1180 Project Report

CHAPTER 1
INTRODUCTION
The role of the Indian government in the accountability of hospitals for quality of care
involves shaping the community of those interested in quality, developing methods and
infrastructure, standardizing information, providing information and technical assistance, and
patient care.
The government role in shaping an atmosphere of trust or distrust is critical but

underestimated. The research and development of methods and infrastructure is widely
acknowledged and many health systems' reform proposals emphasize it. Several state
governments in India have begun standardizing and providing quality information and this
role is also assigned to the government in several reform proposals. Enforcing standards,
including licensure and certification, is the most widely understood governmental role; states
license whereas the government certifies compliance with Medicare conditions of
participation either directly or through accreditation by the Joint Commission. These
standards are evolving rapidly. Only recently has government taken on the role of providing
technical assistance for quality improvement.
We analyze the causal impact of competition on quality at hospitals both in India and
Other countries (from patient’s perspective). To address the variables of market structure we
analyze the hospital sector in India where entry and exit are controlled by the central
government. Because closing hospitals in areas where the governing party is expecting a tight
election race is rare due to the fear of electoral defeat, we can use political marginality as an
instrumental variable for the number of hospitals in India. We find that higher competition is
positively correlated with management quality, measured using a new survey tool. Adding a
rival hospital increases quality of hospitals from patient’s perspective by research and
increases survival rates from emergency diseases. We confirm the validity of strategy by
conditioning on marginality in the hospital’s own catchment area, thus identifying purely off
the marginality of Indian hospitals.
1
PATIENT CARE IN PUBLIC HOSPITALS:
Issues in regard to public and private health infrastructure are different and both of
them need attention but in different ways. Rural public infrastructure must remain in
mainstay for wider access to health care for all without imposing undue burden on them. Side
by side the existing set of hospitals at district and sub-district levels must be supported by
good management and with adequate funding and user fees and out contracting services, all
as part of a functioning referral net work. This demands better routines more accountable
staff and attention to promote quality. Many reputed hospitals have suffered from lack of
autonomy inadequate budgets for non-wage O&M leading to faltering and poorly motivated
care. All these are being tackled in several states are part health sector reform, and will reduce
the waste involved in simpler cases needlessly reaching tertiary hospitals direct These,
attempts must persist without any wavering or policy changes or periodic denigration of their
past working.
More autonomy to large hospitals and district health authorities will enable them to
plan and implement decentralized and flexible and locally controlled services and remove the
dichotomy between hospital and primary care services. Further most preventive services can
be delivered by down staging to a health nurse much of what a doctor alone does now. Such
long term commitment for demystification of medicine and down staging of professional help
has been lost among the politician bureaucracy and technocracy after the decline of the PHC
movement. One consequence is the huge regional disparities between states which are getting
stagnated in the transition at different stages and sometimes, polarized in the transition.
Some feasible steps in revitalizing existing infrastructure are examined below drawn from
successful experiences and therefore feasible elsewhere,
2
FEASIBLE STEPS FOR BETTER PERFORMANCE:
The adoption of a ratio based approach for creating facilities and other impulse has
led LO shortfalls estimated up to twenty percent. It functions well where ever there is diligent
attention to supervised administrative routines such as orderly drugs procurement adequate
O&M budgets and supplies and credible procedures for redressal of complaints. Current PHC
CHC budgets may have to be increased by 10% per year for five years to draw level. The
proposal in the Draft NHP 2001 is timely that State health expenditures be raised to 7% by
2015 and to 8% of State budgets thereafter. Indeed the target could be stepped up
progressively to 10% by 2025. it also suggests that Central funding should constitute 25% of
total public expenditure in health against the present 15%.
The peripheral level at the sub centre has not been (and may not now ever be)
integrated with the rest of the health system having become dedicated solely to reproduction
goals. The immediate task would be to look deepening the range of work done at all levels of
existing centres and in particular strengthen the referral links and fuller and flexible
utilization of PHC/CHCs. Tamil Nadu is an instance where a review showed that out of 1400
PHCs 94% functioned in their own buildings and had electricity, 98% of ANMs and 95% of
pharmacists were in position. On an average every PHC treated about 100 patients 224 out of
the 250 open 24 hour PHCs had ambulances. What this illustrates is that every State must
look for imaginative uses to which existing structures can be put to fuller use such as making
24 hours services open or trauma facilities in PHCs on highway locations etc.
The persistent under funding of recurring costs had led to the collapse of primary care
in many states, some spectacular failures occurring in malaria and kalazar control. This has to
do with adequacy of devolution of resources and with lack of administrative will probity and
competence in ensuring that determined priorities in public health tasks and routines are
carried out timely and in full. Only genuine devolution or simpler tasks and resources to
panchayats, where there will be a third women members- can be the answer as seen in Kerala
or M.P. where panchayats are made into fully competent local governments with assigned
resources and control over institutions in health care. Many innovative cost containment
initiatives are also possible through focused management - as for instance in the streamlining
of drug purchase stocking distribution arrangements in Tamil Nadu leading to 30% more
value with same budgets.
3
The PHC approach as implemented seems to have strayed away from its key thrust in
preventive and public health action. No system exists for purposeful community focused
public information or seasonal alerts or advisories or community health information to be
circulated among doctors in both private practice and in public sector. PHCs were meant to be
local epidemiological information centers which could develop simple community.
Tertiary hospitals had been given concessional land, customs exemption and liberal
tax breaks against a commitment to reserve beds for poor patients for free treatments. No
procedures exist to monitor this and the disclosure systems are far from transparent, redressal
of patient grievances is poor and allegations of cuts and commissions to promote needless
procedure are common.
The bulk of non-corporate private entities such as nursing homes are run by doctors
and doctors- entrepreneurs and remain unregulated cither in terms of facility of competence
standards or quality and accountability of practice and sometimes operate without systematic
medical records and audits. Medical education has become more expensive and with rapid
technological advances in medicine, specialization has more attractive rewards. Indeed the
reward expectations of private practice formerly spread out over career long earnings are
squeezed into a few years, which becomes possible only by working in hi tech hospital some
times run as businesses.
The responsibilities or private sector in clinical and preventive health services were
not specified though under the NHP 1983 nor during the last decade of reforms followed up
either by government of profession by any strategy to engage allocate, monitor and regulate
such private provision nor assess the costs and benefits or subsidization of private hospitals.
There has been talk of public private partnerships, but this has yet to take concrete shape by
imposing pubic duties on private professionals, wherever there is agreement on explicitly
public health outcomes. In fact it has required the Supreme Court to lay down the
professional obligations of private doctors in accidents and injuries who used to be refused
treatment in case of potential becoming part of a criminal offence.
4
The respective roles of the public and private sectors in health care have been a key
issue in debate over a long time. With the overall swing to the Right after the 1980s, it is
broadly accepted that private provision of care should take care of the needs of all but the
poor. hi doing so, risk pooling arrangements should be made to lighten the financial burden
on theirs who pay for health care. As regards the poor with priced services, taking into
account the size of the burden, the clinical and public health services cannot be shouldered
for all by government alone.
To a large extent this health sector reform m India at the state level confirms this
trend. The distribution of the burden, between the two sectors would depend on the shape and
size of the social pyramid in each society. There is no objection to introduce user fees,
contractual arrangements, risk pooling, etc. for mobilization of resources for health care. But,
the line should be drawn not so much between public and private roles, but between
institutions and health care run as businesses or run in a wider public interest as a social
enterprise with economic dimensions. In a market economy, health care is subject to three
links, none of which should become out of balance with the other - the link between state and
citizens' entitlement for health, the link between the consumer and provider of health services
and the link between the physician and patient.
5
FUTURE OF STATE PROVIDED HEALTH CARE
Historically the Indian commitment to health development has been guided by two
principles-with three consequences. The first principle was State responsibility for health care
and the second (after independence) was free medical care for all (and not merely to those
unable to pay)
The first set of consequences was inadequate priority to public health, poor
investment in safe water and samtati on and to the neglect of the key role of personal hygiene
in good health, culminating in the persistence of diseases like Cholera.
The second set of consequences pertains to substantially unrealized goals of NHP

1983 due to funding difficulties from compression of public expenditures and from
organizational inadequacies. The ambitious and far reaching NPP - 2000 goals and strategies
have however been formulated on that edifice in the hope that the gaps and the inadequate
would be removed by purposeful action. Without being too defensive or critical about its past
failures, the rural health structure should be strengthened and funded and managed efficiently
in all States by 2005. This can trigger many dramatically changes over the next twenty years
in neglected aspects or rural health and of vulnerable segments.
The third set of consequences appears to be the inability to develop and integrate
plural systems of medicine and the failure to assign practical roles to the private sector and to
assign public duties for private professionals.
To set right these gaps demanded patient redefinition of the state's role keeping the
focus on equity. But during the last decade there has been an abrupt switch to market based
governance styles and much influential advocacy to reduce the state role in health in order to
enforce overall compression of public expenditure an reduce fiscal deficits. People have
therefore been forced to switch between weak and efficient public services and expensive
private provision or at the limit forego care entirely except in life threatening situations, in
such cases sliding into indebtedness. Health status of any population is not only the record of
mortality and its morbidity profile but also a record of its resilience based on mutual
solidarity and indigenous traditions of self-care - assets normally invisible to he planner and
the professional.
6
Such resilience can be enriched with the State retaining a strategic directional role for
the good health of all its citizens in accordance with the constitutional mandate. Within such a
framework alone can the private sector be engaged as an additional instrument or a partner
for achieving shared public health outcomes. Similarly, in indigenous health systems must be
promoted to the extent possible to become another credible delivery mechanism in which
people have faith and away fond for the vat number of less than folly qualified doctore in
rural areas to get skills upgraded.
Public programs in rural and poor urban areas engaging indigenous practitioners and
community volunteers can prevent much seasonal and communicable disease using low cost
traditional knowledge and based on the balance between food, exercise medicine and
moderate living. Such an overall vision of the public role of the heterogenous private sector
must inform the course of future of state led health care in the country.
7
KEY ACHIEVEMENTS IN HEALTH
Our overall achievement in regard to longevity and other key health indicators are
impressive but in many respects uneven across States, The two Data Annexure at the end
indicate selected health demographic and economic indicators and highlight the changes
between 1951and 2001. In the past five decades life expectancy has increased from 50 years
to over 64 in 2000. IMR has come down from 1476 to 7. Crude birth rates have dropped to
26.1 and death rates to 8.7.
At this stage, a process understanding of longevity and child health may be useful for
understanding progress in future. Longevity, always a key national goal, is not merely the
reduction of deaths as a result of better medical and rehabilitative care at old age. In fact
without reasonable quality of life in the extended years marked by self-confidence and
absence of undue dependency longevity may men only a display of technical skills. So
quality of life requires as much external bio-medical interventions as culture based
acceptance of inevitable decline in faculties without officious start at sixty but run across life
lived at alt ages in reduction of mortality among infants through immunization and nutrition
interventions and reduction of mortality among young and middle aged adults, including
adolescents getting inform about sexuality reproduction and safe motherhood. At the same
time, some segments will remain always more vulnerable - such as women due to patriarchy
and traditions of infra-family denial), aged (whose survival but not always development will
increase with immunization) and the disabled (constituting a tenth of the population).
Reduction in child mortality involves as much attention to protecting children from

infection as in ensuring nutrition and calls for a holistic view of mother and child health
services. The cluster of services consisting of antenatal services, delivery care and post
mortem attention and low birth weight, childhood diarrhoea and ARI management are linked
priorities.
Programme of immunization and childhood nutrition seen in better performing stats

indicate sustained attention to routine and complex investments into growing children as a
group to make them grow into persons capable of living long and well Often interest fades in
pursuing the unglamorous routine of supervised immunization and is substituted by pulse
8
campaigns etc. Which in the long run turn out counter-productive. Indeed persistence with
improved routines and care for quality in immunization would also be a path way to reduce
the world's highest rate of maternal mortality.
In this context we may refer to the large ratio-based rural health infrastructure
consisting of over 5 lakh trained doctors working under plural systems of medicine and a vast
frontline force of over 7 lakh ANMs, MPWS and Anganwadi workers besides community
volunteers. The creation of such public work force should be seen as a major achievement in
a country short of resources and struggling with great disparities in health status. As part of
rural Primary health care network lone, a total of 1.6 lakh subcenters, (with 1.27 lakh.' ANMa
in position) and 22975 PHCs and 2935 CHCs (with over 24000 doctors and over 3500
specialists to serve in them) have been set up.
To promote Indian systems of medicine and homeopathy there are over 22000
dispensaries 2800 hospitals Besides 6 lakh angawadis serve nutrition needs of nearly 20
million children and 4 million mothers. The total effort has cost the bulk of the health
development outlay, which stood at over Rs 62.500/- crores or 3-64 % of total plan spending
during the last fifty years.
On any count these are extraordinary infrastructural capacities created with resources
committed against odds to strengthen grass roots. There have been facility gaps, supply gaps
and staffing gaps, which can be filled up only by allocating about 20% more funds and
determined ill to ensure good administration and synergy from greater congruence of
services, but given the sheer size of the endeavor thee wilt always be some failure of
commitment and in routine functioning. These get exacerbated by periodic campaign mode
and vertical programme, which have only increased compartmentalized vision and over-
medicalization of health problems.
The initial key mistake arose from the needless bifurcation of health and family
welfare and nutrition functions at all levels instead of promoting more holism. As a result of
all this the structure has been precluded from reaching its optimal potential. It has got more
firmly established at the periphery/sub-center level and dedicated to RCH services only. At
PHC and CHC levels this has further been compounded by a weak referral system. There has
not been enough convergence in "escorting" children through immunization coverage and
9
nutrition education of mothers and ensuring better food to children, including cooked midday
meals and health checks al schools. There has also been no constructive engagement between
allopathic and indigenous systems to build synergies, which could have improved people's
perceptions of benefits from the infrastructure in ways that made sense to them.
One key task in the coming decades is therefore to utilize fully that created potential
by attending to well known organizational motivational and financial gaps. The gaps have
arisen partly from the source and scale of funds and partly due to lack of persistence, both of
which can be set right. PHCs and CHCs are funded by States several of whom are unable to
match Central assistance offered and hence these centers remain inadequate and operate on
minimum efficiency. On the other hand over two thirds cost of three fourths of sub-centers
are fully met by the Center due to their key role m family welfare services. But in equal part
these gaps are due to many other non-monetary factors such as undue centralization and
uniformity, fluctuating commitment to key routines at ground level, insufficient
experimentation with alternatives such as getting public duties discharged through private
professionals and ensuring greater local accountability to users.
10
HEALTH STATUS ISSUES
The difference between rural and urban indicators of health status and the wide
interstate disparity in health status are well known. Clearly the urban rural differentials are
substantial and range from childhood and go on increasing the gap as one grows up to 5
years. Sheer survival apart there is also then we known under provision in rural areas in
practically all social sector services. For the children growing up in rural areas the disparities
naturally tend to get even worse when compounded by the widely practiced discrimination
against women, starting with foeticide of daughters.
In spite of overall achievement it is a mixed record of social development specially

failing in involving people in imaginative ways. Even the averaged out good performance
ides wide variations by social class or gender or region or State. The classes in may States
have had to suffer the most due to lack of access or denial of access or social exclusion or all
of them. This is clear from the fact that compared to the riches quintile; the poorest had 2.5
times more IMR and child mortality, TFR at double the rates and nearly 75% malnutrition -
particularly during the nineties.
Not only are the gaps between the better performing and other States wide but in same
cases have been increasing during the nineties. Large differences also exist between districts
within the same better performing State urban areas appear to have better health outcomes
than rural areas although the figures may not fully reflect the situation in urban and peri-
urban slums with large in migration with conditions comparable to rural pockets. It is
estimated that urban slum population wilt grow at double the rate of urban population growth
in the next few decades. India may have by 202 a total urban population of close to 600
million living in urban areas with an estimated 145 million living in slums in 2001.
11
HEALTH FINANCING ISSUES
Fair financing of the costs of health care is an issue in equity and it has two aspects
how much is spent by Government on publicly funded health care and on what aspects? And
secondly how huge does the burden of treatment fall on the poor seeking health care? Health
spending in India at 6% of GDP is among the highest levels estimated for developing
countries.
In per capita terms it is higher than in China Indonesia and most African countries but
lower than in Thailand. Even on PPP $ terms India has been a relatively high spender
information sheets based on reporting from a network associating private doctors also as has
been done successfully at CMC Vellore in their rural health projects or by the Khoj projects
of the Voluntary Health Association of India. It is only through such community based
approach that revitalization of indigenous medicines can be done and people trained in self
care and accept responsibility for their own health.
PHC approach was also intended to test the extent to which non-doctor based
healthcare was feasible through effective down staging of the delivery of simpler aspects of a
care as is done in several countries through nurse practitioners and physician assistants,
ANMs; physician assistants etc can each get trained and recognized to work in allotted areas
under referral/supervision of doctors. This may indeed be more acceptable to the medical
profession than the draft NHP proposal to restart licentiates in medicine as in the thirties and
give them shorter periods of training to serve rural areas. Such a licentiate system cannot now
be recalled against the profession's opposition nor would people accept two level services.
12
PATIENT CARE IN PRIVATE HOSPITALS:
Quality of care in private hospitals has seen a paradigm shift from a traditional focus
on structural approaches to a broader multidimensional concept which includes the
monitoring of clinical indicators and medical errors. Strong political commitment and
institutional capacities have been important factors for making the transition. What is still
lacking, however, is a culture of rigorous programme evaluation, public involvement, and
patient empowerment.
Quality care is by no means a new concept in private hospitals, where it has long been
assumed to be an implicit goal of the healthcare system. What is new is the adoption of a
systematic and scientific approach to its measurement and management.1 Likewise, the
recognition of ‘‘medical errors’’ as a systemic problem requiring systemic solutions2 is a
recent and positive development.
The impetus for change, however, is not coming from public pressure for hospitals to
be held accountable for the quality of care they deliver, but from a paternalistic government
that strives to be proactive in most matters. The government—as the regulator, major
purchaser, and major public provider—is pushing for change on behalf of private hospitals’s
non-vociferous, law abiding citizens. Although it has not been consciously pursued as such,
the evolutionary path taken by the largely ‘‘top down’’ quality healthcare movement can be
described in Donabedian terms.3 Initially focused on structures, it has recently turned on
processes and outcomes.
13
Private hospitals inherited a clean style, largely tax based, and publicly provided
healthcare system at independence in 1965. Over the years it has evolved under a pragmatic
government bent on eschewing egalitarian welfarism in favour of market mechanisms to
allocate scarce healthcare resources. N Today, health care is financed by a combination of
state subsidies (25%), employer benefits (35%), out of pocket payments (25%), compulsory
medical savings for acute care expenses (8%), risk sharing for catastrophic illnesses (2%),
and private health insurance (5%) (Ministry of Health, unpublished data, 2000). National
health care expenditure has remained fairly constant at 3% of GDP over the last two decades.
Patients have complete freedom of choice of providers. Primary health care is easily
accessible through private medical practitioners (80%) and government outpatient polyclinics
(20%). There are 26 well equipped hospitals and specialty centres providing 11 798 beds
(ratio of 3.7 beds per 1000 population). Eight public hospitals and five specialty centres
(ranging from 80 to 3110 beds) account for 80% of the beds while 13 private hospitals (from
25 to 500 beds) account for the remainder. Three private hospital chains are listed on the
Stock Exchange in India.
N Since 1985 every public sector hospital has been ‘‘restructured’’—the latter term
referring to the granting of autonomy in operational matters so as to inject private sector
efficiency and financial discipline, but with the government retaining 100% ownership of the
hospitals. Initially managed by a monolithic government company, the restructured hospitals
underwent further reorganization in 2000, splitting into two competing clusters—the National
Healthcare Group and the Health Services—but ultimately reporting to the MOH.
Private hospital doctors enjoy a high reputation, as attested by the steady streams of
well heeled patients who fly in from the surrounding region for medical care. In 2000 an
estimated 150 000 foreign patients sought treatment in private hospitals. Recently, a
governmental Economic Review Committee has set a target of one million foreign patients a
year in 10 years’ time, which would bring in an estimated $3 billion annually and create 13
000 jobs.26 As private hospitals strives to become a regional medical hub of excellence, a
major challenge will be to ensure uncompromising standards in the quality and safety of
health care that is both affordable and accessible to all Indian.
14
CHAPTER - 2
INDUSTRY PROFILE
INDIAN HEALTHCARE INDUSTRY:
Indian Healthcare industry is a wide and intensive form of services which are related
to well being of human beings. Health care is the social sector and it is provided at State level
with the help of Central Government. Health care industry covers hospitals, health
insurances, medical software, health equipments and pharmacy in it.
Right from the time of Ramayana and Mahabharata, health care was there but with
time, Health care sector has changed substantially. With improvement in Medical Science and
technology it has gone through considerable change and improved a lot.
The major inputs of health care industries are as listed below:

1. Hospitals
2. Medical insurance
3. Medical software
4. Health equipments
Health care service is the combination of tangible and intangible aspect with the
intangible aspect dominating the intangible aspect. In fact it can be said to be completely
intangible, in that, the services (consultancy) offered by the doctor are completely intangible.
The tangible things could include the bed, the décor, etc. Efforts made by hospitals to
tangiblize the service offering would be discussed in details in the unique characteristics part
of the report.
In our project our focus has been the hospital sector which is the major component of
the healthcare industry.
15
HEALTH CARE SERVICES AVAILABLE IN INDIA
 Hospitals
 Pathology Clinics
 Blood Banks
 Meditation Centres
 Emergency services like Ambulances, etc.
 Online Medical Services
 Telemedicine
 Naturopathy
 Yoga Centres
 Fitness Centres
 Laughter Clubs
 Health Spas
In the Constitution of India, health is a state subject. Central govt’s intervention to

assist the state govt is needed in the areas of control and eradication of major communicable
& non- communicable diseases, policy formulation, international health, medical & para-
medical education along with regulatory measures, drug control and prevention of food
adulteration, besides activities concerning the containment of population growth including
safe motherhood, child survival and immunization Program. The plan outlay for central
sector health programme in the Annual Plans 1997-98 is Rs.920.20 crore including a foreign
aid component of Rs.400 Crore. A major portion of outlay is for the control and eradication of
diseases like malaria, , blindness being implemented under Centrally sponsored schemes.
Another major component of the central sector health programme is purely Central
schemes through which financial assistance is given to institutions engaged in various health
related activities. These institutions are responsible for contribution in the field of control of
communicable & non-communicable diseases, medical education, training, research and
parent -care.
16
SPECIFIC FACTS:
 India’s healthcare industry is currently worth Rs 73,000 crore which is roughly 4

percent of the GDP. The industry is expected to grow at the rate of 13 percent for the
next six years which amounts to an addition of Rs 9,000 crores each year.
 The national average of proportion of households in the middle and higher middle
income group has increased in last couple of year.
 The population to bed ratio in India is 1 bed per 1000, in relation to the WHO norm
of 1 bed per 300.
 In India, there exists space for 75000 to 100000 hospital beds.
 Private insurance will drive the healthcare revenues. Considering the rising middle
and higher middle income group we get a conservative estimate of 200 million
insurable lives
 Over the last five years, there has been an attitudinal change amongst a section of
Indians who are spending more on healthcare.
Corporate hospitals mushroomed in the late eighties. The boom remained short lived
and out of the 22 listed hospital scrips, most are being trading below par. An increasingly
fragmented market, lack of statistics, capital intensive operations and a long gestation period
are all wise reasons to shy away from investing in the healthcare industry. Government and
trust hospitals dominate the scene. Many of the trust hospitals suffer from poor management.
Good corporate hospitals are still too few to amount to a critical mass.
Corporate hospitals failed a decade ago because they emerged in isolation and weren’t
part of a larger phenomenon. However, now, there are the insurance companies, the hospital
hardware and the software companies that have come together to create the boom.
17
FACTORS ATTRACTING CORPORATES IN THE HEALTHCARE SECTOR
 Recognition as an industry: In the mid 80’s, the healthcare sector was

recognized as an industry. Hence it became possible to get long term funding
from the Financial Institutions. The government also reduced the import duty
on medical equipment’s and technology, thus opening up the sector. Since the
National Health Policy (the policy’s main objective was ‘Health for All’ by the
Year 2000) was approved in 1983, little has been done to update or amend the
policy even as the country changes and the new health problems arise from
ecological degradation. The focus has been on epidemiological profile of the
medical care and not on comprehensive healthcare.
 Socio-Economic Changes: The rise of literacy rate, higher levels of income

and increasing awareness through deep penetration of media channels,
contributed to greater attention being paid to health. With the rise in the
system of nuclear families, it became necessary for regular health check-ups
and increase in health expenses for the bread-earner of the family.
 Brand Development: Many family run business houses, have set-up charity
hospitals. By lending their name to the hospital, they develop a good image in
the markets which further improves the brand image of products from their
other businesses.
 Extension To Related Business: Some pharmaceutical companies like

Wockhardt and Max India, have ventured into this sector as it is a direct
extension to their line of business.
 Opening Of The Insurance Sector: In India, approx. 60% of the total health
expenditure comes from self paid category as against governments
contribution of 25-30 %. A majority of private hospitals are expensive for a
normal middle class family. The opening up of the insurance sector to private
players is expected to give a shot in the arms of the healthcare industry.
18
Health Insurance will make healthcare affordable to a large number of people.
Currently, in India only 2 million people ( 0.2 % of total population of 1 billion), are covered
under Mediclaim, whereas in developed nations like USA about 75 % of the total population
are covered under some insurance scheme. General Insurance Company, has never
aggressively marketed health insurance. Moreover, GIC takes upto 6 months to process a
claim and reimburses customers after they have paid for treatment out of their own pockets.
This will give a great advantage to private players like Cigna which is planning to launch
Smart Cards that can be used in hospitals, patient guidance facilities, travel insurance, etc.
The Consultants, Financiers and Insurance Agencies are to benefit from this boom.
The insurers will use PPOs, that will grow into HMOs, to assume insurance risks on clients
behalf. Medical Equipments, Medical Software and Hospitals will see the biggest boom.
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HEALTH CARE SERVICE MARKETING TRIANGLE:
 Company: Here, the hospital is the company that dreams up an idea of service
offering (treatment), which will satisfy the customer’s (patient’s) expectations (of
getting cured).
 Customer: The patient who seeks to get cured is the customer for the hospital as he
is the one who avails the service and pays for it.
 Provider: Doctor, the inseparable part of the hospital is the provider, as he is the one
who comes in direct contact with the patient. The reputation of the hospital is directly
in the hands of the doctor. A satisfied patient is a very important source of word of
mouth promotion for the organization.
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UNIQUE CHARACTERISTICS:
The service industry has the following characteristics.

Intangibility: -
Intangibility means that a customer would have to visualize the service

offering. Since the offering cannot be seen or felt there would be no stock and hence one
would not be able to jeep a track of the sales etc. This characteristic also makes it different to
measure the benefits and utilities of the product. An individual would only be able to
experience the same.
In the product service continuum, hospitals fall in the bracket of highly intangible
where the service has credence qualities.
 The services of a doctor i.e. the consultation provided by the doctor , his
diagnosis etc cannot be touched felt or seen. One can only visulalise the
same.
 They can also not measure the benefits. These can only be experienced by the
customer.
 There is no ownership over the doctor or the services provided by him
 The remedial measures to overcome intangibility are:-
Association: -
The association of a hospital with any well known personality would help as a
good image building exercise . It would also give the customer a certain level of confidence
regarding the services provided in the hospital.
 (eg 1)- Hospitals like the Tata Memorial Hospital or the Hinduja hospital are
associated with Corporate Houses. They are owned by these corporate families.
Hence a customer is sure about the services provided in these hospitals.
 (eg 2)The Dinanath Mangeshkar Hospital. Since it is owned by Lata Mangeshkar the
customer is sure to receive quality services.
21
Physical Representation:-
Intangibility could also be overcome in case of hospital through physical

Representation in the form of :-
 Color- The Red Cross signifies the Hospital.
 Uniforms- The white uniforms of the Doctors And Nurses in enemy hospitals.
 Symbols – The Red Cross is the common logo with which people identify
hospitals.
 Also logos of hospitals like Wockhardt.
 Buildings – In case of hospitals the external appearance of the building or the
maintenance i.e how well maintained it is
 Documentation –There are a numbers of hospitals which have received ISO 9000
certificates. ( Eg) Apollo Hospital.
Perishability
A services cannot be stored. So if the service is not consumed immediately then it

loses its value. For Eg – If a doctor does not reach his dispensary on time or has his clinic
locked for that particular day. He loses all his patients for that day.
A situation may also arise when the doctor may be unable to attend to some of his
patients due to a huge rush. In such a case again the doctor could lose out on all his patients.
Same would be the situation faced by the hospitals. In such a case the hospital too may lose
all its patients for that day.
22
Solution To The Problem Of Perishability
a) In such a situation the doctor can appoint an assistant who could cater to the
excess patients or he could have students training under him who during their course of
training could also help him with the excess patients.
b) (Eg)- Rajgovind Hospital in CBD appoints interns of Medical College for night duty
on a stipend
Peak time Essential Services
In a rush hour situation when there are too many customers to attend to only
essential services should be catered to.
 (eg 1) In hospitals during the late night when accident reportings are high all
hands are required at the trauma centers
 (eg 2) Part time volunteers for national Emergencies.
23
QUALITY IN HEALTHCARE INDUSTRY:
India has achieved extraordinary results both in the high quality of its healthcare
system and in controlling the cost of care. In per capita terms and as a percentage of Gross
Domestic Product (GDP), its healthcare expenditures are the lowest of all the high-income
countries in the world. How did this happen? How has India been able to achieve these kinds
of results? Answers are bigger than just the process of putting a healthcare system together. -
ere are larger factors that have to do with the spirit and philosophy of India itself, the way it is
governed, how the government approaches domestic issues, and how it deals with the world.
In my study of India, I have found three compelling qualities woven into the fabric of
the country that have enabled it to achieve outstanding successes in so many areas, healthcare
included. ey are long-term political unity, the ability to recognize and establish national
priorities, and the consistent desire for collective well-being and social harmony of the
country.
POLITICAL UNITY AND CONSTANCY OF PURPOSE
From the time the British withdrew from India and left its former colony to fend for
itself, India has been able to develop and grow as an integrated whole. e People’s Action
Party (PAP) has been in power since independence, resulting in sustained political stability.
Along with stability has come a unity and constancy of purpose and action throughout
government. Contrast this condition with other countries where government regularly
changes hands and different parties espousing different agendas go in and out of power. A
clear and uninterrupted approach to solving a nation’s problems is very difficult to achieve in
such situations. e government has been steady in its broad general vision of what care should
be and what role it should play in the lives of Indian. at continuity of philosophy and
approach, I believe, has made possible the ability to plan and execute over a long period of
time.
I have also observed an unusual degree of unity among the country’s various
ministries—an acknowledged spirit of cooperation among governmental departments that
makes possible the formulation of policies that reaches across ministries. A member of the
24
team that assembled the 1983 health plan discussed in this chapter and Health Minister from
2004 to 2011, Mr. Khaw Boon Wan, has noted that each month, Permanent Secretaries of
each ministry meet to focus on issues that require participation by more than one ministry.1 It
is simply assumed that ministers will work as a team on issues that need interdepartmental
cooperation.
I find it relevant that the government realized early on that improvement in health
conditions and care had to be approached as an integral and inseparable part of the overall
development planning for the country. As a heavily urbanized city-state with a population of
two million at independence, caring for the health of the people meant more than just
building hospitals and clinics. Health would be affected by almost every aspect of life in an
urban setting: housing, water supply, food supply, air quality, waste disposal, road traffic,
parks, tree planting, and more. Ensuring the health of the people of India had to be built into
every aspect of urban planning, requiring a comprehensive approach and the cooperation of
numerous ministries over all the various sectors of government. e culture of cooperation
made it all possible.
Some have suggested that India is a thinly-disguised dictatorship, and that political
stability is attained at the cost of democratic freedom. at is simply not the case. Although one
party, the PAP, has been in power since independence, it is elected and does not hold power
through force, and could not have maintained its rule without being highly responsive to the
concerns of the electorate.
Government is responsive to the concerns of the electorate. In the 2011 elections,

healthcare was one of the issues raised. ere were concerns that the government was not doing
enough for the elderly and that families were experiencing severe financial strain and even
bankruptcy as they tried to pay for older family members’ care. Opposition parties organized
themselves around issues of healthcare affordability and eldercare costs.
Early the following year, the government responded with a new program of increased
spending—doubling the Ministry of Health’s budget over the next five years—to address
citizens’ concerns. It announced increased subsidies for long-term care, even for patients
being cared for in the home, and expanded eligibilities for subsidies, giving middle-income
families some financial relief. Subsidies were increased for nursing homes (including eligible
25
patients in private nursing homes), day care, rehabilitation care, and home-based care. ese
actions by the government seem to me to be a direct response to the issues raised in the
elections.
ESTABLISHING PRIORITIES
Health of the populace was not a top priority for the government at the start of
independence. As Lee Kuan Yew observed in his memoirs, he had three immediate concerns
to deal with: international recognition for India’s independence; a strong defence program
that would “defend this piece of real estate”; and finally the economy—“how to make a
living for our people.”2 Yong Nyuk Lin, the Minister for Health at the time, stated the
situation bluntly: “health would rank, at the most, fifth in order of priority” for public funds.
National security, job creation, housing, and education were in the queue ahead of health, in
that order.3 With the exception of the basics of public health, healthcare planning and
development would have to wait until the nation achieved a level of military and economic
stability.
It seems to me that this ordering of priorities was apt for the time, as it was vitally
important first to set up the defence of this small nation, and then to attract investors to set in
motion economic growth, and tackle glaring issues of unemployment, housing, and
education. After these critical problems had been dealt with, others, including healthcare,
could be taken on. Exactly where health comes in the priorities of an emerging economy may
vary. In countries where HIV/AIDS is highly prevalent, or if another epidemic or disease
threatens a broad segment of the population, health may become the first or second national
priority.
Wisely, the initial focus in India was on public health: putting proper sanitation
procedures in place, controlling infectious diseases, all successful efforts. Early initiatives
were launched to provide clean water, develop a vaccination program, and guarantee access
to basic medications, clean food, and more. In time, the priorities set by the government
proved to be effective. e security situation stabilized and the economy grew to the benefit of
all. e creation of the healthcare system was aided immeasurably by the outstanding growth.
26
Promoting a Sense of Collective Well-Being and Social Harmony One of the most
important tenets of Indian governance is that a strong society requires social harmony. If
tensions between social groups and races are to be avoided, all groups should be included in
the life of the country and should benefit, to some degree, from its successes. e government’s
actions on behalf of this belief have undergirded the building. As part of the social fabric, the
government built a system that promotes a sense of fairness and well-being through both
economic opportunity and delivery of social services. I find these words of Lee key to
understanding and approach:
A competitive, winner-takes-all society, like colonial Hong Kong in the 1960s, would
not be acceptable in India. To even out the extreme results of free-market competition, we
had to redistribute the national income through subsidies on things that improved the earning
power of citizens, such as education. Housing and public health were also obviously
desirable. But finding the correct solutions for personal medical care, pensions, or retirement
benefits was not easy. One important solution Lee and his ministers found was the Central
Provident Fund (CPF). It was set up during British colonial rule as a compulsory
savings program for workers to build a nest egg for retirement. Individuals put five percent of
their wages into the fund and their employers matched it. e accumulated money could be
withdrawn at age 55. Lee’s government expanded the program, upping the contribution
levels, and allowing funds to be used for home-buying (widespread home ownership was
seen as vital for political and social stability).
e CPF has become one of the key pillars supporting social stability. e government had
a long-range vision to increase the use of the Fund over time and broaden it to allow
individuals to save for and pay for education and healthcare as well as retirement and home-
buying. Mandatory contribution rates have risen over the years and now stand at 16 percent
of wage for employers and 20 percent for employees. After age 50, the rates decrease. The
Central Provident Fund’s contribution to the viability of the healthcare system cannot be
overstated: it helps control costs by instilling in patients a sense of responsibility about their
spending—after all, it is their money to save or spend; and it helps make care available and
affordable to all. Eventually, however, the government recognized that the health savings
program would not be enough to support care, and other systems were put in place, including
a medical insurance program and a social safety net.
27
CHAPTER 3
REVIEW OF LITERATURE
Patient has traditionally been associated with powerlessness against the medical
establishment (Sitzia & Wood, 1997). In the 1980s, the concept ‘consumer’ began to appear
in quality literature as part of a general shift towards consumerism evident in aspects of
public service. The consumerist approach to healthcare was evident through governmental
acts and regulations in different countries (Carr-Hill, 1992; Greeneich, 1993; Sitzia & Wood,
1997; Ministry of Health and Care Services, 1999; The Norwegian Directorate of Health,
2005). ‘Consumer’ originates in the private rather than the public sector, and is strongly
connected to the commercial world. There has been strong criticism of the use of the concept
in the healthcare field (Carr-Hill, 1992; Sitzia & Wood, 1997).
Consumers’ rights cannot easily be applied in a healthcare context (Carr- Hill, 1992).
Greeneich (1993) and Sitzia and Wood (1997) argue, on the other hand, that the concept of
‘consumer’ dignifies the professional healthcare patient relationship in a way that the concept
of ‘patient’ does not. ‘Consumer’ and ‘customer’ satisfaction are concepts commonly used in
economic research. Patient satisfaction is the concept most often used in research within the
healthcare sciences. Using the concepts ‘consumer’ or ‘customer’ does not automatically give
power to the person in need of healthcare. As is shown in the Norwegian Patients’ Rights Act
of 1999 (Ministry of Health and Care Services, 1999), the patient is no longer looked upon as
powerless and passive. Both healthcare authorities and healthcare personnel expect the
patients to be actively involved in their own healthcare. Boudreaux, Ary and Mandry (2000)
view the patient provider interaction as a dynamic one, during which both the patient and the
provider are constantly giving, receiving, and evaluating information about one another.
Recently hospital wards have been implementing ‘patient-centred’ care (Olsson,

Hansson, Ekman, & Karlsson, 2009). The development of patient-centred nursing and
healthcare, changes the focus from the illness in a person to the person with an illness
(Pelzang, 2010). The term is described as the unique way to care for the individual patient,
and is also recognized as a measure of quality of healthcare and used in quality research
(Robinson, Callister, Berry, & Dearing, 2008). More recently the concept of ‘person-centred’
care has been introduced in the delivery of nursing and healthcare (McCormack & McCance,
2006). Implementing a person-centred approach to nursing and healthcare may provide a
28
more therapeutic relationship between healthcare personnel, patients and their families
underpinned by values of seeing patients as equal partners in planning, developing and assess
healthcare (McCormack, Dewing, & McCance, 2011).
The focus of this thesis is quality of care and patient satisfaction with healthcare in
hospital. Hospitalised persons are still called patients, and patients today have rights and
obligations when being part of the healthcare system. The concept of ‘patient’ will be used in
this thesis.
QUALITY IN HEALTH CARE
The World Health Organization (WHO) (2009) and The International Council of
Nurses (ICN) (2006) state that the overall goal is highest possible health for all people, and
providing high quality care is one approach for reaching this goal. The Norwegian national
action plan on health and social care (Ministry of Health and Care Services, 2011)
emphasises the importance of high-quality care through patient-centred care and the
importance of building systems for patients’ to take part in the evaluation of quality of care
on a regular basis. ‘Quality of care’ is a concept that can be given different meanings,
depending on different cultures, whether it is on an individual level or a social level, which
aspect we are looking at; process, structure or outcome, whether it is the patients, the
relatives, the healthcare personnel, the administrators or the politicians who define the term
and the time at which it is defined (Donabedian, 1966, 1980; Wilde, 1994; Pettersen,
Veenstra, Guldvog, & Kolstad, 2004).
It is considered by researchers to be a multidimensional concept (Crow, et al., 2002).

Florence Nightingale was the first to organise and structure nursing care in the middle of the
19th century. Her notes have to be understood in the context of her time, but much is relevant
today in hospitals around the world. She described in her book, Notes on Nursing
(1859/2010), her views of good nursing. The aim of nursing was to place the individual in the
best condition for nature to act. She was concerned about the quality of care given to each
patient.
During the Crimean War she was a proficient bedside nurse with great concern for the
soldiers, and she also took systematic notes of the care and the patients’ reaction to the care to
29
improve nursing (Nightingale, 1859/2010). She did not explicitly use the concept ‘quality’,
but quality care is what she implicitly aims at with her notes on nursing. She saw, however,
the quality of care from the nurses’ perspective.
Donabedian (1966) is one of the leading researchers in quality of care research, and
has found that aspects of structure, outcome and process are indicators of the quality of
medical care. ‘Structure’ was described as the fixed part of the practice-setting and consisted,
like today, of providers, resources and tools. ‘Process’ was the relationship between care
activities and the consequences of them on the health and welfare of the patient. ‘Outcomes’
were interpreted as changes in the patient’s condition. Donabedian (1966) wanted to turn the
assessment process from evaluation to understanding, i.e. from “What is wrong here?” to
“What goes on here?” He claimed that the quality of care is as good as the patients say their
satisfaction with the care received, and stated that patient satisfaction is not simply a measure
of quality, but the goal of health care delivery (Donabedian, 1980). In other words, patient
satisfaction is both an outcome and a contributor to other objectives and outcomes, according
to Donabedian (1980, 2003). This is supported by Zastowny, Stratmann, Adams and Fox
(1995). Donabedian was among the first to make a link between quality of medical care and
patient satisfaction (1966), and to view quality of care from the patient’s perspective (1980).
Based on a literature review, he found that quality of care from a patient’s perspective is a
combination of the quality of three aspects: technical ward, interpersonal ward and
organisational ward environment (Donabedian, 1980).
Wilde, Starrin, Larsson and Larsson (1993) using a grounded theory approach
developed a theoretical model of quality of care from a patient perspective. Through this
approach they turned the perspective of quality of care from that of the healthcare workers’ to
the patients’. Patients’ perceptions of what constitutes quality of care are formed by their
systems of norms, expectations and experiences, and by their encounters with an existing care
structure. The theoretical model outlined two basic conditions that quality of care builds on,
i.e. ‘the resource structure of the care organisations’ and ‘the patients’ preferences’. The
resource structures are person-related qualities that refer to the caregivers, and physical and
administrative environmental qualities that in turn refer to infrastructural components of the
care environment, such as organisational rules and technical equipment. The patients’
preferences consist of a rational aspect that refers to the patient’s strive for order,
predictability and calculability in life, and a human aspect that refers to the patient’s
30
expectations that her/his unique situation is taken into account. The patients’ perception of
quality of care based on this theoretical model may be considered from four dimensions: the
medical-technical competence of the caregivers, the identityoriented approach of the
caregivers, the physical-technical conditions of the care organisation, and the socio-cultural
atmosphere of the care organisation (Figure 1) (Wilde, et al., 1993).
PATIENT SATISFACTION
Patient satisfaction, which has its roots in the consumer movement of the 1960s, has
both practical and political relevance in the current healthcare system. It is commonly used to
guide research into patients’ experiences of healthcare (Gut, Gothen, & Freil, 2004;
Danielsen, Garratt, Bjertnes, & Pettersen, 2007). A commonly accepted conceptual definition
has not been established (Merkouris, Ifantopoulos, Lanara, & Lemonidou, 1999). There are,
however, different ways of looking at the concept of satisfaction. The discrepancy theory, the
fulfilment theory, the equity theory (Lawler, 1971), and the value-expectancy model (Linder-
Pelz, 1982), are alternative approaches to the concept of satisfaction. A tentative model
developed by Larsson, Wilde and Starrin (1996), and further developed by Larsson and
Wilde-Larsson (2010) that view patient satisfaction as an emotion, presents an alternative
approach to the concept.
Lawler (1971) categorized satisfaction studies according to their implicitly theoretical

perspective due to the way in which satisfaction was measured. He identified discrepancy
theory, equity theory and fulfillment theory (Lawler, 1971). The three theories are similar, in
that they define satisfaction as being concerned with differences between what one wants and
what one perceives receiving. There is no agreement about what the concepts of ‘want’ or
‘desire’ encompass (Linder-Pelz, 1982; Williams, 1994). In addition, equity theory states that
satisfaction is the perceived balance of inputs and outputs, and one evaluates one’s own
balance against the balances of others (Lawler, 1971), which introduces the role that social
comparison processes might have in healthcare evaluations (Linder-Pelz, 1982; Williams,
1994).
Linder-Pelz (1982) has developed a value-expectancy model of satisfaction. The

model was based on the attitude theory and the job satisfaction research carried out by
31
Fishbein and Azjen (1975). Linder-Pelz (1982) defines patient satisfaction as: ‘positive
evaluations of distinct dimensions of the health care’. The care evaluated might be a single
visit, a particular healthcare setting or healthcare in general. Very little of patient satisfaction
has been explained in concepts such as ‘values’ and ‘expectations’ (Williams, 1994). The
nature of expectation is complex and a theoretical description is lacking (Schmidt, 2003).
Just as Williams (1994) and Schmidt (2003), Wilde (1994) found it more relevant to
relate a patient’s experience of actual healthcare to his or her preferences, rather than to
expectations. Preferences show the subjective meaning of a care episode to a person. This
means that measuring patients’ expectations does not tell us much about the patients’
perception of quality of care or patient satisfaction. It tells us something about how the
patients believe it will be. To measure the subjective importance (preferences), expresses how
the patients wish it to be (Wilde, 1994). Index of measures based on patients’ preferences and
experiences of actual healthcare (perceived reality) has been developed to provide an overall
picture of the responses for instance on a hospital ward. If the patients give high or low scores
on both perceived reality and subjective importance, a state of balance is indicated. However,
high scores on subjective importance and low scores on perceived reality indicate a deficit
and something has to be done. On the contrary low scores on subjective importance and high
scores on perceived reality, indicate conditions that should be given low priority in quality
improvement work (Wilde, Larsson, Larsson, & Starrin, 1994; Larsson & Wilde Larsson
2003).
It is open to discussion whether patient satisfaction is an attitude, a perception, an

opinion of healthcare, or an attitude towards life in general, and not especially towards the
healthcare in hospital (Merkouris, et al., 2004). It is also unclear whether patient satisfaction
and dissatisfaction are opposite ends of the same continuum, or two different phenomena that
require two different definitions (Biering, Becker, Calvin, & Grobe, 2006). In a review, Coyle
and Williams (1999) go even further and claim that research should theorise the concept of
dissatisfaction and develop a framework for exploring dissatisfaction with healthcare to gain
additional insight into patients’ healthcare experiences in hospital.
32
CHAPTER 4
RESEARCH METHODOLOGY
4.1 Research Aim and Objectives:
In a few studies it was presumed that the exchange capacity of Service Quality scale
to distinctive administration setting required to be tried. Inquire about on health care industry
has demonstrated that the five nonexclusive sizes of Service Quality were not further
affirmed showing the need for further research directed on examples from diverse parts of the
planet. The project additionally endeavours to form key vision to empower India's stroll in
public clinic way to convey a larger amounts of patient fulfilment Quality.
4.2 There are three objectives of the study: -
 To determine is there any critical differences in the level and sort of health
care administrations In India's public and private hospitals as recognized by
patients.
 To identify the safety and quality dimensions which play important role on
patient satisfaction
 To test the dimensionality of the healthcare system in India between public

and private hospital.
33
4.3 Research Questions:
 How long do the patients have to wait for in the Out Patients Department?
 Where are the patients coming from?
 How many critical patients are being admitted in the public hospital or private
hospitals in India for further treatment?
 What sorts of preparing about formal quality systems are available for health
professionals?
 What evidence is there about the best techniques for preparing clinicians in
quality change?
4.4 RESEARCH METHODOLOGY
This research is considered quantitative, descriptive and explanatory, and to

some extent exploratory. It follows the survey strategy approach and consists of
survey instrument. This study is conducted in two major hospitals in India.
(i) KEM hospital Mumbai, India

(ii) Lokmanya Tilak Municipal General Hospital, Mumbai, India
The questionnaire was randomly distributed to five most busiest and crowded clinics among
Indian hospitals. The total size of the sample is 125. The data analysis is obtained through
using different statistical techniques by using the SPSS software.
34
4.5 RESEARCH LIMITATIONS
The research area had never been conducted before in other countries, and the absence
of previous experience especially has created some difficulties and challenges during
research. This study was subjected to certain limitations which should be pointed out:
 A major limitation of this study is that it was conducted to outpatients only. It is indeed
an important point if inpatients were including in the study.
 The data was collected from only four public hospitals in India. A large sample size
comprised of outpatients from other hospitals should be examined to validate the
findings from this study.
 Our study is conducted on only one sector that is out patients and lacks the management
participations, having the hospitals` management perception to service quality would
give a good understanding to the patients` overall satisfaction.
 Our sample is not representative of the general population concerning service quality
because business people and people with high income levels tend not to use public
hospitals.
 The current study chooses to use the perception measurement of public hospitals quality
as a predictor of the service quality concept. It would be interesting to study whether the
only use of perception is more acceptable than the expectation-perception approach.
35
CHAPTER - 5
ANALYSIS AND INTERPRETATION

...........................................................................................................................
5.1 Are doctors and nurses are familiar with their Duties and Responsibilities
assigned by Public hospitals in India?
Table 5.1
DIMENSIONS NO.OF RESPONDENTS PERCENTAGE
Strongly agree 59 47
Agree 46 37
Disagree 10 8
Strongly disagree 2 2
Neither agree nor disagree 8 6
TOTAL 125 100.0
Graph 5.1
Inference:
From the above graph, it is observed that 84% of the respondents (47% strongly
agreed, 37% agreed) have accepted that they know about their duties and responsibilities and
8% of respondents are not aware of their duties and responsibilities.
36
5.2 The Public Hospital provides proper Authority, Responsibility, and
Accountability to its health workers.
Table5.2
Agree 52 42
Disagree 15 12
TOTAL 125 100
Graph 5.2
Inference:
From the above graph, it is observed that 74% of the respondents have accepted that
they are assigned the job with authority responsibilities and accountability to perform well.
Around 14% of the respondents have not accepted the statement.
37
5.3 Identified new diseases and cases by the hospital management.
Table 5.3

Agree 50 40
Disagree 15 12
TOTAL 125 100.0
Graph 5.3
Inference:
From the above graph, it is observed that 64% of respondents strongly have
accepted that they are identified new treatments and diseases especially after providing some
healthcare training to them. Around 23% of respondents have not accepted the statement
38
5.4 Stress on public hospital employees (doctors and nurses) converts into
positive manner.
Table 5.4

Agree 50 40
Disagree 20 16
TOTAL 125 100.0
Graph 5.4
Inference:
From the above graph it is observed that 64% of respondents have
accepted that they convert stress into positive manner and 20% of the respondents have not
accepted the same.
39
5.5 Job rotation leads to the individual improvement.
Job rotation refers health workers moving from one job to another job and in this it is
to identify whether job rotation leads to the individual improvement and to public hospital
benefit or not.
Table 5.5

Agree 40 32
Disagree 17 14
TOTAL 125 100.0
Graph 5.5
Inference:
their job is rotated and led to both individual improvements and hospital benefits around 28%
of respondents have not accepted the statement.
5.6. Doctors and physicians identifies patients diseases and treatments
40
Table 5.6

Agree 50 40
Disagree 23 18
TOTAL 125 100.0
Graph 5.6
Inference:
the concerned in charge identifies their diseases and treatments. Around 18% of respondents
have not accepted the statement.
5.7. Public hospitals provide new treatments and researches apart from other
hospitals
Table5.7
41
Agree 50 40
Disagree 22 18
TOTAL 125 100.0
Graph 5.7
Inference:
From the above graph, it is observed that 66% of the respondents have
accepted that public hospitals provide new treatments apart from other hospitals. Around 16%
of respondents have not accepted the statement.
42
5.8 Chief Doctors in the Public hospitals guides to their juniors as and when
required.
Table 5.8

Agree 50 40
Disagree 14 11
TOTAL 125 100.0
Graph 5.8
Inference:
they are asked to take decisions and their Seniors guides them as and when required. Around
21% of respondents have not accepted the statement.
43
5.9 Management of the hospital addresses grievances immediately?
Table 5.9

Agree 45 36
Disagree 12 10
TOTAL 125 100.0
Graph 5.9
Inference:
accepted that Management of the hospital addresses grievances immediately. Around 20% of
respondents have not accepted the statement.
44
5.10 Public hospitals utilize employee services effectively and efficiently.
Table5.10
Agree 40 32
Disagree 19 15
TOTAL 125 100.0
Graph 5.10
Inference:
accepted that the hospitals utilize their services effectively and efficiently. Around 29% of
45
5.11. Present job leads satisfaction to the health workers in the public hospital.
Table 5.11
Agree 53 42
Disagree 13 10
TOTAL 125 100.0
Graph 5.11
Inference:
accepted that they derive satisfaction in performing the job. Around 18% of respondents have
not accepted the statement.
46
5.12. Seniors and subordinates are very cooperative in the hospitals
Table 5.12

Agree 52 42
Disagree 16 13
TOTAL 125 100.0
Graph 5.12
Inference:
their seniors and subordinates are very cooperative and they work as a team. Around 13% of
47
5.13. Doctors, nurses and technicians are recognized and rewarded suitably by
the public hospital.
Table5.13

Agree 40 32
Disagree 22 18
TOTAL 125 100.0
Graph 5.13
Inference:
From the above graph, it is observed that 53% of the respondents have accepted
that they have been recognized and rewarded suitably by the hospital for their performance as
per the government policy. Around 30% of respondents have not accepted the statement.
48
5.14. Public hospital provides compensation based on qualification, experience.
Table 5.14
Agree 64 51
Disagree 17 14
TOTAL 125 100.0
Graph 5.14
Inference:
accepted that they know that the compensation commensurate with the qualification,
experience exposure and especially with their job performance during the period in delivering
results in time. Around 15% of respondents have not accepted the statement.
49
5.15. Public hospital provides job security to the employees.
Table5.15
DIMENSIONS NO. OF RESPONDENTS PERCENTAGE
Agree 55 44
Disagree 9 7
Neither agree nor
5 4
disagree
TOTAL 125 100.0
Graph 5.15
Inference:
From the above graph, it is observed that 76% of the respondents strongly have
accepted that they feel a sense of job security and sense of social belongings in the hospital.
Around 17% of respondents have not accepted the statement.
50
CHAPTER - 6
FINDINGS , SUGGESTIONS AND CONCLUSION
 It is found that 84% of the respondents (47% strongly agreed, 37% agreed) have
accepted that they know about their duties and responsibilities
 It is found that 74% of the respondents have accepted that they are assigned the job
with authority responsibilities and accountability to perform well
 It is found that 64% of respondents strongly have accepted that they are identified for
new treatments and procedures especially after providing training to them
 It is found that 64% of respondents have accepted that they convert healthcare job
stress into positive manner
 It is found that 60% of the respondents have accepted that their job is rotated and led
to both individual improvements and hospital benefits
 It is found that 64% of the respondents have accepted that the concerned in charge
identifies their present skills and potentials in performing the hospital services and
training is imparted to them accordingly
 It is found that 68% of the respondents have accepted that they are asked to take
decisions in job and their senior staffs guides them as and when required
 It is found that 60% of the respondents have accepted that their immediate in charge
or hospital management addresses their grievances and gives them feedback on the
same.
 It is found that 56% of the respondents have accepted that the hospital utilizes their
services effectively and efficiently
51
 It is found that 72% of the respondents have accepted that they derive satisfaction in
performing the job
 It is found that 74% of the respondents have accepted that their seniors and
subordinates are very cooperative and they work as a team
 It is found that 53% of the respondents have accepted that they have been recognized
and rewarded suitably by the hospital for their performance as per the policy.
 It is found that 73% of the respondents have accepted that they know that the
compensation commensurate with the qualification, experience exposure and
especially with their job performance during the period in delivering results in time
 It is found that 76% of the respondents strongly have accepted that they feel a sense
of job security and sense of social belongings in the public hospital
52
SUGGESTIONS:
 Identify the key performance areas of the health workers in public hospitals in India
and other countries conduct training programmes to develop their skills and
knowledge.
 30% of the respondents are dissatisfied due to lack of recognition and rewards. This is
especially happened in India not in other countries. A positive recognition for work
boosts the motivational level of doctors and nurses in public hospitals. Recognition
can be made explicit by providing awards like best employee of the month.
 Immediate resolution of the grievance is necessary otherwise it will effects the
productivity of the public hospital so immediate actions should be taken to resolve the
grievance of the employees.
 30% of the respondents are not identified for new treatments so extend their work
by providing proper training to the junior health workers in hospitals in other
countries.
 Provide opportunities for career personal growth through training, challenging
assignments and more.
53
CONCLUSION
Despite differences in how healthcare is organised, financed, and resourced, our cross
sectional data suggested that both types of hospitals studied face problems of hospital quality,
safety, and nurse burnout and dissatisfaction. Although workers shortages have been
moderated partly by the global economic downturn, nurses’ reports of their intentions to leave
their jobs in hospitals could indicate future difficulties, especially with the substantial rates
seen in India. In other countries, staffing and the quality of the hospital work environment
(managerial support for nursing care, good doctor-nurse relations, nurse participation in
decision making, and organisational priorities on care quality) were significantly associated
with patient satisfaction, quality and safety of care, and nurse workforce outcomes.
More specifically, public hospitals with good work environments and nurse staffing
had improved outcomes for patients and nurses alike. Although we cannot be sure of
causality because the data were cross sectional, the public hospital work environment was
associated with outcomes in each country.
Patients’ and nurses’ ratings of public hospitals were similar. Whether patients rated
their hospital as excellent or would recommend their hospital to other patients was associated
significantly with nurses’ ratings of their hospital work environment and reports of nurse
staffing. Data from nurses in every country suggested a lack of confidence that hospital
management would solve identified problems in patient care.
Management’s uncertainty of nurses’ complaints reflecting objective clinical

observations of care quality might need to be tempered by our results, which show that
nurses’ assessments concur with those made independently by patients. Our data support the
conclusion reached by the World Alliance for Patient Safety that organisational behaviours
are important in promoting patient safety and quality of public hospitals.
54
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57
APPENDIX
QUESTIONNAIRE
1) Are doctors and nurses are familiar with their Duties and Responsibilities assigned by
Public hospitals in India?
 Strongly agree
 Agree
 Disagree
 Strongly disagree
 Neither agree nor disagree
2) The Public Hospital provides proper Authority, Responsibility, and Accountability to

its health workers.
 Strongly agree
 Agree
 Disagree
3) Identified new diseases and cases by the hospital management.

 Strongly agree
 Agree
 Disagree
4) Stress on public hospital employees (doctors and nurses) converts into positive
manner.
 Strongly agree
 Agree
 Disagree
58
5) Job rotation leads to the individual improvement.
 Strongly agree
 Agree
 Disagree
6) Doctors and physicians identifies patients diseases and treatments

 Strongly agree
 Agree
 Disagree
7) Public hospitals provide new treatments and researches apart from other hospitals
 Strongly agree
 Agree
 Disagree
8) Chief Doctors in the Public hospitals guides to their juniors as and when required.
 Strongly agree
 Agree
 Disagree
9) Management of the hospital addresses grievances immediately?

 Strongly agree
 Agree
 Disagree
59
10) Public hospitals utilize employee services effectively and efficiently.
 Strongly agree
 Agree
 Disagree
11) Present job leads satisfaction to the health workers in the public hospital.
 Strongly agree
 Agree
 Disagree
12) Seniors and subordinates are very cooperative in the hospitals

 Strongly agree
 Agree
 Disagree
13) Doctors, nurses and technicians are recognized and rewarded suitably by the public
hospital.
 Strongly agree
 Agree
 Disagree
60

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CHAPTER 1

The government role in shaping an atmosphere of trust or distrust is critical but

The second set of consequences pertains to substantially unrealized goals of NHP

Reduction in child mortality involves as much attention to protecting children from

Programme of immunization and childhood nutrition seen in better performing stats

In spite of overall achievement it is a mixed record of social development specially

INDIAN HEALTHCARE INDUSTRY:

The major inputs of health care industries are as listed below:

In the Constitution of India, health is a state subject. Central govt’s intervention to

 India’s healthcare industry is currently worth Rs 73,000 crore which is roughly 4

 In India, there exists space for 75000 to 100000 hospital beds.

 Recognition as an industry: In the mid 80’s, the healthcare sector was

 Socio-Economic Changes: The rise of literacy rate, higher levels of income

 Extension To Related Business: Some pharmaceutical companies like

The service industry has the following characteristics.

Intangibility means that a customer would have to visualize the service

Intangibility could also be overcome in case of hospital through physical

 Also logos of hospitals like Wockhardt.

 Buildings – In case of hospitals the external appearance of the building or the

maintenance i.e how well maintained it is

certificates. ( Eg) Apollo Hospital.

A services cannot be stored. So if the service is not consumed immediately then it

Peak time Essential Services

POLITICAL UNITY AND CONSTANCY OF PURPOSE

Government is responsive to the concerns of the electorate. In the 2011 elections,

Recently hospital wards have been implementing ‘patient-centred’ care (Olsson,

QUALITY IN HEALTH CARE

It is considered by researchers to be a multidimensional concept (Crow, et al., 2002).

Lawler (1971) categorized satisfaction studies according to their implicitly theoretical

Linder-Pelz (1982) has developed a value-expectancy model of satisfaction. The

It is open to discussion whether patient satisfaction is an attitude, a perception, an

4.1 Research Aim and Objectives:

4.2 There are three objectives of the study: -

 To test the dimensionality of the healthcare system in India between public

 Where are the patients coming from?

hospitals in India for further treatment?

4.4 RESEARCH METHODOLOGY

This research is considered quantitative, descriptive and explanatory, and to

(i) KEM hospital Mumbai, India

ANALYSIS AND INTERPRETATION

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

5.6. Doctors and physicians identifies patients diseases and treatments

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO. OF RESPONDENTS PERCENTAGE

FINDINGS , SUGGESTIONS AND CONCLUSION

accepted that they know about their duties and responsibilities

with authority responsibilities and accountability to perform well

new treatments and procedures especially after providing training to them

stress into positive manner

to both individual improvements and hospital benefits

training is imparted to them accordingly