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.
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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
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revitalizing existing infrastructure are examined below drawn from successful
experiences and therefore feasible elsewhere,
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
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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.
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.
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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.
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.
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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
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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.
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.
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
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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 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,
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(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 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
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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.
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
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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.
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.
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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.
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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.
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.
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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 equipment’s
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.
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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.
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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.
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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.
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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 Equipment’s, 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.
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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.
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.
21
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.
22
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.
23
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 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
24
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 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
25
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.
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
26
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
28
(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 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).
29
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 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
30
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 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
31
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
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
32
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.
33
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.
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?
34
 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.
35
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.
36
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
8 6
disagree
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.
37
5.2 The Public Hospital provides proper Authority, Responsibility, and
Accountability to its health workers.
Table5.2
NO.OF
DIMENSIONS PERCENTAGE
RESPONDENTS
Agree 52 42
Disagree 15 12
Neither agree nor
8 6
disagree
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.
38
5.3 Identified new diseases and cases by the hospital management.
Table 5.3
NO.OF
RESPONDENTS
Agree 50 40
Disagree 15 12
Neither agree nor
10 8
disagree
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
39
5.4 Stress on public hospital employees (doctors and nurses) converts into
positive manner.
Table 5.4
NO.OF
RESPONDENTS
Agree 50 40
Disagree 20 16
Neither agree nor
10 8
disagree
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.
40
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
NO.OF
RESPONDENTS
Agree 40 32
Disagree 17 14
Neither agree nor
11 10
disagree
TOTAL 125 100.0
Graph 5.5
Inference:
that their job is rotated and led to both individual improvements and hospital benefits
around 28% of respondents have not accepted the statement.
41
5.6. Doctors and physicians identifies patients diseases and treatments
Table 5.6
Agree 50 40
Disagree 23 18
Neither agree nor
11 9
disagree
TOTAL 125 100.0
Graph 5.6
Inference:
that the concerned in charge identifies their diseases and treatments. Around 18% of
respondents have not accepted the statement.
42
5.7. Public hospitals provide new treatments and researches apart from other
hospitals
Table5.7
Agree 50 40
Disagree 22 18
Neither agree nor
6 5
disagree
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.
43
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
Neither agree nor
12 10
disagree
TOTAL 125 100.0
Graph 5.8
Inference:
From the above graph, it is observed that 68% of the respondents have accepted that
they are asked to take decisions and their Seniors guides them as and when required. Around
21% of respondents have not accepted the statement.
44
5.9 Management of the hospital addresses grievances immediately?
Table 5.9

Agree 45 36
Disagree 12 10
Neither agree nor
18 14
disagree
TOTAL 125 100.0
Graph 5.9
Inference:
From the above graph, it is observed that 60% of the respondents

have accepted that Management of the hospital addresses grievances immediately.
Around 20% of respondents have not accepted the statement.
45
5.10 Public hospitals utilize employee services effectively and efficiently.
Table5.10
NO.OF
RESPONDENTS
Agree 40 32
Disagree 19 15
Neither agree nor disagree 12 10
TOTAL 125 100.0
Graph 5.10
Inference:
From the above graph, it is observed that 56% of the respondents have
accepted that the hospitals utilize their services effectively and efficiently. Around 29%
of respondents have not accepted the statement.
46
5.11. Present job leads satisfaction to the health workers in the public
hospital.
Table 5.11
NO.OF
RESPONDENTS
Agree 53 42
Disagree 13 10
Neither agree nor disagree 5 4
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.
47
5.12. Seniors and subordinates are very cooperative in the hospitals
Table 5.12
NO.OF
RESPONDENTS
Agree 52 42
Disagree 16 13
Neither agree nor
4 3
disagree
TOTAL 125 100.0
Graph 5.12
Inference:
that their seniors and subordinates are very cooperative and they work as a team. Around 13%
of respondents have not accepted the statement.
48
5.13. Doctors, nurses and technicians are recognized and rewarded suitably
by the public hospital.
Table5.13

Agree 40 32
Disagree 22 18
Neither agree nor
15 13
disagree
TOTAL 125 100.0
Graph 5.13
Inference:
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.
49
5.14. Public hospital provides compensation based on qualification,
experience.
Table 5.14
Agree 64 51
Disagree 17 14
Neither agree nor
4 3
disagree
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.
50
5.15. Public hospital provides job security to the employees.
Table5.15
NO. OF
RESPONDENTS
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.
51
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
52
 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
53
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.
54
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.
55
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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
59
9) Management of the hospital addresses grievances immediately?
 Strongly agree
 Agree
 Disagree
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
60
13) Doctors, nurses and technicians are recognized and rewarded suitably by the public
hospital.
 Strongly agree
 Agree
 Disagree
61

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CHAPTER 1

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

We analyze the causal impact of competition on quality at hospitals both in India

FEASIBLE STEPS FOR BETTER PERFORMANCE:

Historically the Indian commitment to health development has been guided by

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

KEY ACHIEVEMENTS IN HEALTH

Reduction in child mortality involves as much attention to protecting children

Programme of immunization and childhood nutrition seen in better performing

On any count these are extraordinary infrastructural capacities created with

HEALTH STATUS ISSUES

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

HEALTH FINANCING ISSUES

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

Another major component of the central sector health programme is purely

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

 Extension To Related Business: Some pharmaceutical companies like Wockhardt and

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

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

Solution To The Problem Of Perishability

Peak time Essential Services

POLITICAL UNITY AND CONSTANCY OF PURPOSE

Some have suggested that India is a thinly-disguised dictatorship, and that

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

A competitive, winner-takes-all society, like colonial Hong Kong in the 1960s,

Consumers’ rights cannot easily be applied in a healthcare context (Carr- Hill,

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

QUALITY IN HEALTH CARE

Donabedian (1966) is one of the leading researchers in quality of care research,

Lawler (1971) categorized satisfaction studies according to their implicitly

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

Index of measures based on patients’ preferences and experiences of actual

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: -

4.3 Research Questions:

 Where are the patients coming from?

in India for further treatment?

4.4 RESEARCH METHODOLOGY

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

(i) KEM hospital Mumbai, India

ANALYSIS AND INTERPRETATION

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

From the above graph, it is observed that 60% of the respondents

Neither agree nor disagree 12 10

TOTAL 125 100.0

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

DIMENSIONS NO.OF RESPONDENTS PERCENTAGE

FINDINGS , SUGGESTIONS AND CONCLUSION

that they know about their duties and responsibilities

authority responsibilities and accountability to perform well

new treatments and procedures especially after providing training to them

into positive manner

both individual improvements and hospital benefits

training is imparted to them accordingly

services effectively and efficiently