Periodical reports of such
information could include:
(a)
■Vo.^lp ad stat is tics - admissions, bed occupancy, surgical
procedures, length of stay
(b)
Activity audii P°or scheduling, list of pending tasks/p. •ocedures in critical areas, review of repeat investigation!
(c)
g;acti_cionor. profiles - workload, competence, patient
satisfaction
(d)
^i^ncio-1..Jje.rfnce - use of consumables, breakages,
profitability, budget-actual variance, cash flow.
•••6
•••
•
6 s4.
Patient Sat is f act ion^ jSjiryeys.:
Surveys to ascertain index of patient satisfaction may be
undertaken at fixed points in time or on an on-going .basis. Such
surveys, carried out through questionnaires, interviews, etc. by
social workers, hospital management trainees, consultancy groups,
etc. help to document patient satisfaction.with respect to 4
variables:
(a) Be,lax
attendance by doctors, nurses, helpers
(k) Discourtesy shown to patient during course of hospitalization
(c) Lack of amenities.* especially those charged for
(d) Incidents of incorrect treatment, iatrogenic complications.
However it is important to note that one c^n still have a dissatis
fied patient who may have actually received good quality care and
vice versa. Patient satisfaction is a better indicator of quality
of art-of-care, quality of nursing care, and quality of facilities
provided than of quality of technical aspects of care per se.
V, ■.c^sthamts Jacld^Jwders_ UL.ality_ cme
Hospitals and doctors encounter the following constraints which
often result in poor quality care:
(a) Lack of Kespurces: Insufficient resources - infrastructure, equip
ment, consumables, money for recurring expenses, staff - makes it
impossible for output of a certain quality to be turned out under
the prevailing circumstances.
(b) P-r-u-£s- JfflcL di cal Sup pl i es: Non-availability of essential drugs
and supplies, spurious, adulterated and sub-standard drug prepar
ations and medical consumables, improperly sterilized or pyrogenic
materials, etc. have a deleterious effect on the course of hos
pitalization and final prognosis.
(c) Improper Maintenance: Building and equipment require proper
maintenance for efficient use. To minimize equipment down-time it
is necessary to ensure adequate after-sales service, availability
of spare parts, service manuals, etc.
(<*) I3or.sonnet problems: Lack of motivated employees,, staff indiscipline,
irresponsible trade union activity, strikes and go-slows, etc.
compromise the quality of care.
^££PX^a^A14iX: Where medical care is not free or subsidized,
the ability of the patient to meet the expenses of treatment is
of critical importance in deciding what care to give and the
intensity and quality of such treatment.
(f) toreasonable patients and attendants: Illness, anxiety, absence
of immediate response to treatment, ignorance about prognosis,
late attendance, etc. cause patients, their families and friends
to adopt an unreasonable, uncooperative and belligerent atti
tude*
7
IhPSTUS
1•
A
FOR
QUALli’Y . ASSURANCE
Wc 11 - Inf o.rm ed_
J:
In his book ’’Limits to Medicine” Ivan Illi ch argues that
the ultimate cure for the ’epidemic of iatrogenesis’ rests
with the lay public whom he exhorts to rise up and counter the
professionalization of medicine. To do this, the populace must
be well informed. In India, because of the high level of
illiteracy, the ready willingness of the patient to accept his
karma, and particularly since the demand for health care ser
vices in the rural areas grossly exceeds supply, it is unlikely
that patients, consumer forums and lay organizations can exert
sufficient pressure on the medical establishment to demand a
better standard of care.
2.
Hospital -tatAo.n_Lavrs:
Unlike, as in the U.S.A, vzhoro there exists a Joint Com
mission for Accreditation of Health Care Organizations, in
India there is no organization empowered by legislature to lay
down standards for hospitals and health professionals so as to
regulate the quality of care. The Medical Council of India
looks into the requirements of medical education and for this
purpose it inspects facilities available in medical college
hospitals. The quality of care rendered is however not
api^raised and there is no regulafcory/supervisory body for
granting recognition to non-medical college hospitals and
nursing homos. The State Medical Council does look into com
plaints from aggrieved patients regarding negligence and
unethical practices against doctors, but it is largely ineffect
ive in regulating the non-technical aspects of quality of cai*e
in hospitals. India requires a legislation that provides for
setting up of a statutory Accreditation/Vigilance authority in
each State to inspect hospitals and ensure that basic require
ments are met, to issue licences for carrying out specific
diagnostic/operative procedures, to enquire into major incidents
of negligence and to take stringent' action against hospitals/
health professionals involved in gross malpractice.
3.
Third-Party Payors:
In the U.S.A, bills relating to hospitalization and other
medical expenses are generally met bi” third-party payers Medicare, Medicaid, Blue Shield, Blue Cross, employers. Beyond
payment of insurance premiums and government taxes, patients
are not involved in settlement of the major portion of the
hospital bill. It was therefore customary for patients to
demand the ’best* and hospitals and practicioners, to play
safe and to increase their revenue, administered more diag
nostic and treatment procedures than necessary claiming the
full cost for the same from* third-party payers. All this
resulted in spiralling costs of medical care. Recently, with
the introduction of the diagnosis related group (DKG) reimburse
ment, an effective way has been found of curtailing hospital
costs while at thessane time increasing quality and efficiency.
Through use of the 467 BRGs, the US Government Health Care
financing Administration has begun to reimburse hospitals
involved in Medicare and Medicaid predetermined amounts based
• •^8
8
on the diagnosis reported and not on the basis of length of
stay> jr ocedures carried out, etc. Efficient hospitals can
profit through.this system by retaining th$ difference between
the amount reimbursed for the particular disease treated and
tho actual costs of treatment, whereas inefficient hospitals
must absorb the difference. In India, there is an increasing
trend towards third—party payments by employers and insurance
firms. Although insurance, firms have fixed an upper limit for
medical reimbursement liability, third-party payn-jnts are
'sure to result in inflated hospital bills as patients do not
immediately feel the pinch and are hence demand more than what
is necessary. To offset this phenomenon, insurance firns in
India must draw from the experiences of America and work out
a system similar to BRG reimbursement. Hospitals in the
voluntary and private sector do find it convenient to collect
payments fron^third-party apyers, more so as their clientele
is assured. Haployers, insurance firms and the Government thus
can exert sufficient pressure to demand' a bettor quality of
service at a reasonable cost.
4.
The Law of Torts nakes it possible for aggrieved patients/
their families to file malpractice claims against doctors for
compensation for iatrogenic damages arising out of negligence.
Further, under the doctrine of ’respondeat superior* (let the
master be responsible), hospital managements too can be held
responsible for vicarious liability, i.o. the conduct of their
employees, including doctors, and dan be hold liable for payment
of malpractice claims.
The duties of a hospital/doctor to a patient, the ambit of
medical negligence and the factors necessary to establish
liability in India have been detailed extensively in AIR 1969
Supreme Court 128-135, AIR 1975 Bombay 306-324, and AIR 1985
Madhya Pradesh 150-171 as follows?
f
(a)
The duties which a doctor owes to his patient are clear.
A person'wno holds himself out ready to give medical
advice and treatment impliedly undertakes that he is posses
sed of skill and knowledge for the purpose. Such a person
when consulted by a patient owes him certain duties, viz.
a duty^of care in deciding whether to undertake the case, a
duty of care in deciding what treatment to’give of a duty
of care m administration of that treatment. A breach of
any of those duties gives a.right of action for negligence
too tho patient. The practicioner must bring to his task a
reasonable degree of skill and knowledge and- must exercise
a reasonable degree of care. Neither the very highest not
a very low degree of care and competance judged in the
light of the particular circumstanced of each case is what
the law requires(ch. Salsbury’s Laws of England, 3rd ed.
’ vol. 26 p 17)”.
(b)
Mistaken diagnosis is not necessarily a negligent diagnosis.
No human being is infallible. A practicioner can only be
helu liable if his diagnosis is so palpably wrong as to
prove negligence.”
...9
9
(c)
"A person is not liable in negligence because someone else
of greater skill and knowledge would have prescribed differ
ent treatment or operated in a different way nor is he
guilty of negligence if he has acted in accordance with a
practice accepted as jproper by a responsible body of riedlical men skilled in that particular art,i <even though
‘
a body
of adverse opinion also existed among nodical men.
(d)
'*A doctor cannot bo held negligent simply because something
went wrong.” "It would be wrong and indeed bad law to say
that simply because a misadventure or mishap occurred, the
hospital and doctors
--- j are thereby liable (Lord Denning in
Hatcher v Black and others, 1954).”
(e)
”V/e must not condenn as negligence that which is only a
misadventure. The doctor is liable when he falls below thle
standard of a reasonably conpetant practicioner in his
field, so much that his conduct might be deserving of
censure or .inexcusable.u
(f)
”To establish liability, it must bo shown: (l) that there
is a usual and normal practice, (2) that the defendant h .8
not adopted it, and (j) that the course in fact adopted ii
one no professional man of ordinary skill would have take:
had he been acting with ordinary care.”
Despite the above clear pronouncements by the major Courts
in India, with thq prolonged delay in fighting legal battles in
India, only the rich and the very well-infomed can afford to
seek the necessary legal help. Besides, the traditional rever
ence chat doctors enjoy (when the patient is sick, the doctor is
Godi; precludes a patient from seeking compensation for damages
caused, more so since the patient may have further need of the
same doctor. Legal redress is therefore not an effective
impetus to quality assurance of health care.
5.
There is an understandable reluctance on the part of docto,rs
in defining parameters and standards within which they will
render care and, traditionally, no doctor likes to sit in judge
ment over his colleagues. If health care providers have topla.
a., role in ensuring a higher quality of care, the responsibility
rests on the medical administrators - Directors, kedical Superin
tendents, Hospital Administrators - for it is- these management
representatives who generally have to face the consequences of
malpractice in terms of poor reputation of the hospital, loss of
clientele, legal expenses, .compensation for iatrogenic damages
and higher hospital costs. It is therefore‘necessary for hospital
management representatives and their professional forums to
strive towards bringing about this changes adoption of quality
assurance programmes, laying down minimum standards for hospitals/
professionals, instituting an accrediting process and regulating
the quality of hospital care in India.
.*•10
•.»7 •
10
VII.
REFERENCES
1.
All India fieporter 1969 Supreme Court 128-135, Dr. Laxman
Balakrishna Joshi vs Dr. Trimbak Bapu Godbole and another.
Division bench of Justices R.S. Bachawat, J.M. Shelat, and
A.M. Grover.
2.
All India Reporter 1975 Bombay 506-324, Philips India Ltd.
vs Kunju Punnu and another. Division bench of Justices
Vaidya and Sapre.
5.
All India Reporter 1985 Madhya Pradesh 150-171, Ran Bihari Lal
vs Dr. J* N. Shrivastava. Division bench of Justices C.P. Sen
and S. Awasthy.
4.
Berki, S.E., Hospital. Economics♦ .Massachusetts: D.C. Heath
and Co • > 1972, pp 85-120T
5.
De Souza, M. C., ”A Note on Hospital Cost Concepts’". A
.'JJ
bhipraya,
Fellowship Journal of the Indian Institute of Management,
Bangalore, August 1980.
6.
De Souza, M.C.,, "Quality Assurance as a System for Cost Reduct
ion of Hospital Care". ^L9^A4A^s_of .the. Seventh Annual
.PpMj.^ence, Indian Society of Health Administrators .’’ Bombay,
1986, pp 253-265.
7.
De Souza, M.C., "Costs versus Quality: Conflicts in the Indian
Context5'.
Adninistration, Vol. XXV, No. 1 , March
1988, pp 94-102.
8.
Goyal, R.C
"Health Care Administrators and Law of Torts”.
Hospi t al Adil inis t rat i on, Vol. XXV, No. 2, June 1988, pp 163-170.
9.
Pena, J. J., Haffner, A. N., Rosen, B», and Light, D. W. (eds.)’,
kPfilAiX .4^sur91A9.9.: ^isk management and Pro.gran
^^Ij^Lt.ipn. Maryland: Aspen Systems Corporation, 1984.
10.
Rowland, H.S., <and Aowland B.L. Hospital Adriinistration HapdBook. Maryland: Aspen Systems c^p^^ion7^9^
11 •
Shanahan, li. (ed.)
12.
Srivastave, M’>, and Ghei, P.K. "Myth of Medical Audit",
fiosjliial AclEiinistration. Vol. XXV, No. 2, June 1988, pp 171—179.
13.
Timiappaya, A. "Medical Audit."
March 1968, pp 112-115.
/'
j^p.cepdings of an International Syuposium
* # * *
Hospital Administration,
-- --- -------------
I
PUR CHASES
A
VO
HOSPITAL
(Paper prepared for presentation at the 1989 National Hospital
Convention of the Indian Hospital Association on IHosj3it_al_and
Dr^Ks’ bo be held at the Lady Hardinge Medical College,~ New Delhi
on 11 - 12 November 1989.)
by
Dr. Mario C. de Souza, MBBS, FIIM
Deputy Hospital Administrator*
and
Sr. Mary Clare, M. Pharm
Chief Pharmacist*
*St, John’s Medical College Hospital
Sarjapur Road,
Bangalore 560 034.
I.
Ij^ROPUCTIpN
A Pharmacy in a voluntary hospital is of major concern to
every Hospital Administrator as, beyond ensuring the continuous
availability of prescribed drugs, it is an important cost and
revenue centre. V/hile its ’profits’ are critical for subsidizing
the non-income generating departments of the hospital - Jie higher
the surplus the better - drugs cannot be dispensed at prices greater
than the .specified maximum retail rates. In fact, in keeping with
the charitable image of such hospitals, drugs should be priced lower
than that prevailing at for-profit retail drug stores. In order to
achieve the above conflicting objectives simultaneously - generating
profits despite under-pricing - the Pharmacy must procure good
quality drugs at economical rates and further decrease costs by
strictly adhering to concepts of materials management.
ihis paper describes hoxv policies and procedures have boon
revamped to streamline purchase of drugs and modical/surgical
supplies in a large teaching hospital in the voluntary sector so as
to ensure higher financial surplus to subsidize free and concessidnal
care. The case study documents the experiment, problems encountered
and results obtained.
II.
PX^.LIzatiujul setting
The study was undertaken at St. John’s Medical College Hospital,
Bangalore which has a large out-patient department catering to over
700 patient visits 'per day as also an in-patient facility with 781
cods located in the 1 7 general wards and 1 97 beds in the 9 private
wards (as on 31-12-1 988). Beyond care being Rendered at subsidized
rates in the general wards, about /3rd of patients admitted to
these wards are given totally free care while1, an almost equal number
are given concessions on the total bill as assessed and recommended
• ••2
2
by the 4 medico-social workers. Since no Government grants are
received by the institution, the financial deficit incurred because
of the above free and concessional care (ks.56.48 lakhs out of a
total recurring expenditure of Rs. 646.98 laklis in. 1 988-89
(15 montns audit year)) is met through an endowment fund established
for the purpose as also through 'revenues in excess of expenditures
generated by the Pharmacy, Diagnostic Services, Private Wards
and Operation Theatres.
In attempting to augment resources to finance charity care,
special attention was given to the Pharnacy in view of its tremend
ous potential to generate surpluses. The Pharmacy dispensing
section at St-.. John’s Medical College Hospital is well established
and stocks all the drugs required for patient care and for hospital
use. Despite the constraint of having to keep the dispensing rate
of drugs below the approved maximum retail rates and below the
rates prevalent at for-profit retail drug stores (because of the
charitable image of the hospital)9the Pharmacy, after accounting
for salaries and all other expenses, generated a surplus of
its. 14»42 lakhs in 1988 (proportionately calculated from 15 months).
Limited by the constraints of under-pricing and a price inelasticity
02. uemand, the only option available for augmenting the surplus was
to apply the below listed cost-containment measures to procurement
(and stocking) of drugs and modical/surgical supplies purchased
directly by the xharmacy as also by the Central Stores Purchase
Department.
III,
mEUVEi'iTlOHAL
1.
SrCESS,
Ljy£ULT^
2O_C_. .Analysis • In January 1989 an 8-digit code was developed
for urugsstocked by the Pharnacy and those were categorised in
a manner as done in the Monthly Index of Medical Specialities
(MUIS India). The average unit purchase cost and quantity of
each formulation consumed (dispensed out) in 1988 were recorded.
Those data were fed to the computer and the ABC analysis report
printed out in March 1989 revealed the followings
Catogorv
Ho • of f omulations !
-
C
Coiisunption Valuo
1------- U---------------
1 65
*' 10.83
10.83 j Bs. 46,65,981 .77
H—
— -*j ———
j-*
; 20.07 H Hs. 13,45,277>O5
568
j 69.10 h Rs.
89
B
%
4
822
6,71 ,376-91
poo.00 |j Rs. 66,82,635-73
%
69.82
20.1 3
j 10.05
poo .00
-------- !_____ jJ__ _________
2«
fiagSB£tilajiAaa_0jt,the. Drugs and Therapeutic Cormitteo: The Drugs
and Therapeutic Connittee was reconstituted in March 1989 with
7 ox—officio nenbers and 5 senior clinicians connanding high
.e.3
credibility.
included:
Two important objectives of the Committee
- preparation of a hospital formulary listing the drugs
to bo prescribed, stocked and dispensed in the hospital;
- selection of suppliers, short-listing of brands, place
ment of major orderso
A-t its first neeting on 1 7-3-1 989, the Connittee was apprised
of the ABC analysis exercise that had been undertaken, The
uenbers discussed and approved:
- inviting quotations for ‘A’ category drugs and related
products from reputed manufacturers;
~ selection and stocking of only one brand of the required
drug formulation based on cost, user preference, reputation
of the brand and company’s reputation; it was also recom
mended that effectiveness of different brands of an anti
biotic be tested nicrobiologically for in-vitro sensitivity,
though bio-availability, in-vivo oifectivenoss and sensiti
vity to specific strains of organisms could not be tested
in the hospital situation;
- it was recommended that clinicians be advised to use generic
name of drugs while prescribing;
- the Pharmacy was authorised to stock only one brand of each
drug formulation as selected by the Committee and to dispense
this brand irrespective of the brand actually prescribed i
the clinician;
- the Pharmacy should not stock banned and bannable formulations
as advocated by the Voluntary Health Association of India,
unless the respective formulation was essential and no
alternative existed.
A decision was also taken to circulate to the heads of Clinical
Units the list of drugs stocked in the Pharmacy and to invite
from them suggestions for:
- doleting/adding drug formulations to the list;
- brands preferred by the respective clinical unit;
- exclusion of specific brands based on past experiences of
non-effectiveness, adverse reactions, etc.
!
3.
Brand .5 e1o ct i on and Orde ring: Accordingly a list of 1 66 drug
formulptions was prepared along with the approximate annual
requirement, and quotations were invited from 60 manufacturers
distributors and stockists of repute. The firns were advised
to offer their lowest effective unit rate for each formulation
after taking into account free/promotional offers, quantity
and payment discounts, excise, central and state sales tax,
...4
}
4
freight and insurance. The firns were also required to give
an undertaking to bind their prices for one year, i.c. uptil
50-6-1 990. These data were fed.to the computer and comparative
statements generated for each product. Appendix I lists out
a sample comparative statement, the current purchase cost of
the respective drug and the savings achieved for that formul
ation through this exorcise.
The comparative statements were reviewed by the Drugs and
Therapeutic Committee over several meetings and based on the
guidelines listed above, one brand of each drug was selected
for ordering while a second brand was short-listed as a reserve.
In the case of few products where product specifications were
not strictly comparable (eg. vitamin - iron preparations), more
than one brand was selected* Appendix II lists out the drug
formulations considered by the Connittoe, the- unit rate of the drug
as _was.being purchased at that point in tine, the company
selected and new rate applicable for the sane drug as per the
tender. It nay also bo noted that none of the conpanies/brands
selected arc substandard.
Tho order, in the form of a committed volume contract, included
the following safeguards:
- specification of drug fomulation, strength^ pack size, approxi
mate quantity required, unit rate inclusive of excise and
taxes;
- delivery at hospital promises;
- nonthwise delivery schedule, the quantity to be supplied each
tine dependent on the econonic order quantity;
- fixation of price for a period of 1 year, and clause prohi
biting revision in price for any reason whatsoever;
- provision for decrease in quantity by 25% based on consunprion
patt ern;
- provision for purchase of additional requirements of the sane
product at the sane specified price;
- name mid particulars of third party if supply was to be effect
ed by distributor/stockist;
-
coluiitrwnt
to pay v/ithin 1 nonth;
- in case of delay in supply, provision to purchase similar
product from sone other source and charging of the difference
in amount to the firn;
- in case of defective supply, provision to take back consign-;
nent and effect imediato replacement, cancellation of order;
- confirmation by firn of above toms and conditions•
..•5
5
Tho experiment achieved the following results:
- purchase planning and placement of a single order for a
product with predetermined stock replenishment schedules;
- selection of a single brand acceptable to clinicians, thus
cutting down on multiple orders, duplicate inventory, stock
ing costs;
- fixation of prices for the whole year thus preventing price
escalations and increase in purchase costs;
- savings because of committed volume contracts and inter-firm
competition; as can bo seen from Appendix IIt without this
exercise, at current rates, tho hospital would have spent
Rs.55*84 lakhs for purchase of these A category and related
drugs; through this process, the projected purchase cost was
brought down to Rs. 45*95 lakhs, effecting substantial savings
of Rs. 11.89 lakhs for free and concessional care at the hqspital.
- these savings wore possible without any negotiation of price
with the respective firns; further savings are likely in
future years because of the credibility of the hospital, its
purchase policy becoming known, inter-firn competition,
quantity discounts, et c.
4.
: In order to contain costs, the Centra.! Sto res
Purchase Department of the hospital also has been exercising
controls on purchase of major items’ of expenditure relating .
nodica.l/surgical supplies (eg. adhesive tape, plaster of pa:, is
bandage, cotton, guaze, x-ray films, etc.). Through purchas
planning, forcasting of demand, inviting quotations, intense
negotiations with competing firns, seeking quantity and payr.
discounts, and placement of committed volume contracts (or rate
contracts where demand could not be accurately forecasted)f
substantial savings have been effected. Appendix. Ill shows the
decrease in the purchase cost of one such item over the years
as compared to the officially published-wholesale distributors
rate applicable for sale in bulk to hospitals. In attempting
to decrease costs still further, a meeting was convened on
21-1-1989 with representatives of two other large hospitals
in tho voluntary sector. Appendix IV shows the quantity
purchased in 1988 and the difference in rates then being paid
by tho three hospitals for the same products. A decision was
taken to pool the requirements of the three hospitals and try
out group purchasing on an experimental basis. Further negoti
ation with competing firms ensured additional price discounts
and a combined order was sent on behalf of all three hospitals
including tho following provisions:
■
- all safeguards cited above for placement of a cormitted volune
contract;
\
- delivery to be made to the individual hospital consignee
departments as per the respective delivery cchedules spi-or■'
throughout the year;
• ..6
6
- assurance of paynent by the individual hospitals within 2
weeks of receipt of the consignnent.
.Q-tfeQj?- St_ock Control Measures; Beyond streanlining purchase of
drugs and nodical/surgical supplies, inventory costs were
nininizod by fixation of reorder level and nininun stock
level for each iteri, identification of non-noving drugs and
follow-up action with doctors and/or firn, and increasing
turnover of inventory by decreasing the value of closing
stock.
IV.
PROBLEMS
1 .
EjTCOTOIWXP
Skp.ptism; Resistance was initially faced fron clinicians not
involvotl with the short-listing of brands. This was further
precipitated, by disinformation spread by representatives of
firms which had not been successfull in obtaining orders for
their key products. Clinicians had therefore to bo convinced
• that:
- low cost does r_ot infer poor quality just as high cost drugs
not automatically assure good quality? with the system
of loan licencing, drugs fron reputable firns
^e manu
factured by other lesser known firns; further, higher costs
are invariably due to royalty on patents, expensive packing
materials, sales promotional expenses, etc.;
- the hospital need not stock multiple brands of the same
product to suit the individual whims of clinicians; repre
sentatives of clinicians, keeping in mind certain objective
criteria, jean agree on a single brand of choice;
- clinicians insisting on specific brands will be required to
justify their requests supported with technical data to the
Drugs and Therapeutic Committee.;
- immediate action
will be taken on receiving reports regard
ing. non-effectiveness, spurious supplies, quality, etc.
2.
Ereezinpy of. Pric_GSJ Pharnaceutical firns have not been willing
for price fixation for one year in view of possible changes
in Governnent policies, increase in raw materials costs,
inflation, etc. Hence, although they have accepted the orders
and executed supplies, the public sector firns and a few others
have conmmicated their inability to bind their prices. Faced
with the throat of being blacklisted, and the. possibility of
having to bear the difference in cost if the drug is procured
fron sone- other source in accordance with the terns of the
order, it is likely that any general price revision will not
apply to the drugs ordered as above. The hospital has been
successful in the past in enforcing the terns of cncli' orders
(including not yielding to upward rate increases consequent to
change in statutory duties) for nodi cal/surgical supplies being
purchased under comitted volume contracts. The private finis
seen likely to oblige though the public sector companies nay
not bo able to overcome the bureacracy in the long run and noy
lose out on future orders.
.•.7
7
9
V.
Pi s advent a/^s . of__gr ou^. Pur ch asinA’: Group purchasing necossitktos
that nonbers of tho group colic to an agreement on a single brand
of a product so as to avail of quantity discounts possible
through bulk orders. This can bo a difficult process as inddvi-. .1 1
hospitals often have discrete preferences regarding brands,
suppliers, etc. Dissonance created by suppliers and distrust
with regard to' tho interests of the person ■ cd«5^dixiat±ng- the purchase
can further create problens in arriving at an objective decision.
Further, non-couplianco of the terns of the contract (especially
payment delays) by nenber hospitals can make a group purchasing
endeavour infructuous.
CONCLUSION
Tho case studjr documents tho attempts made by St. John’s Medical
College Hospital to effect substantial savings to be utilized for
charity care by bringing down tho purchase cost of drugs and medical/
surgical, supplies. These strategies arc not in itself innovations
as, since several decades, government hospitals have conformed to
the system of tenders and rate contracts by which firms and their
products are screened by Committees and procurement rates fixed for
a defined period. Tho system has not worked zs well as it should
have because of vested interests at various levels which have
allowed suppliers to alter tho quality, quantity, price and other
terms of the contract to the detriment of the hospitals. However,
in voluntary and charitable hospitals across the country, even
though constraints of money exist, purchases have not been stream
lined as suggested above. The experiment is but one example of what
is possible in the Indian context, particularly when resources arc
to be used as imaginatively as possible to deliver efficient and
effective care at an economical rate to the greatest numbers - tho
primary objective of any hospital in the voluntary sector.
Appendices
I
IV
follow.
* * * * * * *
Appendix
8
St. John’s
Medical College
DRUG . TB-NPM
EVALUATION
I
Hospital
REPORT
Page: 69 .
Strength: 500ng
Annual Requirement: 55000
Drug None: - Anpicillin
Presentation: Vial
r/mp. of
Company/
Trade Name
jDistill.
| Water*
Unit
Rate
Drug Code:
v7010305
Curr. Pur ch. Cost:Rs. 8.22
(•Aristo)
Dis count
Icst/kst
Effect.
Rato
I___ _4—-
No
4.50
14+10
No
5.46
| 4+10
No
5.60
10
<6 Mohan & Co
kampibiotic
No
4.54
10
4.99
5. Ranbaxy
RosciIlin
les
5.15
10
5.67
6. Aristo
Aristocillin
Yes
6.45
1°
5.52
7. Biocheri
Anpicillin Sodiun
No
6.20
4+10
7.09
8. HAL
Anpicillin
No
5.65
10
4.95
9. Unique
No
9.61
4+10
io Jo:
1. Cadila Ltd.
I
*
Capicillin
5 J5
i
2, Lyka Labs. Limited
6.25
Anpilin
3. Indian Drugs & Pharma
ceuticals
i
6.16
Broacil(Anpicillin)
25 free/100
20 free/100
Anpicillin
10, KAPL
Anpicillin
No
11. Pharnindia
Synthocilin
No
5><>9
4+10
5.90
6.75
*Cost of Distilled Water ampoule: 0.40 p.
IxTistocillin :
Current
Proposed
Lnit Rate
Total Value
Saving
Rs. 8.22
Rs. 5.32
Rs. 4,52,100
Rs. 2,92,600
Rs. 1,59,500
54.5% discount
.Appendix
9
LIST
OF
SCRUTINIZED
DRUGS
BY
DRUGS
AND
THERAPEUT ICS
COWITTBE
r
Existn.
Rato (Rs)
1988-89
Conp
On.
Revised Savings
Rate(Rs) achieved
1 989-90 ‘ (Rs)
Conpany
Selected
Pago
Formu
lation
Present
ation
Qty.
1
Gelusil
tab
6,000
0.15
0.05
480.00
Parke Davis
2
Gelusil
liq
170 al.
5,672
10.54
5.85
16,160.72
Parke Davis
5
Gelusil
liq
400 nl.
500
11 .02
11.02
0.00
Parke Davis
4
Gelusil
MPS
| tab
8,400
0.15
0.15
0.00
Parke Davis
5
Gelusil
MPS
liq
170 nl.
5,870
9.17
9.15
117.40
Parke Davis
6
Gelusil
MPS
liq
400 nl.
2,075
17.99
17.99
0.00
Parke Davis
Ranitidine tab
Hgl
150 ng.
75,545
1.77
1.42
26,570.75
10,
Ranitidine tab
HC1
500 ng.
1,045
5.56
2.67
950.05
Thenis
12
Ranitidine anp
50 ng.
18,220
5.56
1 .84
51 ,558.40
Gufic
14
Dipyrida
mole
tab
25 ng.
4,560
0.19
0.19
0.00
Ceman Rene dies
15
Di pyri dano le
tab
100 ng.
24,625
0.67
0.67
0.00
Gernan Reuedies
16
Nifedipine cap
5 ns.
57,560
0.56 »
0.1 9
6,585.20
Pharaindia
17
10 ng.
55,520
0.45
0.27
8,551.20
Pharnindia
18
Nifedipine cap
Nifedipine cap
20 ng.
28,400
0.66
0.56
2,840.00
Cadila
19
Clonidine
100 ng.
73,480
0.45
0.18
18,570.00
Gernan Remedies
25
Streptoki vial 750000
I.U.
nase
65
1215
900
20,475.00
Kabivitrun
24
Pentazoci inj
ne lac.
50ng/nl
19,225
5.22
5.09
2,499.25
Biochen
Pentazoci tab
ne HC1
25 ng.
5,025
1.71
1.71
0.00
Ranba.;<y
-J
tab
_ ___ L
Astra-IDL
27
Paracetanol
tab
500 ng. 115,020
0.19
0.11
9,041.60
ZDPL
28
Paraceta
mol
0yp
60 nl.
2,550
4.90
5.41
5,471.70
Uni que
29
Dextro
propoxy
phene •
analgesic
diazeparf
65 ng/
550
75,775
0.75
0.65
7,577.50
Wo "jkhardt
50
Phenobar tab
bitone
Phenobar tab
bitone
50 ng.
65,600
0.11
0.04
4,452.00
May & Baker
60 ng.
99,000
0.15
0.07
7,920.00
May c: Baker
51
/
...2
J.
Appendix II (Contd.)‘
- : 1-0
n
Coup
Qn. ! Formulation
Page
Present
ation
Qty.
32
Diazepam
amp
lOng/nl
33
Diaze.pan
tab
34
Diazepam
tab
35
Diazepam
37
Inipramine HC1 tab
Existn.
Rate(Es)
1988-89
Revised
Rate (Rs)
1989-90
Savings
achieved
7,500
1 .78
1 .50
2,100.00
ILPL
2mg
8,100
0.20
0.18
162.00
Roche
5ng
65,000
0.29
0.14
9,450^00
IDPL
tab ‘ lOng
17,300
0.43
0.56
1 ,211.00
Hanbaxy
25ng
44,000
0.55
0.54
9,240.00
Torrent
6,720
1.21
0.87
2,284.80
Torrent
39
Inipranine HC1 cap 75mg
j Carbamazepine |tab 100mg
3,200
0.78
0.65
480.00
Torrent
40
j Carbamazepine
tab 200mg
1.3,100
1 .49
1.20
5,7'99.00
Torrent
41
| Ibuprofen
tab 200ng >
50,000
0.26
0.22
1,200.00
Boots
42,43 i Ibuprofen
tab 400mg
96,000
0.45
0.44
960.00
Boots
Ibuprofen
tab 600ng
1,070
0.64
0.64
0.00
Boots
6,500
5.28
3.85
9,295.00
IPPL
532
5.74
6.45
577.72
Me rind'
5,640 |
0.21
0.2?
338.40
Merind
8,210
12.51
8.92
29,475.90
Iyka
1,28,600
0.29
0.18
14,146.00
IDPL
24,135
1.11
0.92
4,585.65
IBPL
i 60,000 1
0.16
0.16
500mg
7;560
2.49
38
44
47
! Dexamethasone |Vial 8mg/2ml
48
j Dexamethasone i'(
49
Dexamethasone jtab 0.5mg
jHydrocortisone vial lOOng
Sod Succ
50
51
- --- pr
2.5m
I
57
Prednisolone
Frusenide
58
Frusenide
59
Nalidixic acid j tab
60
wika ci n Sul
phate
vial lOOng
‘580
61
I Aiikacin Sul
phate
vial 250r.ig
62
Aiikacin Sul
phate
vial 500ng
65,64
65
Ai oxy ci Ilin
! Aaoxycillin
67,68
Amoxycillin
69
tab
5ng
20ng/
;•
2nl
tab . 40ng
amp
(Rs)
^ouprny
Selected
0.00
Hoecsb
1.30
8,996.40
Micro
15.06
l‘l .43
2,105.40
Pharnindia
850
31.11
22.88
6,995»5O
Pharriindia
350
53.10
45.76
2,569.00
Phamindia
i
jeap
250ng
12,985
2.00
1 .20
10,588.00
BPPL
| cap
50 Ong
29,485
5.26
2.50
28,505.60
BPPL
2,125
15.04
|
9.07
12,686.25
Unique
Aipicillin
isyr. 60ml
I
jvial 500ng
55,000
8.22
I
5.52
159,500.00
70
Aristo
AipiciIlin
cap
2 5 Ong
18,400
1.16
0.72
8,093.00
HAL
71,75
Ampicillin
cap
500ng
88,500
5.20
2.20
88,500.00
Ardsto
74
Aipicillin
syr
40nl
600
9.01
6.78
1,558.00
Aristo
75
Chlorampheni
col
vial
1 ga
4,415
10.49
9.35
5,053.10
Fan. r de al
76
Chlorampheni
col
cap
2 5 Ong
27,000
0.81
0.50
8,570.00
ID PL
79
Chloronycetin
syr
60nl
140
10.18
6.60
501.20
HAL
80
Cefazoline
Sodiun
vial 500ng
4,500
25.46
21 .12
10,550.00
Cadila
Appendix II (Confed.)
11
Cohp
Qn.
Page
Present
ation
Formulation
Existn.
Rato (Rs)
1988-89
Revised
Rate (Rs)
1989-90
Savings
achieved
1 ,600
42.24
31 .78
16,736.00
Qty.
Company
Selected
fe)
81
Ccfazolinc
Sodium
vial 1 g
82
Cofazoline
So-diurn
vial 250ng
60
42.23
27.46
886.20
83
Cefotaxime
vial 1 g
585
145.14
107.54
21,996.00
Phamindia
cap 250g
98,160
3.20
2.53
65,767.20
Lyka
17,000
6.02
5.12
15,300.00
Cadila
88 j Cephalexin
j cap 500mg
|syr 40ml
1 ,200
14.19
12.66
1,836.00
Searle
89
Cloxacillin
vial 250ng
260
4.85
4.50
91.00
Lyka
90
Cioxacillin
vial 500ng
6,480
6.59
6.11
3,110.40
Lyka
91
Cioxacillin
cap
20,300
1.38
1 .28
2,030.00
Lyka
5,593.60
Lyka
Sodium
84
Cophaloxin
i
86
Cephalexin
250ng
iial
Biochon
F
92
Cioxacillin
cap
500mg
29,440
2.65
2.46
93
Bloxacillin
i syr 24g/
420
9.51
8.82
14,640
1.92
1 .56
5,270.40
Unique
289.80 | Lyka
94
Doxycycline
cap
125 ng
lOOmg
95
Erythromycin
tab
250mg
37,560
2.09
1.42
25,165.20
HAL
96
Erythromycin
syr
60ml
800
11.33
8.05
2,624.00
HAL
97
Gentanycin
vial 80ng
59,800
4.50
4.25
14,950.00
Biochen
98
Gent anycin
eyedrop
3nl
924
3.77
2.77
924.00
cap 400ng
vial 5L
5,800
7.46
5.47
11,542.00
190
2.84
2.73
20.90
3.57
30,870.00 * HAL
0.68
10,500.00 j DPL
■ 99 jNorfloxacin
100 jBenzylpeni-
j ciIlin
j
1.01 I Benzylpeni
cillin
j vial 10L
102
* cap
15 Ong
35,000
0.98
J cap
450mg
62,400
2.71
Rifampicin
j
103 | Rifampicin
j
|
I
104 ? Cotrinoxazole
amp
5ml
105
amp
30nl
tab
SOag/
400m g
Cotrinoxazole
63,000
I
j
4.06
Pharnindia
IDPL
1.96 j 46,800.00 j IDPL
I
1 ,260
4.41
250
5.50
3.36
3,339.00
'adila
535.00 | loche
j130,000
0.60
0.39
27,300.00
ICi'xPL
1 .11
0.86
12,975.00
Pharnindia
7.10
5.11
2,905.40
j
J
L
1.76 |
|
107 j
Cotrinoxazole
4
109,|Cotrinoxazole ! tab
110h
160mg/ I 51,900
30 Ong
111,j Cotrinoxazole
112
syr
50nl
113
Ethambutol
tab
200ng
■ 5,040
0.37
0.31
302.40
HAL
114
Ethanbutol
tab
400ng
4,300
0.68
0.52
768.00
KAPL
115
Ethanbutol
tab
60 Ong
4,500
0.99
0.85
630.C0
Cadila
116
Ethambutol
tab
800ng
28,400
1.31
1.12
5,396.00
Chdila
tab
1OOOng
1 ,200
1 .61
1.26
420.00
Cadila
117
Ethanbutol
j
1,460
|
I
I
BPRL
I
i
Appendix
12
Conp
Qn.
Fomulation '
Page .
Present
ation
II (Cont cl.)
Qty.
Existn.
Rate (Rs)
1988-89
Revised
Rate (Rs)
1989-90
Savings
Achieved
(Rs)
846.00
Conpany
Selected
118
I. N.H.
tab
34OOng
42,300
0.14
0.12
11 9
Pyr&zinaiiide
tab
500ng
10,600
1. 46
1 .14
3,392.00 ?HAL
120
Pyrazinanide
tab
75 Ong
10,400
2.19
1 .67
5,408.00 | Lyka
Metronidazole
vial 100nl
| tab 200ng
15,310
8.55
7.74
|10,781 .10
j Unique
9,720
0.32
0.17
1 ,458.00
KAPL
34,200
0.57
0.37
6,840.00
Eros
250
9.08
8.09
247.50
Unique
121
I
122 jMetronidazole
IDPL
123
Metronidazole
tab
400ng
124
Metronidazole
syr
60nl
125
Mebendazole
tab
10Ong
19,480
8.88
8.67
4,090.80
Cadila
126 |Mebendazole
syr
30nl
425
6.62
5.24
586.50
IDPL
Tonoferon
liq
1 70n 1
1 ,180
14.06
Becadexanine
cap
* 102,240
0.40
130 [ Ostocalciun
tab
= 211,000
Ostocalciun
syr
160b1 .
tab
128
129
I
131
132 fAscorbic acid
i
14.06
I
0.00 ’East India
0.38
2,044.80
Clindia
0.13
0.1 3
0.00
Qlindia
220
6.52
6.52
0.00
Clin di a
lOOng
13,200
0.10
0.07
396.00
Eros
3,688.00 S Ace Chenicals
135
/iscorbie acid
chew, tab
500ng
36,880
0.58
0.48
154
Ascorbic acid
dr
15nl
165
7.18
6.67
84.15
IDPL
156
Becosules ’
cap
57,360
0.32
0.32
0.00
Pfizer
157
B Conplex forte tab
with C
| inhaler
Salbutanol
200 n.d
48,900
0.48
0.35
6,357.00
350 | 24.22
22.46
580.80 !Cipla
138
0.35
0.11
57,600
0.49
0.17
6,864.00 Fairdeal
118,432 .00 |Fairdeal
9.35
290
I
140
7.5C
8.65
197.20 jCipla
6.80
70.00
400
72.30
72.30
0.00 ISuaitono
sol. 50nl ]/(.
620
8.92
8.17
960
70.08
68.64
1 ,382•40 i Uni que
1 ,040
10.75
5.51
5,657.60
Pool Pharn
12.55
10.38
1,784.50
Wbckhardt
8,800
2.1 1
1 .94
1,496.00
Martin &
Harris
565
138.38
115.00
13,209.70
Fairdeal
tab
2ng
140 |Salbutanol
i ’tub
4 ng
Salbutanol
syr
112nl
142 | Salbutanol
j
expectorant
I
110ul
500ng/ j
145 ! Pyridine
I
20ul
145 | Povidone iod
i
31 ,200
1 39 | Salbutanol
141
I
IDPL
Cipla
:
465.00
Wockhardt
ine
146
Povidone
iodine
sol. 500nl 5^
147
Povidone
iodine
oint 10g
nent
148
Povidone
iodine
oint 20g
nent
155
Chynoral forte
tab
154
Dotol anti
septic
sol. 5 Itr.
850 \
Appendix
13
II (Conid.)
Comp |
Qn. ; Poniulation
Page
Present
ation
Qty.
Existn.
Rate (Rs)
1988-89
Revised
Rato(Rs)
1989-90
158
Dextrose 5%
I.V. 540nl
50,348
8.85
6.60
68,283.00 Sri Sai
159
Dextrose 10$
I.V
540nl
5,120
9.90
Dextrose 5$ Na
Cl 0.9$
I.V. 540nl
27,820
8.25
9.35
6.60
2,816vOOI Sri Sai
45,903.00 1 Saibaba
Electrolyte P
I.V
540ril
3,780
9.72
8.45
4,800.60 Core Paren-
160
j
164
Savings
achieved
(Rs)
Company
Selected
terals
I.V. 540nl
5,000
8.25
6.60
8,250.00 Sri Sai
166j Poritonial
Dialysis
SoX. IL
3,400
15.73
15.73
0.00|Sellwell
169
Ringer Lactate
I.V. 540nl
4,280
11 .00
7.62
14,466.40jAce Chemi
cals
170
Mannitol 20/o
I.V. 350li1
1,092
17.32
15.40
2,096.64ISri Sai
165
Sodium Chloride
0.9$
____
Total value;
i
5583993.65 4395399.01
Rs. 1138594.64(21%)
Note:
Beyond the lower limit of cost-reduction of Rs.11.89 lakhs,
price escalations during the year will not be permitted, thus
effecting further savings to be utilized for charity caroo
14
Statenent
showing
Savings possi ble
Appendix
through
Plannocl.. Purchase
Contracts
JOHNSONPLAST
(Adhesive tape USP, 7.5 cns x 10 nctros. per roll* packed in 4 rolls per tube)
Quantity consumed
; Unit Rate (incl. of
by St. John’s Medi
excise and taxes) as
cal College
purchased by
Hospital
Hospital
Year
(in Rolls)
1985
(in Rupees)
(in Rupees)
39.60
1U
1064
Savings
Achieved
ky
Hospital
*
Ron arks
(in Rupees) I
Purchased as and
when required from
authorised dealer
at hospital rate
i
I
I
f
?
1986
Wholesale list price
as published by
M/s. Johnson & Johnson
+ 4^ CST + 10% KST
1384
42.77
i
42.61
I
- 221
!
i
1580
1987
1988
36.76
42.61
Purchased as and
when required from
authorised dealer
at hospital rate
9,243
Committed Volune
Contract beguu
Intense negotiations
with
competitors
for placing contract
1760
33.28
42.61
16,421
2400*
31.62
47.19
37,368
I
1989
■i*i i^aaaM.-rMn*ar
IU:
Not available.
* 1992 for 1
i 1 > W *■■■■■
■■n — ■
■ - .■ —. ■■■ ■
-a—i — —-i
'ionths plus forecast for 2 remain?
»■ r* —i
■■
r—r
months.
Group purchasing
begun.
III
Appendix
15
to du c.t s by Three
Comparative Staten ent showing Quantity Purchase^ -anA^lj^t, Jtprt e_^a^^^^1_988^i^j^ sini l^ar.
Sp e ci fi c at i ons
It on
Hospital ’Y’
(a nediun sized hospital)
Hospital ’X1
(a large hospital)
--- Quantity
Unit Rate*
170
166-00
134.75
60
157.00
360
214.78
40
221.00
436.72
NA
489.60
50
493.60
250
655.08
NA
726.85
65
718.68
15” x 12”
250
982.62
NA
1073.10
120
1027.55
I 14” x 14"
I 17” x 14 ii
100
1059.05
NA
1119.35
125
1176.88
NA
1237.70
30
1352.00
Quantity
Unit Rate
Quantity
Unit Rate*
440
153.10
60
164.10
125
123.20
120
200
148.50
8” x 10”
250
j 12” x 12
*
1 . Adhesive tape
St. John’s Medical
College Hospital
IV
____
j 4 rolls per tube
i
• 7.5 cns x 10 nts.
I
2. Plaster of Paris J a tin of 10 rolls
bandage
■ 10 cns x 2.7 nts.
; 15 cns x 2.7 nts.
---- --- --- r---------3. X-ray filns
polyester base, 50
sheets per packet
1
1..
NA :
~ If
ft-r—
'f
«l
■!
-
■-■I Ilf
Data cn quantity of X-ray filns used not available.
* Prices fluctuated during the year. Anounts nontioned in table reflo£t__averagcZr^en±.
rates paid in 1988 by the respective hospitals.
■■ —
■
- Media
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