21 Ill, • . SECOND REGIONAL SDIINAR ON
HCBP:rrAL AIKrNlBTRATION AND PIANNmG
Sponsored b7 the
WOlUD HBAI4!I ORGANIZM:'ION HmIONAL Oll'PICB lIOR '!'HE WESTERN PACIFIC
Manila~
Philippines
18-29 November 1971
FINAL REPORT
Not for Sale Printed and difltributed by the
Regional Office for the western Paoific of the World Health Organization Manila~ l'h1l1ppines Deoember 1971
•
COH1iiIh'1S 11
I. II.
IN!RODUC!ION ••••••••••••••••••••••••••••••••••••••••••••• SUMMAR! OF 1. 2. ~
1
SIMIHlR •••••••••••••••••••••••••••• u • • • • • •
3. 4.
5. 6. 7. III. IV.
Hospital S8rYi08 in the Westem Pacifio Region. •••••• Adapt1ng the Hospital to CUrrent Needa ••••••••••••••• Effic1ent Manasement of Hoap1tala •••••••••••••••••••• Reuon and Method in Hoapital Dea1gn ••••••••••••••••• Spe01f1c Technical SerY1ces in Hospitals ••••••••••••• H08pital Adllin1atraticn and ~ent ••••••••••••••• Contribu.tiona of Internat10nal and Bllateral
3
6 9 12 15 24
Organizations ••••••••••••••••••••••••••••••••••••••••
28
OORClDBIOIB •••••••••••••••••••••••••••••••••••••••••••••• ~!BA~
•••••••••••••••••••••••••••••••••
32
Annex 1
LiIIt of Part1c1pants. Consultants.
ObserYers, Tempol'8l7' Advisers and
Seoretariat ••••••••••••••••••••••••••••••••
32
Armex 2
Agenda •••••••••••••••••••••••••••••••••••••
v. Annex
Wo:RlCIIG PA.P.&:f&9 ••••••••••,•••••••••••••••••••••••
45
3
'!'he Hosp1tal Service in the Vestem Pac1fic Region: A Consolidated Report from Fifteen Countr1es and Territories •••••••••••••••••• Modem Concepts and Quidelines for Adapting the Hospital to the Medical Care Demand ot Countr1es at Ddfterent Stages of
45
Annex 4
Develo.-aeIlt .................................
60
Armex 5
1'0 Explore Means for Moblliz1ng Resources and the Use of: Systems for the Development of Efficient Management of Hospitals •••••••
68 80 88
Armex 6 Annex 7
Hospital Construot1on:
Reason and Method ot Dea1p •••••••••••••••••••• 0 • • ' . . . . . . . . . . .
The Responaibi1itie. of the Non-Medical Hospital Administrator ••••••••••••••••••••••
.f!e. VI. ANNEXJ!S - BIBI.IOORA.PliIC •••••••••••••••••••••••••••••••••••
104 104 105
Armex 8 Armex
•
L:l.at of Documents Distributed ••.••••••••••••• Bibliography on Modem Methods of Hospital Planning. Administration and Manasemant ••••• Uat of Referenoes Available in the WPRO Ubr&rJ' for the Seminar on Hosp1tal Administration and Pl.ann1ng ••••••••••••••••• Countr,y ~est1onna1re
9
Armex 10
120 126
Armex 11
on Hospital
Information •••••••••••••••••••••••••••••••••
I. 1'h. S.oond Regional Sainer on Hospital. AdIII1n1stration and Plann1ng
wu h.ld in Mllnila. J.8-29 Mo.-ber 1971. It 1ftUI attended b)" 24 participats tro. 18 oountries ot the Western Pacitic Region. plus , conaultents troll oth.r oountri.s and .everal obe.rvars. 1'he III&1n obJeotives ot the Seminar were:
(1)
To review and .....s the current situation. including probl. . and trends. in the planning and adadn1.tratico
ot hospitals in the oountries and territories ot the WHO Western Pacific Region; (2) To di_cnaa. IIOdem oonc.pts and tolWUlate guidelin.s tor adapt:tns the hospital to the aed1cal oare deJund ot oountries at diUerent stages of de ....lopaent; To .xplore Ileana tor mobilizing resource. and the wse ot S7Btems tor the development and etfioient manas-ent ot
(')
hoapitala; (4)
---------"--. --".. ~-"---
-~-- ...
'fo cCll'l8iel.r the role
ot international agencies in the orderlJ anel .tt.otiv. deve10plent ot hospital services particular,q ot the deve10pins countries.
Dr MII.IrOIf I. RODER served as Seminar Direotor. . .s1sted by two oonsultantsz Dr R. GLYN 1'H0JIfAS and Mr D01fAU) A. GOLDPDlCH. Prior to the
Seminar these persons -.de visits to several oountries ot the Reglco (Hong Kong. Japan. Malays1a. the Philippines. the Republic ot Korea and Sinppore) tor first-band obaervation of hospital atters. '1'0 collect current intONation on hospital. attaiN in the countri.s
ot the Region. a questlC11lD&1re was sent to the participants prior to the Seminar. IntONation gathered from these returned questionna:lres addecl speoifioity to the S ..1nar d1aOWlBions. b)" one
Beoause ot a labour dispute the open1ns ot the Seminar was delayed da7 (to 19 November 1971). but through a de01810n to work on
Sunday. 21 November 1971. the entire agenda ... tollowed without gaps. During the Sednar. vuits were made b)" the participants to tOlU" general hoapitala in or near Man1la. ibese were chOlJen to represent three levels of govemaent hospital (emerpncy lev.l. provincial and teaoh1ng aedioal oentre) and on. private hospital. Dur:I.ng these visits. the tunct1ona. de_ian. _""inistration and problems ot the s.veral hospitals were obaervecl and cl1scnaaaed •
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On the opm1zlg dq or "the S-1nar. Dr B.J. SBKA or Auatral1a. was eleoted Cha1man. and Dr 11.11'. JUAN or the Ph1l1PJ1in•• was eleoted l'1oe-cba1man. !Wo...u d1IIowsaian srouP Cba1:&'1M111 were alao eleoted, Dr T. IA1IIRIB or .e. ZealAnd end Ill" PIIRRI: QAOtiUIR or Prench Po1Jn,es1a. 1'broughout the Ssner. Rapporteurs were appointed b7 the Cha1man each dq. '1'heae .ere: Dr II. Sm!CXL\IID of the Cook Ialmda. Dr S.K. Bl8WAS or JIala7llia. Dr V.H. CHIAJrI or Qa1na ('fa1wan). Dr B.S. LDI or the "publio .r Korea. Dr T. JAlBTJ8D Vl3OUDll1'1iCIIIS or Laoa md Dr s.c. RAMBAIRA or fiji.
,
•
..
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II.
SUlIIIlRY OP 1'BE SIMIRAR
'l'be SeII1nar ... opened by the Reponal Director of WHO/WPRO. Dr P.J. D'i. who spoke ots
- the previous WHO work on hoap1tala (1951 Resolut1on). - the :lJapori;ance
ot hoap1talB 1n health aernee8.
_ an empbaa18 GI1 prevention 18 not contr&r1' to a hospital viewpoint. bu.t rather oalm tor widen:fng f'lmctiOllS ot hosp1tal!1 to 1nclude prevention ot both pr1Mr7 (1~1 zatlea and health educat1on) and aecODdarT (ou.-t1ndingand PrGIPt ubulato1"7 medical care) typea. - hoap1tal8 Bhould play a key role in tra1n1ng also. and in overall delive1"7 ot all health services in a district.
1.
Hospital Service in the Western Pac1fic Region
Dr GBORaB M. IMIRY then presented a cCl'Ulol1dated report on "Hospltal Sernce 1n the Western Pacific Repon". baaed OD data 8ubaitted by 15 countrie8 and territonea.
Wlth respect to sovemaental respons1b111ty for hosp1tal.v. cOWltriea of the Region 11&7 be div1ded among those With: - 2;' ot beda under government <at any level). e.g. PiJ1. ~1a. New Zealand and Viet-Nam. - 1;' to 2;' of beds under govemment. e.g. Japan, the Philippines and the Republic of Korea. - under 1;' of beds under government. e.g. China (Ta1wan). It 1& intere8tlng that this measure ot p,lblic reapons1b1l1ty for hospitalization 18 not parallel with economic deyelo~t ("rich and poor" countr1es in _ch cJ.aas). but rather would seem to relate to nat10nal soc1al polioy in health serv1ce8. ben in pUblic general hosp1taJ.a. however, countries V&1"7 in the1r exPectationa ot pa;vmenta trOll pat1ents. SOlIe opeot patients to ~ nothing d1rectly (e.g. New ZeaJ.end). some share support between aooial 1nBurenee and private p~t (Japan). SOlll8 opect patient. to ~ moat of coats direot1J' (Republio ot Korea) and there are other combinations ot financing mecbAn1ama.
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Hospital legislation II&Y be very cCIIIIPrehenaive and specific or rather general and outdated. Some country le81slation is on17 for publio hospitals and other is for both public and private facilities. Regarding govenuaental fund1ng ot hupital operations, it ia unally troll central governalellts, but sometimes alao fro. provincial and looal government levels.
'J.'he bed !!Ul?Rb in oountriea varies 111th the general. econOlll1o level. Considering both publio and private beds, the suppb in 1969 varied !rem about 0.5 per 1000 population (Republic of Korea) to abotlt 1, or 14 per 1000 population (Japan and Mew Zealand). Between 1961f. and 1969. the ratio deolined in a few oountries (probab17 because ot rapid population growth), wt in Il10810 it inoreased. Judplllent on the d.egree of total national. resOllroes being allocatecl. to health .purpoaes ahoa.ld be baaed proper17 GIll percentage ot Oross National Product (GlfP) apent CD health. Unfortunate17,· th1a 18 a difficult oOilputation - requiring knowledp ot both priftte and publio spending that baa been _cle anl.7 in a tew countries (see Brian Abel-8m1th. "An International S'tudy of Health Expenditures and Its Relevance tor Health P1ann jng," Geneva. WHO, 19(7). ille percen.tye .t lfational Government IUC!ge1o, however. allocated . tor health purpoaea gives aOlle renectian ot the iIIIportance attaohed bT govemment to health. '1'h1a varies in 1969 froJI about, per cent. in the Republic of' Korea and Ch1na ('1'a1wan.) to between 15 and 20 per cent. in Japan and the 'frwst 'ferr! tory ot the Paoitic Islands. Within th1a goTemmental health u;penditure, the share allocated tor hospitals (when reported) se_ generally high - around ~ or higher. A 81 ven bed supp17 may aerve .ore or fewer people. depending on the percentac. of bed occupancT and average length-ot-stay per case. 1'b1s alao varies greatly eons countries. For public general h08pitals, the average stq varies frODU
- about 5 - about
da1a (Philippines) to da;rB (Japan).
,a
'rbe length of' staT is wrually shorter in private hospitals. although there are no fim data on this in the Westem Pacific Region. Average stay, of' course, 1ntluenoes the number ot patients treatable per bed per Tear. 'Dxws, this varied tor ptlblic general. hospitals in 1969
trom: - 74 patients per bed (ver,r or01lded) in the Philippines to - 11., patients in Japan.
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1he :f\mctions of hospi tala reported b7 moat countries are very broad, including for moat (in addition to in-patient and out-patient oare) J - domiciliary services, - some preventive services, - rehabilitation and - teaching and. re.earch. As for costs of hospital care, data are diffioult to interpret, but
it 18 olear that evel'7'lhere they have been rising - tlPical.ly b7 about 75 per cent. between 1964 and. 1969 (15 per cent. per year). t~s
In the subsequent discussion, there was classification of the two of IIpr1vate hospitals":
- voluntary non-profit insti tuti01'lll (typically under church groups), - private for profit or "proprietary" (typically ollDed and operated b7 pr1 vate doctors). Based on oral reports by all participant., it was evident that even within governmental hoapitals there was in al.moet all countries (exception: New Zealand) provision for several classes of patients. These "pay beds" in public hoapitals permit additional privacy and uenit1es, but theoretically no differenoe in the technical quality of medioal oare from that received by indigent or non-paying patients. Moreover, in most countries, there are also private (both nonprofit and proprietary) hospitals, in which the great lII!Jority of patients are private, with privately-paid and individually chosen doctors as well. In voluntary non-profit hospitals, also there are otten SOMe :tree beds for indigent patients. BOIIIe countriea have insurance programmes (oompulsory or voluntary) which help patients to P87 for services in either public or private hospitals. It was recognized that there might be a differenoe between theoretioal polioy and actual practice in a countr.r. Hospital administration JIIWIt rai•• enouah money to _et costa of operating the hospital - henoe, oharge. are made to patients . .0 can afford to P87. From the patient'. point of view, however, one IIWIt faoe the queation ot equity in receipt of oare, in relaticm to needs. 'l'h1. involves:
-
(1) (2)
priority for admission. qualifications of the doctor (resident or C01'lIIultsnt),
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(,)
diaanoatic and treatment prooedure. and
(4)
personal . .en1 ties.
eleaents. ~
In practioe. dinereno .. in the pron..l_ ot the tourth eleaent III1ght. in tact. 1nt1uenoe the equ1t;r ot .ervio.. inTolrtng the other three
Resard1na .ooial 1nsuranoe f'1r:um0 1PI, it ... broasht GIlt that thi. 1aproye equ1table aoo... to .errio.. bJ" Jt8rsCIDB ot dinerent .001al
clas.... '!here baa. boweTer. been a ten4aoJ' ot iDnranoe to put exce••i Te ""'IPh,d. _ laoapi tal rather than pr8T11ltiTe or ...... ,·to1'7 .errio... !'he latter .errio... neTel"tlM1e••• are ptt1ns IIOre e.pbaa1a in recent J'8A1"11.
.errio...
.,."teM
2.
AcIapt1Dl the 8_,1tal
1;0
Current Heeda
Dr M. I. llOBMIli then presented a paper OIl .adem ooncepts tor adapt1nt; the bo.pi tal to current needs in the health .erTioes of countrie••
. '!'be role pl.qed. bJ" hosp1tals m a oGUnt1'7 tiependa an two bu10 dete1'll1nants s (l) (2)
its 1eTe1 ot eoan.m.o UTe1op11e1lt and the preva111ns .cdal pbilOllop1Q' applied te health .ervio•••
lleprcl1Da .J!!I?,!erald.p. a II1xI:ure 18 tCllllld in all oountries aaang diUorent branOhea ot pTeft1ll8l1t and. 1eTob ot gOTem.nt. and alao dittol'ell.t tJ'PU ot nan-goTe1'Dll8l1ta1 ali; the ..m trend baa been teRl'd more..ins .pclIUIorab1p b7 gOTeftlll8l1t - ...oc1ated nth ri.ing rate. ot utiliatian and r1B1n8 outs.
bec!1...
l'ImetlGlllll ot hoep1tals eTe1"J1lb,are are nd"'ng. to inolude the to1l.ow.1ng s (1) (2) 1a-pat1ent care (trad1t1cnal l'G1e. ot oourse). out-patient serrice.
0) (4) (5) gceraJ. health .ervioe re.pcmaib111tiea m a d1atr1ct or ·oatcblent area".
•
- 7Reprd1ng all theae f'lmct1cma. repcnallzation 1a be1ns inoreu1ng17 appl1.... that 1a. reoolD1z1ng boep1tal8 as part ot a pos:N.JIh1c .,.t_ wS:t11l
- peripheral. - inte1'lled1ate and - central. units. and a two-1rq'
now
ot Jl&t1l11lts and. teolm1cal ocmaultaticn.
In-patient ~ 18 inoreu1Jlcl7 ......1a1lls lM41eal, :rathel" 'Ulan outod1al aapeota - as reflected. b7 a deoUDSnS anNee l.eDs'th-ot..... (MN'o' .oo1..... ClDCII!1c and prot...1C111&l. factors intluea•• the leastA-ot";.ta7). . OUt-patient .errioe was o~ not a ....p1'tal tImoU_ at all (until the 19th oen'tw:7) blat .now 1e increu~ beth tbl"oqh .,..__t10 .e..1oa8 and. .-rpnOJ' p1'eT1a1ca11. 1'he out-JI&ti_t uparillct (on) u alIIo uaef\Jl tOl" pl'eTeIlt1ve .errio... n.101l1gT caN exteDda hoe,l'tal .Jd.lla to paUents in theu om hoIIe. (oonvale.oent Ol" obroft1o cue.) thcNsh lt 1. -17 JIl"&Otloal fol" patients llrine ne&l"b.r. Bdueaticn ot pzoet...1C111&l. and. paraecU.oal persoanel u 1noreu1nsl7 a hospi'tal t.uk. oft_ in affllJ.at101l with un1vereltl•••1" ooU..... aenoZ'all.T. ot oeQl'lle. th1a u •• in lal"pl" hoapltalal. Ile4ige1
.0.
."rab ot both
olinical and. l,al)ol"atol"7 t7J)e. 1. alao
ooa.duotH in l..al"pl" hoIIpital.a.
Health .ftrV1oe ree,...l~U.. in a dbtr10t a .... that the hoapl'tal ao~ an ...... n:t.Vatb. rolo inftlTins POl7el1n1oa 01" health oentres as .atellltea. To plq th1a 1'010. howeYel". the hupl'tal direotol" alsoul.d. have a brdacl pabl10 health tra1n1ns and. v1"PO:lnt. 'DIu8. the hoIipltal bee. . . the bub
.t a wheel
tOl"
both oa:ratb. and
prevent1ve .el'''l1088. be left
aat1C111&l. "0Ol1tl"018" ovel" l108p1ta18 oannot ~ to the -curative .1de- (1Ib1le anothel" bNnch bandl.ea the preventive al..).· Jlational 0011101'018 ovel" hoap1tala l'Oqu1re e.tabl1.hwett ot a1n1BIII a1lanclarda. which .,. be exo.eded. in looal 011"Oa8tanoea.
Acool"d 1 nslJ'.
to c:me brench ot a Health 1Un1atl"7 clevoted.
Jt.lated. to ·OOlltl'o18· 18 hoapl'tal ,leufpL 1Ib1oh aut be din. b7 oentral autboritl... to aaaure equ1tJ' ..-s repou ot a oountl"7 and. to avold wasteful dupl1cati_ Ol" 'lm8c:nmd. sape.
Iya1pUe ot .erno•• :In hoap1tala1 18 alao a rea....lb1l1tJ' .t oentral authoriti... d.epeDdet ell . . . .to reo..... It 18 neo...U7 tel" gu141ng .teJIII to ~ents.
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All theae oontro18 are ...ler to QP17 to )II1bl1o hOIIpltal8. but the,. to private :b.oapltal8. 8pok.aen ot private hoepltal8 and pret...1CB1&l. sroupe ahould. partlclpate in the toJSll.atlan ot 8tM4al'da. ahcNld. properq be appl1ed. . . all
P1nanc1n.l ot lloapltal operatiClllB 18 be1nc increulngly derived troll .001&1 both a.nl'DlleDt revenu.s and. .801&1 :lnsuranoe oalins trc. private pqIHI3.ta 01' obar1t,-. ~ proMt.. equ1t,.. but Ja¥ alBo l.ad. to ...te, It '\;Aero are Dot prudent -1IhOCI8 ot nmmerat1nc hOIIpltal8.
.OIU"O" -
1...
lQIIent 18 beat &rJ."8Dpd. t.brouah a .J8~tio proapeotin budpt. rather tban a tee or obara. tor eaoh da¥ ot care 01' It_ ot ••1"9'10•• BwlptarT tiJaano1Da aftl_ exc...lve De ot hOIIpltal8 and alBo to.ters equ1tabl.pol101.. (e.a. aal.ar7 levels) . . . . dltt01'mt lloapltala in a natlcm. '1'h1a SJ8te. require. It11IaI.IIslcm ot bIIq.ta b7 indiv1dual. hospltal8, baaed. _ D&ticmal. .1IanUrda, and rev1ew ot thea. b7 cmtral authorltl... It lloa,!tal8 in '\he future are to , l q the broad role mv1aapd. there _ t 1M in their - - . - a t bul0 phil._ _ ot ~ s.1"9'1.o rather 'tban priftte cc.lerolau.. !bo enlutl_ ot th1a role 1d.llobv1.W8q V&l"J' in Ita rate ot 8Oourranoe end. Ita preo18. cbar&ner1atl0. 8IIOIl8 ooantr1...
•
In the pneral tiaoualem ot the abcmt paper. It wu eapilu1zed that 'there ahcRlld. be olM. t i.. betn_ hOIIpltal8 and o~t,- praotitiCillers (elth.r printe doctors or peraGlUl.l'1il. h.alth oentres) with respeot to 1nd1v1dual. ~ 18 aohievable tbrouah:
0.....
- a1v1n& the _talde doctor lloa,ltaJ.,
&00". to h1a
patlanta in the
In the l1sht ot the adII1t~ expad1na rol. ot conl'!Ulent in the wtal ,l"Ov1aleo ot heal.th ••1"9'1oe.. one IIal' questlon whether adequate health oare can be ape.ted in a population, witb.1n a f'rutework ot "free enterprise". It ... 1I1I8PIIted.. bowev.r. that tb1a ls quite po.slble under two ccmd.1tlC11lB:
(l)
ad.eq&Iate
t1IIaDo1al'support tbroqh aovel'lllllental revenue.
or soo1&1 1naurImo.,
(2) Bued em onrall CJI'CIIIIP dlaOUa101l8. there ... ..eral acre.eDt with the 1Iu1o taea.. ill JIr . . . . . _1_tatlO11 ot the broad .t .....tal tDotl_. lI.owenr. 18 .tta tWlld. te be d.1tt1cul.t uncleI' leeal ~_. !b1a .0.... In 8Jl7 event. . . . reoOSDized all suitable mq tR paoral hoapltal8,' not tor varina speo1al1zed. 1n8tltutlona.
.0.,.
,.,.1'.
-9-
In aeveral cauntl'1ee. it ,... po:1nted out, goveroment may usut private hoepitals f1nanciall7. both for oonstruotion and operation. So long as govel'nlllent has very l1nd.ted resources. moreover. private enterpriae ..,. be expected to play a significant role :1n providing medioal care. 1'h1a 11111 prolab~ be true :1n the developing oO\Dltriea (as well &II the :1ndutrialized ones) tor seTeral decades.
A propoa ot po~cl.1n1cs and health centres, it was augeated that a te. beds should proper~ be :1n tbem tor ...rgency cues and tor t.aJ)or&17
observation and holding ot patients until tl'BDJlferral to a district hoeplta1. Reprding ccmtrola over ~pitala, it T
waa -.pbaa1zed that at.nderda
mat ult1llate:q be l.a1d down b.r oentral governJl8llts. Moreover, sove:rDllct tunc1a ahould be used to aupport hoapltal care. mether :1n p.abl1c or prift'te iilatitutiOllll, ~ when IlUch atendarda are 1IIpl_ented.
3.
Effioient Management of HospitalS
Dr- R. GLDr mONAS then presented a paper an 1118an8 for mobil1sing reaouroea and the use ot IISJ8te.a" for etf'ioient !!P!I!!!Ot ot hospitals. He _pbaaized that the hospital. IIWIt be viewed as one cClllPOl'lent et a total S)"llt_. :1nvolv1ng a social environment (houeing. food. sanitation, etc.) u well u other oomponents of health service (prevention, cont:1nu.1ng care, etc.).
Changes in disease patterns - e.g. chronic illness or road accidents - change the demands on haspitals. '!he reduction of suoh cues requirea actlon on a broad social point. 'lhe resouroes available for planning and operating a hospital s7stem are: (1) (2) knowledge - about health needs :1n a population (morbidity, disablll t:v, etc.) , JIb7IIical resources - bulldinp and equi}lMnt, persClUlel of ~ t;ypes (enough bIlt not an exce.s). and econOlll1c aupport.
(3) (lj. )
tOI
- cantro1 r1aing oosta, - improve quallt7 oare,
- 10 -
- make IIOre effecti.,.. wse of soarce Janpower.
- aeet inoreu1ng daanda, and th.se preuurea call tor widen1n& the so... ot hospital tlmotiena. Proper empbu-ia on O11t-ot-hospital servic.. - ...blJ"tory~ preventive and. rehab1lltatim - is necessary to conserve on the UIIe ot 8XpeI18ive hospital resources. Good. quaUt7 aed.1cal oare reqa1res conaideraticm of: - adequao7 (aaount). - effioienC7 (output per un1 10 ot mpat) and - teqbn1cal level. i'o aoh1eve abge m a slllta~ one . .10,
(1)
detine the &111. plan the actiOIl~ orpnize Jallpo1nlr and material resources. provide the services and evaluate the results.
(2) (,) (.\) (5) oues~
In hospital ~t• •e IllUSt al..,. realize tbat h1sh-oost cOilplex like open-heart lIlU'Sery. oOIlSWle a'd1sproportionate17 h18h IIbare ot available resources - tbereb7 leaving tear resourc.. tor O'ther people.
a..pitals ted to be ftr,' stable 1nstit\ltiGD8~ with llUIleroua intemal ocmstra1nta •• :lnst obaDae - like the us1gnJlent ot ardIS to JIale or t~e patienta or the sovereisn ,,,..1n. ot var10W1 spec1al1zed de~ts. •
Etficient
~t
requires:
- eUCN:tlve authori t,.. - deleption ot reapcmaibl1110,.. 'fell 1Jrprove IUZlAPrial effioient7 requires operaticoal r ...arch (1nf'oraation). OI1e mat ldentif')" all the oo.ponents in a prabl_ (the total a,.ts) betore
-.k1n8 a decision. Plenn 1ng a sound. lI8d1o&l. care .,.tea ~ ineta ot effort not on17 te the patients ruM:fng care~ bat to the ...1e ,.palatiClll. beto.re 1l.lD..s enn. st.r1kea. !b1a total populatian ~ be oOBoeptual.1zed in the followiDa oatepr1es ot. cleoreu1nc size:
•
-11-
(2)
pre-symptomatic illness people. persons getting self-care. patients seeking primary health care, ambulatory specialist care cases. hospital in-patients and intensive care cases.
(3) (4) (5) (6)
(7)
•
It is obvious that hospi tala handle only the last two or three sectors - a ~l proportion of the total population - but the,. DNst also be concerned with the inputs to the first four sectors, if the,. are to be efficiently used. Recognition of total "systems" for health service delivery requires integration among hospitals and other agencies. which are often separately administered. 1'his integration should be at all political levels - central, provincial and local - but it is most important that it be strong at the lowest level, closest to the people receiving the services. There are lessons to be learned f'rom the methods of integration applied in the British National Health Service. in the socialist countries, in Ch1le and other countries.
In the small group discussions. emphasis was put on out-patient and domiciliar.y services, as deserving highest priority in hospitals. Regional1zation among facilities was also deemed essential.
RegarcUng personnel, it was brought out that econODly' and efflciency require use of the least elaborately trained persons capable of doing a.n.y specific job effectively. Otherwise, there is waste of resources. Excessive professionalism (professional pride), however. may be an obstacle to 1mplementing this policy. In developing countries. the "brain drain" to North America and lWrope is another serious problem. It is generated by low pay and the desire to travel. among several reasons. To hold personnel in a country, and to achieve coveNSe for rural populations, several countries require new medical graduates to work in the governmental health service. as a legal obligation - sOlllet1JJles for licensure or as a "military" obligation - for one or two years.
A discussion group defined "management" as the proper use of'mone,., materiel and manpower for a clear purpose. In the hospital, there muat be
-12-
oontinuous teamwork to achieve all the purposes (di.cus.ed earlier). hospital adm1nistrator 8I18t: - foresee needs. - organize resources. - oo-ord1nate aotiviti_ and
~e
- oontrol (or supern.se) the whole .~te.. at10 101lle and lICIIle,. are ".I01oial. 'ff>·ra1a. the aGIIlq neo..alU7 for good health aerrioea. health leaders _ t bec. . aale. . . . in a alO8e. in the political arena. Specific . .cban1aa . . . .ted. include: - aocial seourit,. (social insuranoe). - a "healthtax" OIl sale of c . . Ddi1oies. aside :f'rcIII general SOft:mmen1o revcues and
- ev.n lotteries. Greater taxation for health it _10 be reali"zed. does not neceuar1l7 increase the total !!jp!Dditurea for health ;purpeaea in a nation. but rather ab1fte the upenditure :f'rcIII the private to the pablio seotor. where the a;panditure oan be IIOre prudent17 _ed and with greater equit,.. Publio opinion shoW.d be aobil1zed to pt 1noreuing support for the health servioes through ft.rious govemllental ohannelJl.
JIIU'POII".
4.
Reason ad Method in IIOp1.tal
lIe_*
JIIr B.A. OOLD1l'IMCH then pruented a paper on "reasan and method of de.ien - in hoapital oonstruotion. He explained that the aroh1teot requires initially a "brief" em hospital objeotives. rather than an amateur sketch.
1rYeZ7 count1'7 requires "tallor-ade" solutions to hospital oGl18truotic probl_. Advanoe. in medical soienoe mat be applied. within the looal oultural setting. Knowledge of the indwst1'7 supplying equipllent locally ;La alJIo important.
a.- should be adjusted to local ouat.a. 'lbe foar-becl ward used in Sweden IIIN' aot be appropriate in If..,. relat1vea OOlle to s1:&7
uia.
with pat1cta. hostelJl are needed near the hospital. HospitalJl shauld not be prest1siOl18 IICUIHI1ta. but f\1notiaoal. Opera1oiaoal polloies of diUerent depe.rtlMnta _10 be known before structure can be proper17 designed. !be whole environMll1o. with JIOrb1dit;y and . .rtal1t,. data. should be understood. bJ' the arob1teot.
- 13 -
To deoide on the site for a hospital. the population should be known, its time-trends. routes -;)f'transportation and the plaoe of origin of patient~ using existing hospitals. Looal zoning laws IIIWSt be known and, of oourse, the year-rotmd climate - with accuracy.
From the hospital administrator. the architect gets information on the movement of patients between departments. the sources of food. the types of supplies to be stored. eto. Architectural consultants then dedgn the hospital building to maxill1ze efficiency and economy in fUture operations. so that doctors. nurses and others can work with lIl1nimal constraints. In the tropios. e.g •• ane needs surfaces that do not hold heat. Storms and earthquakes must be anticipated in the design. Shading from the sun and ventilation (ldthout permitting cross-infection) are important. Bed tmi ts must take accOWlt of the availabUi ty of nursing staff. '!hey can be designed on the basis of sub-tmita (e.g. 22 beds) 88gregated into larger tmi ts (66 or 88 beds). 'J.'hey must take accOWlt of segregation needed by sex or disease-condi t1on. Renovation of an old building IIIQ' sometimes achieve greatex- etnciency, at low cost. than constructing a new one. But each situation must be individually analyzed. The old "Open ward" of about 2Ji. beds (f'roII Florence Hight1Ilgale days) still has many advantages, although anoillary rooms tor treatment, food preparation, etc. IIIQ' need to be added. Traditional "pavilion style" hospitals have many advantages for developing countries:
..
- good. air movement. without air-conditioning, - less expensive to build and - easier to maintain, than high multistox-y buildings dependent an lifts (elevators) and muoh eleotrioity. High buildings may, however. be needed in cities ~re land 18 soaroe.
In designing rural hospitals. the provisian can be leas for aurcex-y (exoept for emergenoies). but there are greater relative spatial needs for ambulatox-y and preventive servioes. As tor spealaltT department beds, there is no essentlal design differences between medioal and surgioal. but there are for specialties like paediatrlcs and ophthalmology.
- 14 -
Spaoe allotment in modem hol!lpitals ooaacm17 il!l balled on 70 or I!Iquare feet per bed, but a total of' about 300 square feet, i f all the
80
aJl01l.la17 faoillties are oounted (cUvide b7 9 to omvert to appru1ate square metres). _ While ...u rural bNpitala in .... countries . .t provide for .urgel'7, as well as medioine, obstetrios and paediatrio., the relatin oomplex1t;r of ouea within these oategorie. i., of oourae, le•• t.bm in larger urban hospitals, with oODl!lequmt effects on the de.1p needed. Tranaportat1on between ho.pitala in a region 18 1IIIportant. '!'he ocmcept
roOllll to une patients withr
ot "prosres.ive pat1ent oare lt in
a ho.pital calls tor
- intermediate care and - seU-oare. lbt the proportiona ot apace tor each of theae lenla are not alW8lJil wellundel'Btood in advanoe. !he 1Ibl'B1oal d.e.1t;n, theretore, IIWIt pem1t flex1b111t;r • Ltmc-tem patients a&7 be transterred to s.pante bI11ld1ngs 1Ih1ch, in the United states of Allerioa, have cOllIe to be called "extended care faoilitles. 1t !hese faoilit1es must, however, . .et oertain standards to be paid b7 the so01al inaur&noe (ItMedioare") prosrume. 'l'he ooats ot hoap1tal OGll8truotion, depend on many faotol'B. Not cmly' the _ter1als used, the Bize, equipment, etc., but also the relative capaoit1e. of different departaents are iIaportant. Vel'7 relevant to tuture operating eoanamies are also suoh design feature. as: - the walkins distanoe ot nurses, - the location ot toilets, eto. :auio to cCNIts, ot oourse, is the ratio ot beds to be provided per 1000 populaticm. lbe opt:lJlal bed suPP17 is a cUtt1oul.t problem, dependent on maD7 soolal factol'B. In the weal~, developed oountries there 18 eY1dGoe that. - with eoonOllic support asnreel - the ve17 eJd.stence of hOllp1tal bea senerate. deJlan4 for their Wle, henoe there is often excessive use. In the develop!ns oountrie., however, a. . have advooated a Id.n1muJa of abelat 2.5 to smeral hoep1tal beds per 1000, ad Man7 oountries have laUch l ..s taan t.h1B. Even ao, 1t 18 1Japortant in deve1op1ns oountrie. to emphull11e prenotive and IIIIbulato17 sernoe facilitie. more tIwl beU.
,.0
- 15 -
5. 5.1 SUAHl!B.
Speoifio Technical Service. in Hospitals
Team nursing ••rvice. A discussion of team nursing .ervices was then presented. by Mrs H.P.
She spoke first of the nece.sity ot te&lllWOrk in the hospital as a whole, involving the doctor (as team leader), the nurse, the social worker, Ph7aiotherapist, dietician and others.
'feu nursing is defined as a group of nuraes, with graded levea of .klllJr. taking oare of a nUJaber of patients (rather than simply having one
level of nurse doing .verJ1;b1ng). div1ded among:
'!'h. .pectl'lDl of nursing fUnotions are
-profes.ional nurae as team leader, - "practioal" nuraes (or "Assi.tant Nurse.") and - nurae aides, so that the t1me of the professionally trained nUl'll. 1& conserved for lIore c . .plex fUnctions. ':me nurse, it aust be realized, is aonaemed not cnly with bedside care but alao with special hospital departments, Uke the operating theatre, intensive care unit, out-patient department, oentral supply, etc.
To have an etticient hoepital, the nurae ehould participate with other hospital personnel in:
- policy formulation, - cOllllllUIl1ty relat1ona, - quality controls, etc. Starting of nurses in a hospital depends on the influenoe of lII8ny factors, such as: .
(1) (2) (.3)
Bize and type of hospital, space arrangements, accessibil1ty to equipment and supplies, complexity of' c .... ,
(4) (5)
age of patients and length-ot-.ta:r, responsibility ..sipled to nura •• by doctors (the medical care plan), .
(6)
- 16 ~ical care needed by.patienta,
(7)
(8) (9)
emotional. support ot patients,
teaching and rehabilitative needa ot patients and
(10) availability ot other ancillary personnel. ~e nursing tea ahou.ld be oriented 'to p.Uct-oentred oare. Beoause it uses nan-professional. nurses to a -Va'lI, howeftr, it aob1eTeS eocnOlllies, so much needed in developing countries. A ward ot J040 patients I\ight be served by two nursing telUlS.
tra1nins progruae lead 1 ng
'!be protes81onal. nurse ~ be a graduate ot a three-year n.o.pi tal. to otticial registration, or a university cOIIl'8e grantina a bachelor's degree.
Practical nurses typically do not require secondar7 .chool c...leUan, and get training tor eme or two years. Nurse aides get a variable amount ot training (otten , lIantha) entirely on-the-Job. Regarding the problem ot holdins nura.. in their pro:te.sion or oooupaticm, it was suggested that there be: - inoreases in salaries, - shortening ot work1nc hours, - 1Japroved working oandi Ucma and - lIore supplies, so that good nursing oare oan be rendered. '!hese aeasures, it waa cl.a1aed, oould also redlloe the ftbra1n c1ra1nft ot nurses to other oauntries. Regarding nursing teams, it was warned that too much should not be delepted 'to nurse aides, •• that the protes81emal nurae does not loae her oontaot nth the patient.
5.2
Paruaed10al persannel in hosp1tals Dr A.M. lWIKDr then presented a di8CUSsion an training par&IIIed1cal
pel'llODl101
inbiepi/tala. ~
'!'hese include:
-
at all levela,
- l.abel'atOl"7 tecbn101ana,
- 17 -
- physiotherapists. - occupational. therapl8ts. - dieticians. - medioal record personnel. - dental awd.l1arie. and technic1ans. - I118dical uBistents (or health or hospital aui.tents), - pbarwaoists and - hospital adm1n1atrators. Por IIIIInJ' of these disoiplines there are alao aux1l1arz level 1fOrkers. these personnel 111&7 be trained in hospitals. All of
'the lowe the level of the personnel, the more speoifio IIIWIt 1M their training progr&/lllle. M1n1stries of Health must, theretore, give aocurate Job desoriptiows tor the lower level poBit1cna. so that the training can be appropriatel.y" plamled. yield better use of personnel and aoh1eve eoonOlll1os - especially in ..u. h08p1 tals, where there IIIIL7 not be enough work to keep a very speoialized worker busy. For example, phanaaol8ts may be combined with laboratory technicians. or laboratory teohnioians may also be trained for rad1ograpby. The setting in which paruedioal peracmnel are trained 18 relevant. If they are to work in rural health centres. their tra1n1ng should not be exclusively in a teaching hospital. But it they are trained partially in a health centre. proper teaohers should be available there. Hoapitals may be a:f'f1l1ated with un! veraities in providing training although, it was noted, un!verai ties have often reJ eoted training prograDllles f'or paramedical persaunel. On the other hand. SOllIe un!versities have developed "schools for allied health sciences" in whioh several ditterent types of pe.remedical perscxmel are trained jointly - tbiLt is. s.e ot the basic medioal fields (like anatomy or physiology) being taught in oonsolidated classes. Regarding general. aed1cal praotitiCllers. i t wu emphasized that their tra1n1ng should inolude def1n1te studies eu.taide hospitals. Development of new types ot paramedioal perscmnel, such as "oombined technicians" is often resisted b.r existing prot.ssional or ocoupational groups. beoause of' competition or jealousy. Ministries of Health should provide leadership to overcome this opposition. On the other hand. a cOlllb1nation of two disoiplines in one person oan
-18-
Reprd1ng the " . ' sn-n't ot 'techD1oian duUes W nurses 1n _11 hoep1'tala. 'there were conn,1oUng op1n!OI18.
ft.Dantal nuraes ft ot 'the X. . Zealand 't;ype are a .ound adJuat....'t th. short.qe ot f'ul.l3'-'trained dentists.
w
'fo . .ore 'tre:f n1 ng ot lM'th lI8d1oal and )Ia1'UIH1oal pere_el 1;0 . . .'t 'the heal'th n.eds ot a OMID'tI'J'. 1't 18 1Japorta:I1't 'tha't lI1n1II'trl_ ot Beal1:h aus't intlueno. 'tra:lnfn. . . . . .18 oon't1l111&l.lT. .Ta . . . . tau. . . . .18 are under 'the lepl. ccm10Nl et 1Unl.'tr1e. ot . . . .U_.
5.' ••rvio.
IoaDorateq .em.o_
Dr R. UIIII<'"'N then presen'ted a d180W1111en em laboraW17 md b100d. bank .em.c•• , reterr1Dc 1;0 ••veral. WHO dooUIIen1;s 111 tbl. field.
I.aboraw17 a.m.... are ••aenUal oa.pen.u ot lUll" na't1on' a heal'th t0l'2 .
- .; m' cabl. di.eas. 1I1Il'V.1llance md ocmtrol. - eulT de'teoUan ot ohralio d1seas_. - qua11't;r oontrol ot food and drqa md
!!'pn1za't1en ot labora'ter7 a.m.... IIal' be oarrle4 eu't UDAler ditteren't arraDpMnU2
(1)
a a1ngle unifi.d. .;ra1oeJl tor all .ervic... ouraUve and prevan't1 vel cbIal .;rate. tor Ca)
(2) (,)
hoap1'ta18 end. Cb)
PIlbllc health;
ind.ependen'tlabora1io17 .ervio. . tor .,.oiai diae... OMP""'•• Uke -.lar1a or Wheroul. .1••
A't eaol!l heal'th ....,n:l.-tra't1w level Coa'tral. provincial and local). labora'tol"J' ••m.ces ...-t be m 1I1"tesral o.........'t. UnfOR\ID&'t.lT. oa'tral laboraWri.. otten IIU8't Oarl'J" "teo. 'areat • 10M ot routin. work, 1nste.d .t . beiq _le 'to o...oen'tra'te 0111 re~ work, oentrol 111 'the labora'ter7 87111iea end. .p1um.olO81cal l'eIIearoh.
.-uV
Xo ,.oIm1oal :.reoecllare in laboratori. . 18 lDtend.ed .xo11l81ve17ter prevenUve or ouraUve .ervices. theretore, lDtesraU. ot hoep1ta1 mel ptbllo heal1:h tan.,1.. 18 reasonable.
- 19-
Good laboratory work depends on: adequate funds. properly trained persormel and well-standard1zed equipment and supplies. Without superv1Bion. however, the quality of work inevitably deteriorates. 'Jherefore. a network of responsibility is important fran local to regional to central laboratories - with comprehensive services for both clin1cal and public health purposes at all three levels.
i'hus, efficiency of laboratory servioes requires:
(1) (2) C~)
organize:loion of work in a national system, with unifonn standards, to achieve and maintain quality, oo-ordination of aU t;r.pes of laboratory work in each geographic area, for opt1mal use of al1_ resourees, colleotion and analysis of' all data f'rCII laboratory services for all health surveillance and control purposes.
To avoid the overwhelming of' the preventiva by the clinioal WOnL:. laboratories may have to be subdiv1ded into sectiCllD8. Yet certain procedures, like syphilis serology. can be done in one place for both hospitals and public health caDlpa1gns. Bcon08l1cal use of' automated laboratory equipment requires a large volUJae of specUaens - another reason for integrated functions. The laboratory work for special disease-control oampa.1gns should surely be integrated into a national laboratory system. instead of peI'lll1tting separate "empires" to be developed.
5.4
Family
planning services in hospitals
lI'aIII1l.y planning services in hoapitals were then disoussed b7 Dr G. It. EMERY. He discuued different teohnioal aethods of oontraception (honnonal. ~ioal barrIers. st.rilization, "rhythm lIethod", abortions. etc.) and the Changed attitudes forming in most countries.
The maternity-centred approach was advocated as the most praotical ohannel - that is. reaching the woman in c~on with antenatal care, childbirth, or post-partum oare. WHO re~ excessive numbers of children as deleterious to the health of both mother and children. quite asIde f'roJII questions of populatIon policy. through
Mothers may be reached for fuilY planning serriees very convenientlY hospitala - both in obstetrioal deparillente and in the out-patient service. In the hospital, the mother is likelY to be in a receptive mood f'or such advioe.
- 20 -
• In some count.ries, tu117 plann1ng services are admin1st.rat.1vely aeparaw from mat.ernal and child healt.h aerrlces. Whet.her separate or integrat.ed, however, hoap1t.ala are practical channeJJl for delivery of family plann:fng services. 'Dl1s aeelllS to be increaa1ngl.:y appreciated.
Obatacles to the use of fami17 planning include:
_ lepl. restraints and _ concepts of JU,le pride about having any children. 1he latter requires eduoaticm not 01117 bT health personnel, but by the wives th_.lv.s. IAn, of course, can be and are being obanCed.
Tel'll1nolog has terM are uaed 11ke:
S<*8
in1'l.uence in this field.
In soae countries.
.tfpoat_partum faily health",
- "responsible parenthood", et.c.
5.5
Social service, rehabilitat.ion and hoM oare
Dr .D8Rt then ccnt.1nued 111t.h a diaouas181l of social servic., rehabilitat.ion and heM care u hospital tlmctieoa.
The oancept of a "social worker" baa unclerpoe evolution troll that of the .ell-lle1UWlg but untrained upper-clus l.aq to the trained professional 8pec1al1st. !he latter s.rvice should be part of every hospital. J\ehabilitaticn is linked with social service and means restorat1on of the patient to the fullest 80Cial capacity of which he is oapable. 'l'h1s requirea teallDfOrk of medical, social and other health workers. Rehab111tation is need.eci for .J18n7 cases beyond orthopaedic an.., including heart disease, post.-aurs1oal cue, geriat.r1c Pat1ents, etc. Both pbJwiotherapy and occupat1anal therapy are needed to st1lllulate full bodily and mental functions. D1aabled persons IlUSt often be reeducated to carry out "act1vit1es of daily living", and thereby release other family members fraI doing these th1np for the pat1ent. 'Buts. a.rvices should not be reprded u a lUlDU7, but. shnld be inoluded, to aCllle degree, in all provino1al or ectr&! hospitals. a hosp1tal respana1b1l1ty depena on pat.1ents having proper home oCllld1t1ona. If a., it is l ..s apenaive and preferable for the patient 1:ban care in a boBpi tal ward. &8
Orpn1zed hoIIe oare
- 21 -
Home care may vary from simple "home help" in laundry. meals. etc. to provision of compl.ex equipment and bedside nursing. The catchment area of a hospital for home care is smaller than for in-patient care; it is most feas1bl.e for persons who can attend the hospital as out-patients. The cOIIIIIon denominator among home hcae care. rehabilitation end Bocial service 1s linkage of the hospital to the surrounding oommunit;y. '.rh1s linkage requires social. workers on the hospital staff. mo wauld do more than admin1atering "means tests" on the patient's abiUty to pay for hospital. care. Such social workers may have to educate fudUes to avoid doing too much for a d1sabl.ed patient. so that he wil.l. recover his 01111 capacities. Follow-up of the disoharged hospital patient may al.so be faciUtated by public health nurses in health centres -another reuon for regianaUzed linkages between health oentres and hospital.s.
5.6
Medical. records Dr S .K. ~UO
then presented a discussion on medical records. which
are essential. for sound hospital administration. Their obJeotives are to provide for: (1)
recording data on diagnosis and treatment. l:lospital. statistios and evaluation, medical. research and epidemiol.ogical study.
(2)
(3)
(4) (5) (6)
quaUty supervision. teaching medioal. nursing and other students. end
medioo-l.egal. purposes.
A basic series of medical. record forms. of standard size. are needed by all hospital.s. 1hey should be revised :f'roIII time to time, to keep up with changing medical. ideas.
A singl.e record number - the "unit reoord s;vstem" - should be assigned to eaoh patient. This should be used throughout his Ufe, end all til.es, both in-patient end aut-patient. on this patient should be kept together. 1hese numbeZ'll should be consecutive fraD year to year, rather than starting over each year.
Reoords are confidential.. are the property of the hospital.. end . shaul.d never be released without the patient's pemiasion, unless lega1l1' required.
Pil1nei of reoords. by the tem1nal. digit, is etf1cient in large hospitals, while in IIIIal.l hoapitala a simple al.phabetical. fiUng M7 be adequate.
-22-
Indexes of records 10 larger hospitala ahould be kept aooord1ng to several features: - alphsbetical order of the patient's na•• - diagnostio disease oategor;y (lCD' code). - surgioal operations and - physioian respanaible for cases. Regard.1ns diagn08tic indexes. patients with Blltipl. diagn0888 should be classified acoording to the primary one. Hospital records pe1'lll1t oalculation of Milio statistios on such' hospital information as:
•
- oocupancy percentage. - average patient stay. etc. but. to be usefUl. records must be cslete. A "••dioal record Ubrarian" should have responsibiUty for cOIIIPleteness of all records. Also a discharge sU!!!!!l7 on each patient should be prepared by the record Ubrarian and sent to the oClllllltUlity doctor or health centre. Other hospital statistios. like those for .xpenditures or food oonsumption. are derived f'rom other source,s (i •••• not f'rom patient records). In larger hospitals. cClllPUters IU7 be help:t'l1l in producing certain statistioal data, such as lIoney taken in by the hoIIp1tal or expenditures. It 18 1IIportant" however. !!!l to use elaborate cOllPlltational equipment. where it is not justified ecenGllicall.T or tuncU.,.lly. An exterusion of the "1m:1t record s,.t.." being advocated in sOlIe countri.s is a single number assigned to eaoh person at birth. and used throushout his Ufe for all health (and other) purpoaes.
!he lep.]. OlIDersh1p of the patient's record 10 sOlIe oountries. 1t
was stated. Ues aometllles with the patient. rather tlwl the hospital.
5.7
Q;ual1ty controls Dr M.I. IlOl!IIBR then presented a d1aoussien GIl quality controls in Be first outlined bu:1c conditions for aeh1e'Y1n8 quality of
hospital8. (1)
lIed10al oare.
'fheIIe are:
Perscmnel of adequate numbers and t;ypes. including their proper geographic distribution;
- 23 -
(2) (3)
Proper faoilities (hospitals and health oentres) welldesigned; Adequate equipment for diagnosis and treatment; Adequate types and supplies of drup; Max1mwD application of preventiClD. whenever and wherever feasible;
(4) (5)
(6)
Adequate eoanOlll1o support for all the above. on the basis of need rather tlum personal artluence.
Even if all these conditions are met. however, the maintenance of quality requires uny f'Urther continUCJU8 activities. 'lhese Dl&y be classified
as: (1) (2) Effective organization of personnel. emphasizing teamwork; Complete medical records for continuity of care - already discussed; all work performed. e.g. by use of "medical audits". Review by outside experts is preferable to solely internal hospital review; unusual events. like complex oases or deaths - with autopsies cD. the latter;
(3) Systematic review of
(4) Clinical-pathological conferences to discuss (5)
Systematic controls over laboratory or X-ray performance. including X-ray. EKG. etc. These are necessary from a higher adm1nistrative level; Continuing education of all personnel. to keep up with scientific advances; Regionalizatian and its enforcement. with a two-way now of patients (inwardly) and teohnical cGl18Ul.taUon (outwardly); Continuity of patient care. ideal.ly through one primary physician for every patient - whether he is in private practice. in a health centre. a po~cl1n1c. or a hospital out-patient department.
(6)
(7) (8)
As an ultimate control over quality of medioal oare. the importanoeof' an infomed and responsive population was emphuized. With increuing
d eJIooracy. the voioe of the patient should be heard, md can influenoe the diligenoe of professicmal parsamel. Such personnel should be given speolal rewarda for exoellenoe. as a continuing stimulus to good work.
6. 6.1
HOspital Administration and Management
General administrative issues in hOspitals
A paper vas then presented on general administrative issues in hospital care by Dr E. YUJ,Jr.AS. He spake of the great advances of medical sCience, yet the failure to apply them, in spite of generally riSing costs. How maQ7 countries have a national philosophY' of healtht it was asked. In some developing countries, the health system has not been designed from a proper study of local needs, but from inappropriate emulation of models in the vealthY', industrialized countries. How can the WHO principle of Ithealth as a basic human right lt be 1JD:plem.ented t hong other things, this requires a broad cOllllllunit y orientation by hospitals. Kev methods of raising money must also be found, especially in the developing countries. In the discussion of this paper, the relatively high dependence on private spending for health care in the Philippines was brought out. Private hospital and especially medical fees are sometimes very high, and beyond the means of the vast majority of people.
Later, the discussion of this paper posed alternatives that must be considered in developing a national system of health services in a developing country. 'rhese involved choices such as: (1) for financing, between private and public sectors, and in the latter, between social insurance and general revenues; for delivery of ambulatory case, between private doctors and health centres; for hospitalization, between sovereign institutions and regionalized networkB; for prevention, between separate campaigns and services integrated with treatment.
(2)
(3) (4)
It was suggested that it was inappropriate for a developing country with ~ poor and ~ affluent to emulate the'health care system in a country with ~ poor and ~ affluent. Methods of funding inevitably influence patterns of delivering medical care. '!he use of Itbarefoot doctors It in mainland China was m.entioned that is, s~ly trained personnel assigned to a group of families in rural areas _ as a model worth studying. )(ore equitable m.ethods of funding health care BlUst be found, which implies a larger role for goveraaent.
- 25 -
6.2
Role of the
non~edical
hospital administrator
Mr J. DURIEZ then presented a paper on the responsibilities of the non~edical hospital administrator. He first explained the distinction between the organization of various technical services and the administration of services in a managerial or operational sense.
To facilitate the scientific work of the doctor, much administration is needed. that is, management of personnel, supplies, finances, etc. Wbile medical technology has many universal features, administration of health services varies with the legal and financial policies of different countries. The supervision of hospitals administrative plans: (1) (2) ~
be done through several
a Medical Director, assisted by an administrative officer, an Administrative Director, working in co-operation with a Consultative Medical Committee, or dual leadership by both an Administrative Director and a Medical Director with parallel responsibilities.
(3)
In the developing countries, the first of these patterns has been proved to be most practical, in general. Medical service, it must always be realized, is the ultimate objective of the hospital. In developing countries, there is typical~ a hierarchy of hOsPitals with graded responsibilities from cen. tral to provincial to local rural) levels. Peripheral to the rural hospital, or sometimes combined with it, 1s the health centre for ambulatory and preventive service.
l
The distribution and financing of these several types of hospital must, of course, depend on the: - general political structure of· a country, - morbidity of the population, - educational level of the people, - financial resources. A Ministry of Health should ideal~ be responsible for the whole system. In developing countries especial~, hospitals must play a preventive and educational role, as well as serving for diagnosis and treatment.
.26. A nationally centralized system of stores for both drugs and other supplies is important in many developing countries, for econ~ as well as quality considerations. From the financial viewpoint, the hospital design h~ different implications. !he pavilion pattern is less costly to build and has many advantages, but operational costs 1IIq be high and supervision 1IIq be diffieult. The unified block design ~ be more costly to build and may require certain Ter,r skilled personnel to operate, but ~ nevertheless be more economical to operate. A compromise may be possible between these two patterns _ that is, several bloeks of limited height, not requiring elevators. Staff housing must also be considered in designing hospitals of developing countries. In the administration of hospitals, a general Medieal Director has many fUnctions, such as: _ general leadership and supervision, _ co-ordination of all activities, _ responsibility for training programmes, _ preparation of periodic statistical reports to high authorities, . _ weekly inspections to control quality, _ evaluation of medical services and _ relations with other agencies. In small hospitals, the Medical Director may also have clinical duties. Hospital Administrator must be a person of high intelligence and tact. He should have experience and a well-disciplined mind. He must ensure continuity in the implementation of policies, and must understand all hospital activities of the past, the present, and the probable future. The non.medical Hospital Administrator must work closely with the Medieal Directo~, and has specific responsibilities for: _ financial management~
~e non~edical
including preparation'of budgets,
_ institutional services (food, lodging, etc.), _ purchase of supplies, etc., _ equipment maintenanee, _ land maintenance, gardening, etc., _ architectural consultations on construction or renovation, and • personnel management.
-,27-
The non~ical Administrator must maintain many personal contacts with patient's families, hospital personnel, and other bealtb autborities. He bas special duties in accounting, both for collections and disbursements. To prepare hospital administrators for these many duties, special schools are required. Each region of the world should have such schools, to train administrative personnel appropriate for that region. After he is on the job, even the well_trained administrator must learn to work closely with the Medical Director and other personnel. A naandbook of Procedures·, issued by the Ministry of Health, can be a helpfUl tool for tbis purpose.
In summary, the ultimate goal of hospital administration is the good care of the patient. The Administrator, conscious of thiS, must always strike a balance between: - quality of service and econ~
of funds,
non~edical
in pursuing this objective. To learn to strike this balance proper~, the Administrator should not have an -inferiority complex- in his.relations with doctors - a basic reason for his having proper training.
--In the discussion of this paper, there were varying vievs expressed on the necessity of a Medical Director as the top hospital official, even in the developing countries. The reason for this practice, it was pOinted out, was largely the lack of properly trained non~edical administrators and the general prestige of physicians. As more.non~ical administrators are trained, however, they ~ be assigned the top responsibility in hospitals, preserTing the doctor's time entire~ for clinical work. Indeed, if a doctor is assigned administrative responsibilities in a hospital, he too should have proper training - though it can be of shorter duration than that required for the non-physician. Three-month courses are offered in some places for doctors entering hospital administration. Policies differ between and also within countries (for differentsized hospitals) in the appointment of doctors or other persons as the top-level Hospital Director. In either arrangement, it was agreed that the·head of a hospital must have proper training in the principles and tools of administration.
6.3
Financial management Financial management in hospitals vas then brief~
discussed by
Dr R. GLYN TH<»fAS.
-.28 _
Hospital financing (1) (2)
involve~ ~enditure.
for:
capital (construction) purposes aDd l18.intenance.
Maintenance expeDditures involve: (1) (2)
Continuing (staff, supplies, etc.) and .on-recurrent (e.g. equipment) expenses.
'IOr managerial purposes, it is useful to calculate unit~osts indifferent departaents of a hospital, sucb as tbe laboratory or laundry. it ~ be econcm1cal for seTeral b08pitals joint~ use a centralized service facilit,y. can econoa1cal~ prepare certain supplies,
lOr certain servicedepartaents, l.1ke the laundry or kitcben, in a cit, or district to Likewise, a large bospital like infusion solutions, for seTeral smaller hospitals nea.rbT.
Econcm1es in personnel ma:y depend on the use of certain types of supplT, such as the disposab le . sTriDge, wbich saves the time of nurses.
7.
Contributieaa of International and Bilateral Organizations
The final session of the Seainar vas devoted to the contributions of international and bilateral organizations to.hospital affairs. On bebalf of tbe World Health Organization, Dr G.M. EMERY explained WHO actiTities as dependent on wbat a count17 requests and what WHO can finance. WHO has prortded adTisor,y services to countries on specific bospital problems l.1ke record STstellS, biood banks, etc. It also supports fellowahips for foreign study, and seminars like the current one. Dr B. 'YILI.lGAS described the work of the Inter..church Ca.m1ssion on Medical Care. an example of a non..goverIlJlental intez:national ae;encT. !his eo..!ssion conducts educational_progra.aes for imprOYing bospital aanageaent, and also does money_raising. Closer ties with gOTerDlllental authorities were called for. IIr A.B. lUA.GZR described the work of UBlCJ:r, So United .ations specialized &geneT proTiding supplies and equipment usetul for promoting the welfare of motbers and cbl1dren. 'l'echnical adTice on materiel needs is furnished b7 WHO.
-29Currently health-related expenditures use about 50~ Of the UBlCEF total. Relevant to hospitals, the chief emphasis is on materiel for upgrading rural hospitals and smaller centres for training maternal and child health personnel, including nurses-and midwives. Special emphasis recently has been put on family planning supplies. Also aid is given to special hospital wards for malnourished children, and for water supply systems for small hospitals. Dr E. MAU described the United States Agengr for International Development (USAID) activities in health. While these have declined in recent years, USAID previOUSly financed construction of hospitals and development of medical schools. Surplus medical property from American military bases is now sometimes given to countries. Dr V. S. WYCOCO described the health work of "Operation Brotherhood". an organization of Philippine personnel now working in Laos. Started privately in 1954, this agency has since 1963 been financed mainly by USAID.
The programme in Laos involves operation of seven hospitals with a total of 360 beds. It includes training of Laotian health personnel, notably a new type of "village health worker". The Operation Brotherhood hospitals emphasize preventive services, and offer mobile te8.lllS that go to surrounding villages. Since 1967, the work has been fully integrated with that of the Laotian Ministry of Health. Finally, reference was made to the United Nations Development Programme (UNDP) , as a special source of funding for health activities, among others. SpecifiC health services, financed by UNDP, are generally administered by WHO - as in the case of this very Seminar, which has been supported by UNDP funds. The United Nations Fund for Population Activities (UNFPA) is still another United Nations source Of money for health.related services in family planning.
--In closing the Seminar, Dr F.J. Dr noted that since the previOUS such seminar in 1963, much progress had been made in hospital systems even in countries torn by hostilities. Much remains to be done, however, even in the most developed countries of the Region, if the conclusions of the Seminar are to be effective in promoting the role of hospitals in total health care. Dr Dr stated that if any country wished to have WHO assistance in holding national seminars on hospital administration and planning, these requests would be welcome _ reminding the delegates that they must be submitted two years in advance. He then thanked the participants and consultants for their diligent work, expressed the wish that the conclUSions will be discussed with national authorities in health planning, and closed the Seminar.
·30III. COKCLUSIOIS
'lhe participants of the Seminar, after on the following conclusions:
:run
discussion, agreed
{I} 'lhe right of every human being to the enjqyment of the highest attainable standard of health and that Governments have a responsibility for the health of their peoples as expressed in the WHO Constitution. {2} In order to promote Conclusion ell, there is urgent need, in se..-eral countries of the Region, for GoTernments to take responsibility for increased financial support for the hospital B7stem and for its utilization at a time of need. This could be done either throIl8 h taxation, specifical17 allocated for health purposes, or b7 systems of social insurance which remove the financial burden of direct p~ent by the patient of .oat if not all of hospital and medical costs at the tUae of utilisation.
(3) 'lhe hospital has a role much greater than the provision of in-patient care. Further efforts should be made, as discussed in the Saa1nar, to extend pre..-entive services, out-patient diagnostic and treataent serTices, rehabilitation services, and as econoaic conditions p~t in SORe countries extr~al and daaiciliary services.
(4) In the proTision of serTices, there should be the greatest possible desree of co..ordinatioD. 8IlOng the central, inteI"lllediate and peripheral hospitals and between the hospital system and the general practitioner in the comaunity. {5} Begionalization of the hospital s,rstea should be further de..-eloped ~ avoid duplication and praao~e more effective and efficient use of available resources for total health care. The application of the reg10nalization concept requires adjustment to the urban and rural ecoloi7 in different countries. (6) Hospital design must be appropriate for efficient staffing and maintenance patterns ~n the light of local constraints. Continuing attention should be given in all countries to changing concepts in hospital construction and design. Phased development of a particular hospital should not be pbysical17 commenced before a master plan on ultiaate de..-elopaent of the hospital has been envisaged. !here should be regular reT1ewa, in teI"lllS of available resources in relation to changes in patterns of medical care and in sectoral demands because of changing epUemiological and socio-econom1.c conditions.
(1) lOr effieient hospital staffing and operation there are both ecoac.1e aD4 quality aciTailtages in the use of nursing tea:u cOllposed of nursea &D4 auxiliary nursing personnel of different levels of training. In general, paraaedical personnel of IIlB.DY t7Pes should be used to the maximo. to preaerve the liaited time of doctors and to achieve econoaies.
- 31 -
(8) Laboratory services should :)perate as part of a national system with central, provincial and local components. At each level both clinical and public health laboratory services should be integrated.
(9) Family planning services are an appropriate function of the health services in general, including all general hospitals especially as hospitals permit a maternity-centred approach, both in the obstetrical wards and in the out-patient departments. (10) For effective linkage with life in the community, hospitals should operate programmes of medico-social service, rehabilitation, and home care. (ll) Complete and accurate patient records ere necessary for sound hospital administration, especially for quality control, as well as for sound administration of all health services. In addition, accurate data should be available on expenditures, income, and other elements important for sound hospital management. (12) The hospital, in conjunction with other institutions, should be a teaching and training centre for the medical, paramedical, nursing, administrative and related health professions. Supervision and quality control are necessary, and they can be most readily carried out within a training and teaching situation. (13) Hospital development should take place as part of a national health plan. The national health plan should be a sector of an overall plan for socio-economic development, especially as good health contributes to such development. (14) Trained and responsible leadership of the public health and medical care programmes is necessary at all levels to ensure that hospital facilities are most effectively and economically utilized. (15) It is essential that the medical superintendent or director of a hospital be adequately trained for his post. Some countries follow a pattern of appointing medically qualified superintendents. It was unanimously concluded that adequate training is of· greater importance than whether or not the superintendent has a medical qualification. Therefore, increased training schools for preparing such administrative personnel are needed. (16) International, bilateral, and other organizations have a major contribution to make towards hospital construction and operation, bearing in mind the influence of health on socio-economic development. There is need, however, for co-ordination of assistance among the several agencies involved. (11) Seminars of this type should be held more frequently in the future, exploring the numerOus specific aspects of hospital administration faced in developing countries.
- 32 -
ANNEX 1
INFORMATION BtJI.IErm NO. 2
LlBT OF PARrICIPAN'lS, cotSUIlrAN'l5, OFBERVEBS, TDIPORARY ADVD3EfB AND SECFIEI'ARIAT
1.
PAR'l'ICIPAN'lB Dr B. J. Shea
AlSTHALIA
Direotor-General of Medioal Servioes of South Australia Hospitals Department 158 Rundle street, Adelaide S.A. 5000 Australia CHINA (TAIWAN) Dr Ch1ng-tsai Kuo
Superintendent Taiwan Provinoial Keelung Hospital Keelung, Taiwan Republio of China Dr Wan-hsuen Chiang Superintendent Taipei City Hopin Hospital Fuoho Street, Taipei Republio of China
COOK ]sLANIS
Dr Mata Strickland Medioal Officer Department of Health P.O. Box 109 Rarotonga. Cook Islands Mr S.C. Hamrakha
FIJI
Medioal Superintendent Medioal Department ~
Fiji
- 33 -
FRENCH POLYNESIA
Mr Pierre Gauthier Direction du Service de sante B.P. 611, Papeete Tahiti Polynesie fran~aise Dr Lee Shiu-hung Principal Medical and Health Officer (Planning) Medical and Health Department Lee Gardens. 4th floor Hysan Avenue, Hong Kong Dr Kiyoshi Iwasa Chief, Department of Medical Care Administration National Institute of Hospital Administration Ministry of Health and Welfare Dr E11chi Nakamura Medical Officer & Assistant Chief General Affairs Section Medical Affairs Bureau Ministry of Health & Welfare
HONG KONG
JAPAN
KHMER REPUBLIC
Dr Rath Kouth Directeur des hopitaux Ministere de Sante Phnom Penh Dr Tiao Jaisvasd Visouthiphongs Directeur des HOpitaux Directeur de l'Ecole de Sante Publique Ministere de la Sante Publique Vientiane, Laos Dr Sheikh Raihan Bin Hernzah Chief Medical and Health Officer Ministry of Health Johor Bahru MalaySia Dr S.K. Biswas Deputy-Director of Medical Services Ministry of Health Kuala Lumpur Malaysia
LAOS
MALAYSIA
II , \
-34-
N&1 ZEALAND
Dr T. Lawrie Medical Superintendent Cook Hospital Board Gisbome New Zealand Dr J. Onno District Health Officer Department of Public Health Port Moresby Papua New Guinea Dr Manuel F. Juan, Jr. Officer-in-charge Hospital Licensure Di v:ls ion Department of Health Manila, Philippines Dr El1od.oro D. Congco President The Family Clinic and Hospital 1474 Maria Clara Street Sampalcc, Manila
PAPUA lmi GUINEA
PHILIPPINES
REPU!l..IC OF KOREA
Dr Eui-Sun Lilt) College of Medicine Severance Hospital Yonsei University Seoul, Korea Prof. Myung Soo Lee Ewha Woman's University Hospital 287 - 4 Yon Hi dong Su-Daimoon Ku Seoul Korea
TONGA
Dr Supileo Foliaki Director of Health Ministry of Health Nuku' alofa, Tonga Mr Jose T. Seman Hospital Administrator District Health Services Dr Torres Hospital Saipan, Mariana Islands Trust Territory of' the Pacific Islands
- 35 -
VIET-NAN
Dr Pham Trong 59 Hong Thap-tu Saigon, Viet-Nam Dr Huynh Trung Nbi 2, Pham Hong Thai An.- Gi ang, Saigon
WESTERN SANOA
Dr Iakopo T. Esera Medical Superintendent Health Department ~ Western Samoa
2.
CONSULTANTS Dr Milton I. Roemer Professor of Public Health University of California School of Public Health Los Angeles, California 90024 United States of America Dr R. Glyn Thomas Regional Adviser on Organization of Medical Care Regional Office in Europe Copenhagen ¢ Denmark
Seminar Director
Consultant
Consultant on Hospital Architecture
Mr Donald A. Goldfinch 1 Vine Street Uxbridge Middlesex England
- 36 -
Mr A.E. Meqer
UNICEP Representative P.O. Box 883 'Manila. Philippines Mr E. Mau
USAID Manila, Philippines
4.
'l'EMPOJWlY ADVlBBlI5 Dr Eduardo L. Villepe Executive Director Inter-Church COIIIIIis8101'1 on Metioal Care 879 E. de los Santos Avenue Quezon Citl. Philippines
Mrs H.P. Suanes
Director Nursing Services Ospital ng Ma1nila Manila. Philippines
5.
SECRE'l'ARIAT
Dr G.M. EIIel"7
Regional Adviser on Organization of Medical Care WHO Regional Office tor the Western Pacifio Manila, Philippines Dr S.T. Han
Regional Adviser on Communitl Health Services WHO Regional Ottice tor'the Western Pacifio Manila. Philippines
-~
-
Dr A. M. Rankin Regional Adviser on Education and Training WHO Regional Office fQr the Western Pacific Manila. Philippines Dr R. S8lUIonnens
Regional Adviser on Health Laboratory Service. WHO Regional Oftice for the Western Paoific Manila. Philippines Dr S.K. Quo
Short-term Consultant WHO Regional Office tor the We. tern Pacific Manila. Philippines Mr J. l)1riez WHO Regional Office tor the Western Pacific Manila. Philippine. Mr Rene Aouad Translator/Interpreter WHO Regional Office for the Western Pacifio Manila. Philippines
Mr P. Lambert
Interpreter WHO. Geneva Mt' E. Simha
Interpreter WHO, Geneva
- 38 -
lNFOJIo1ATION BULLE'l'IN NO. 3 . AGIi:NIlt\
Thursday, 18 November
0830 .. 0930 hours A.M.
-
Registration
- . Self-introduction of participants
0930 - 0940 0940 - 1015
-
Official opening of the Seminar Election of General Chairman and Chairmen of two discussion groups Designation of rapporteurs Explanation of procedures Recess Consolidated Country Report on Hoapi tal Affairs Wnch Dr G.M. Fmery
1015 - 1045 1045 - l215 1215 - 1315
-
-
1315 - 1415 P.M. 1415 - 1445 1445 - 1545
-
Plenary discussion Recess Plenary discussion continued
.. '9 ..
Pr1d!l' 19 November
0800
~08,a
A.M.
.. Report on previous da,y.
08,0 .. 09,0
.. Modem Conoepta and. Ou1d.el1nes tor Adapting the Hospital to 'tlw Medioal
Dr M.I. Roemer
Care Daand by Countries at DUteret stages ot De....lor-ent.
0930
~
1015
.. -
General disouasion. Recess ~etinla
1015 .. 1045
1045.. 1215 1215 .. 1'15 1,15 - 1415 P.M.
.. Discussion;roup IAmch
(2)
.. Report on "Sponsorship", "J'unot1ona" and "Controls". .. Recess .. Report on !'PlnClC1ns" and "Re1at1onshipa"
1415 .. 1445 1445 .. 1545
saturde,y, 20 N(!!!!ber
0800 .. 1000 A.M. 1000 -·1200
-
Visit to a 100al (emersenoy) hospital. Visit to a (Rizal) • provinoial hospital
.. 40 -
Monday, 22 November
0800 - 0830 A.M. 0830 - 0930
-
Report on 19 November session. Means tor Mobilizing Resources and the Use ot Systems tor the Development ot Etficient Management ot Hospitals.
Dr R. Olyn Thomas
o~
- ·1015
- General d1scussion. - Recess - Discussion group meetings (2) lunch
1015 - 1045 1045 - 1215 1215 - 1315 1315 - 1415 P.M. 1415 - 1445 1445 - 1545
Report on "Mobilizing Resources"
- Recess - Report on "Etficient Manacement"
Tuesday, 23 November
0800 -
0830
A.M.
-
Report on previous day. Hospital Construction: and Method of Desisn. Reason.
Mr D.A. 00ldt1nch
o~
- 1015
- General d1scussion. Recess
1015 - 1045 1045 - 1215 1215 - 1,15 1315 - 1415 P.M. 1415 - 1445 1445 - 1545
- Discussion group meet1ngs (2) lunch
Report on ~rban Hospital Desisn"
- Recess - Report on "Rural Hospital Dee1gn"
• 41 -
WPR/G>Mc/IB/3 Page 4 Wednesday, 24 November 0800 - 0830 A.M. .. Report on previous Team day.
Nursing Servioes.
(Mrs) H. P. Suanes
0930 - 1015 1015 • 1045 1045 - 1145 1145 - 1215 1215 - 1315 P.M. 1315 - 1545
.. General disoussion. .. Reoess .. Training Paramedioal Personnel General disoussion. Lunoh Visit to a private haep1ta1. Dr A.M. Rankin
Thursday, 25 November 0800 .. 0830 A.M. 0830 .. 0915 0915 .. 1015 1015- 1045 1045 .. 1145 1145 - 1215 1215 .. 1315 1315 - 1345 P.M. 1345 - 1415 1415 - 1445 1445 - 1545 .. Report on previous day. Iaboratory and Blood Bank Servioes. Dr R. Sansonnens
.. Family Planning S'emoes in Hospitals. .. Reoess Sooial Servioe, Rehabilitation and Home Care. General disoussiQn.
Dr
a.M. mnery
Dr
a.M. !mery
.. Lunoh Hospital Reoorda Quality Control Dr S.K~ Quo Dr M.t. Roemer
.. Reoeaa Plenary discussion.
- 42 -
Friday, 26 November
0800 - 0830 A.M.
-
Report on previous day. Administrative Issues. Role of the Non-Medioal Administrator. Reoess Finanoial Management General discussion Imlch
Dr E. Villegas Mr j . Il1riez
1015 - 1045 1045 - 1145 1145 - 1215 1215 - 1315 1315 - 1415 P.M.
-
Dr R. Olm 'lbomu
-
Contributions of International and Bilateral Orpnizationa to Hospital Aftairs. Reoess Plenary disoussion.
Dr O.M. !}nery Dr B. Villepa
Mr A.B. Measer Mr B. Mau
1415 - 1445 1445 - 1545
-
Saturd!l, Z7 November
0900 - 1200
-
Visit to a Medioal Centre (teaching hoapi tal).
- 43 -
WPR/OMC/!B/3 Page 6 .Monday, 29 November
0830 - 1015 1015 - 1045 1045 - 1215 1215 - 1'15 1415 - 1445
A.M.
-
SW'11111a!'7 Report.
Dr O.M. mner,y Dr M. I. 1to...r
-
lunch
-
CI08ina
ce~.
- 44 -
INFORMATION BJLI..El'IN NO. 3 AGDlIlA.
Corrigend\IJD Delay of Seminar Commencement Due to the strike at the Manila International Airport, the registration of participants will now take place at 0800 a.m. on Friday, 19 November 1971 at the WHO Conferenoe Hall, end the programme for the opening ses8ion given in Information Bulletin No.3 will take place on Friday, 19 November 1971. The visits to hospitals given in the Agenda for Saturday, 20 November will take plaoe as planned. The programme given in Information Bulletin No. 3 for Friday, 19 November 1971 will now take plaoe on Sunday, November 21. All remaining items of the Agenda will oontinue as planned.
v.
ANNEXES - WORKING PAPERS
- 45 -
THE HOSPITAL SERVICE IN '!!IE WlISTERN PACIFIC REGION A COleOLIMTED REPORT FROM PlFfEEN COUN'.l'RIES AND TERRITORl::!::!
Dr George M. Emery
Regional Adviser Organization of Medical Care Weste~ Pacific Regional Office
"'!'be enJo1lllent of the highest attainable standard of health is one of the f\tndamental rights of eve17 human being without distinction of race. religion, political beliet, economic or sooial condition", "Governments have a responeibility for the health of their peoples whioh can be fulfilled only by the provision of adequate health and soc1al measures" • 1. Respons1b1l1ty of Government by Country
Since the hospital is necessary in the provision of health and medical care access to its facilities is a "f\tndamental right". Since "Governments have a responsibil1ty" countries and territories (hereafter countries) may initially be examined aocording to the proportion of all types of hospital beds which are owned by government and the proportion which are otherwise owned. Table I indicates the situation for the year 1969. It thus appears that the provision of hospital beds by government is not necessarily related to the degree of aooio-economic development of a country nor to any particular preceeding or current pattern ot Colonialism. Considering Australia, Japan and New Zealand as the most highly developed countries of the area government ownership of hospital beds ranges from 39% to 89%. The pattern in Laos and Malayaia 1s identical (8~).
Factors which influence the provision of beds by government may be a topic for discussion. Although. government. own hoapital beda there Iaq' be t'inanc1al barriers to their use. In Table II, Public pera! hOilpital beda are presented in the same countI'7 grouping as waa used for all heapi tal beds in Table I. but considered in relation to whether or not direct oharges are made to patienta and under what conditions.
- 46 -
In view of the range of pay beds from n11 to l~ it is difficult to generalize. '!bere is a tendency to claas pay beds and also a general tendency to waive or minimize charges to those who are indigent. '!'he dee1rabllity or otherwise of standards ot hospital care being dete1'lll1ned by patient's ability to pay may well be a subject tor discuse1on.
&
In SOIDe countries the private hospital system is assisted by govemment. and through. this assistance. the patient who is admitted to a private hospital. In Viet-Nam the Government aids private leprosaria and mission hospitals. New Zealand grants a daily benefit for patients in private hospitals and in,.~rta1n cases government loans to bu11d or extend private hospitals. Low interest rates to encourage private hospital bullding are also granted in Japan. In Hong Kong Just over 7~ of private hospital beds are government-assisted. China (Tai.wan). the Republic ot Korea and the Philippines are examples of countries in which there is no assistance by government to private hospitals. 2. IA!giBlation Public haspi tal slStem The eXtent of legislation varies so greatly from oountry to country that a few examples only will be quoted. In the Trust Territory of the Pacific Islands and French Polynesia there are no regulations or ordinances. In Laos. regulations in existence when the country was a French colony have not, been revised. Australia. Japan and Hew' Zealand have well-defined legislation, 'but the Australian situation varies greatly from state to state because of the limited authority of the Commonwealth CJovemment in health under the Australian Constitution. The ccmnents of participants indicate ~hat there is a need for oonsolidating and strengthening hospital legislation in many countries of the Region. Private hospital s;tstem Legislation governing private hospitals varies greatly. There 1s considerable control .in Australia. Japan. Malaysia and New Zealand. In Viet-Ham, the Minister of Health has control only of technical standards and sanitation. In French Polynesia. there are no regulations.
Public general hospitals may be funded 1n a number of walS. <Dly three countries indicated the proportion of funds made available from the various sources. Table III presents the findings.
- 47 -
In only two countries considered the patient makes no direct contribution to his care in a publio general hospital - New Zealand and the Trust Territory ot the Pacit10 Islancla. Peroentages are given tor Australia and Tonga. In Tonga the patient contribution is a nominal 2SC. In Australia i t is 24.~ but 17.9";( of this is reimbursed through insurance. '!he patient pays 6.3%. In onl3" two countries is there participation in fUnding at all levels of government - China (Taiwan) and the Philippines.
4.
Availability of Beds
The number of hospital becla available is of considerable importance. Table IV presents the findings. The relationship between socio-economio development and availability of becla is marked. French Polynesia is an exoeption. The advanoe in Japan over a five-year period is noteworthy. '!he trend in the ratio of public to private beds in Japan and the Philippines will perhaps be a subject for discussion.
5. Table V presents proportiOns and trends over a five-7ear period. Although this table 1a incauplete it reveals some interesting trends which should stimulate discussion. It 18 noteworthy that in New Zealand and Frenoh Polynesia where the Government ..sum.s the total ooat of hospital care and hospital services amount to 60% to 70% of the total health budget. 6. The Funotion of the HosRi tal
Other papers will deal with the funotion ot the hospital at local. intermediate and regional levels within the overall ooncept of regionalization. Of some importance in this respeot all oountries being conaidered except Australia and Japan indioated that the pr.inoiples of regionalization of hospital servioes are being followed. Table VI presents some ot the comaon indioes by Wbich hospital efficiency is measured. . Partioipants will. I am sure. wish to cOlllDent on some of the infonnation they have submitted. One index ot the extent to Wbioh a public general hospital fulfills· its role in making basic health services available to the people is the extent to Wbich domiciliary services are part of the hospital system. The relevant information is presented in Table VII. ManT factors influenoe the tunotion of the hospital in the provision of domiciliary services - sooio-economio. cultural and oentral v1s-~-vis looal authorit7 oontrol are some ot the .ore important. In Japan domiciliary
-48-
aervice. are the responsibility of the looal authority. In aOia. other oountries doaioiliary midwitery .ervioes are not made available beoause all. or virtually all. deliveries take place in hospital.. The partioipants. I am .ure. will 8ive valuable oontributions in the disoussion to follow. Another index of the role of the hospital in basio health servioe. is the extent to .nioh preventive serviaes are made available. ~ble VIII presents the intor.ation on the oountries under oonsideration. The oo.aents made on ~ble VII are likewise applioable to ~ble vnI. Some other indJ.oe. of the flmct10n of the hospital are the extent to whioh rehabilitation service. are developed. the role ot the hoapitalin teaoh1ns and re.searoh aDd the .tancSard of the hospital recorda .Jlltem. Table IX presents data on the oountri.. under review. In the diacuuion to tollow th.re will no doubt be cClllalenta on why .ome partioipant. lefi que.tiona unansw.red. and also on wh7 the lCD i. .aid to be in universal WI. in only ••ven of th.t1fi.en countries und.r oonsid.ration. For four oountries the ~.stion was not anawere4. It i. not.worthy and oa.mendable that .... ot the l ••••r dev.loped oountri•• oonsid.red have adopted the ICD in th.ir hospital reoorda .Jlltem.
Proportionat. coat. of the hoapital sJlltem in oountries under consideraticm have been examined in Seot1~ 5. Speoifio oosta for oountrie. from whioh information has been made available are pre.ented in Table X. The inforaation presented in '!'able X i. ot very l1lllited value only. Conversion te 111$ hu been done at 1971 rates. Int.rnational o.-pari.on of hoapital ooats oan be extremely miBleadJ.ng under anT oiroumatanoea for reasons of whioh I . . sure you all are aware. Th. table ia inoOllPlete but from the evidence available trenda are obviOWl •. capital oost. are high. 'l'h. ooat per oooupied bed per day ia inoreasing in individual oountrie•• .In the two aOtDltries on whioh infonl&t1on ·1s availabl. th.re hu been a maJ or inorease in the oo.t per patient treated over a f1 ve-year period. Partioipants will deubtleaaly enter into d.1aouasion not only on how bett.r aooounting tor tlma in hospital care ~ be oarried out but alao on methoda by which ett101enoy III&Y be inoreased without detriment to patient oare.
8.
Conaluaien
Aa .tated in one of ray lett.rs to our aeminar oonsultants. i t is not po.sible to oondense the oontent of a DPH or MPH oourse into a ten-day a.inar. Ltkew1•• it i. not possible to oondense into one work1nS paper the
- 49 -
valuable information whioh participants have supplied. However, our Seminar i8 not composed of poet-graduate atudenta in a formal sense but we are nevertheless all students. 'rhose of us on the Secretariat are attempting in our working papers to highlight topios for discuasion. '!he real worth of our Seminar will be determined by the quality of the disous.ions and the conclusions which follow. '!hose ot us on the Secretariat hope that we will emerge from the Seminar with a better understanding of the problems of Member countr1es and how we may be of aaBistance. 'lhose of us who are part1c1pants will, it 1s hoped, return to their oountries .timulated to play their part 1n developing the hospital system within the resources available to better serve those tor whom the system ensta - the people of our Member countries. I hope that from the discussions whioh follow this oonsolidated count~ report there will emerge oonclusions to relate the hOIPi tal more 01ose1y to the community. to give better value for money and to adopt "ystelllll of record.l!l and accounting which will enable inter- and intra-oountry evaluation to be carried out more effectively.
... 50 -
Table I HCBPITAL.BEIB BY. COUN'l'R! ACCORDlNO TO <*NERSHIP ,
Proportion of hospital beds owned by the Goverrunent 2;' + Tonga
Countr,r
_ Govet'nllentownedl
-.' ~vatel.y. owned~ -
Trust '!'erritol"T ot the Pacifio Islands ..
100 100
Nil Nil
P.l.Ji Frenoh Polynesia New Zeala'nd laos Mala:rsia Viet-Bu Australia Khmer Republic
96
4 -6 11
a, a, __ 13 77 71
89
94
17 17 23 27 29
1;' - 2;'
Republio of Korea Philippines
Hong Kong Japan
'!JT
rsr
43 43 61 61
39 39
Less than 1;'
China (Taiwan)
29 .
71
Peroentages are to nearest
~.
1
Goverrunent includes mi1itar,r and rehabilitation. Private-inoludes miSSionary.
2
- 51 'lable
n
PROPOR'l'ItW OF PAY B8IE IN PUBLtC GmmRAt. HQSPrl'AIS BY' COUNTRY
PrclpOl'tlC111
ot COuntry
bOep1 tal. ))ede '*led. bJ' the Gove~t
Proportion ot PII1'. beds in public gen.ral h08pl tale
C.-.entll
(-) 'rruIIt '!'emto1'7 ot the Paolfic 18l.uds '1'onp
2/) +
Hil
SOllIe patients oontribUte.
5
Agrepte patient oontri.. bution - ~J (kmt~t -
99J'.
lP1J1 henoh Pol.yn.a1a
4
100
, 01..... care.
BaIIic *.20/_ all ~ ('Im$0. 2,). Pa:r bede ftriable
ot beda. Hon-
indigent PQ' tor hoItplta1
H. . Zeal-nd IAo. MaJ.ara1a V1et-N'1IIII
Nll 14 Not .tated
Ho direct Qbarse. at all. Kip 500 (t8$2) - K1p 2000 (t8$8) , clas... ot beds lM$ (m$O.,o) to , . (TJI$9.90). _ 01..... ot beds piastre•. (UJ$O.29) - ,20 Pl"tN8 (t8$1.17). Hot stated. Clas.e. ot beds 60-400 Riels (111$1.08 - t8$1.45).
10
eo
Awstral1a Kl'iIIer Jlepubl1c
Varies
30
1" -2"
Republic of Korea Phil1ppin•• Hone EOl'I8
Nil - 70
SOllIe 1naured patients covered. Hot stated. , olass.s ot beds. Soo1al Insurano. SOh.... Covel'll n.arl,. all the patient coste.
10 100
Japml
17
Leils than 1"
China (Taiwan)
Hot stated
Not stated.
-52-
Table
m ,
Boarott of lIbnds lI~t'1.
py't.
eta.
01' ~'1.
Loqal
py't.
autborl't7 O.~
Patient
Others
Australia Cb1na (Taiwn)
zr.1$ + + +
42.1$
2-\._* +
6.'"
I':I.Jl lI'Nnoh Pol.7n•• la
..
+
+ + + + + lOO.~
Rona Kens Japan m.er Republic Laos
..
.. .. ..
+
.. + .. .. W
+
Mal.Q81a lIew Zeeland Philippines
+ +
+ ,
.. +
.. .. +
ero..
+
+ + ?~
+
RepubUo of Korea 'lanp
-
98.~
Trut Territol'J' of the faclfic Islands
..
..
..
.. .. .
..
'l'ru8t '!emtol'J
Vlet-Nam + - Yee
+
-
+
- • 11'0
*-
lDcllades 17.91' ftllmtu:r lDsuNnce
....
- 53 -
Table IV
AVAIUBII.o1'n OF HClSPl'rAL BI!m. AlL T!PES. BY COUNTRY
AND OWNRHIP FOR!lWfI 1964 AND 1969
(PER
1000 OF POPOi:ATION) ,
. . .
Public Beds Countrr
Public plus PM. vate Beds
1964 Australia China (Taiwan)
1969 8.26 0.37
1964 12.27 1.10 3.00 7.30 3.56 10.60
1969 12.01 1.20
0.37
Fiji French Polynesia Hong Kong
7.00 1.47 4.56
7.00 1.60 4.88
Japan Khmer Republic
2.90 7.50 4.12 12.51
0.30 3.23 12.40 0.61
0.50 3.02 13.00 0.71
0.36
0.60 3.64 14.20 1.27 0.52 2.62 4.83 1.52
lAos Malaysia New Zealand Philippines Republic of Korea Tonga Trust Terri tory of the Pacific Islands
3.99 13.60 0.95
2.90 5.14 1.04
2.62 4.83 1.10
2.90 5.14 1.27
Viet-Nam
- 54 -
Table V
, Caunt1'7 Year
Health aadAR National Badpt ~
Bo82!ta1 8JdAet Health Budpt ~ ~.85
Awstal.1a ~ (Taiwan) ....
~1
1963-64 ,
4.81 ....\i4
~.~ ,,~:~
J.9ij4 !~~
"4.7Q ~'~!5f'
' "QQ.QQ
fiJ1 Prenoh Pol1n_1A BGbg
1964 1$169 1964 1969 1~
Kcas
Japm
Kimler RepabUc IAo8
1969 1964 1969 1964 1$169 1964 1969 1~
1l.65 16.20 ll.,o 9.29 10.70 U.,o 18.60
1',~
74.crr 61.~ 5.~
-
1II.l.qB1A New Zealand
6.,c) 7.80 6.80 4.90 ,.61 2.84 1'.17 (Ord. plWl dev.)
.0
Ph1Uppin.. RepabUc ot Korea 'l'anp.
1969 1964 1$169 1964 1$169 1964 1969 1964 1$169
(fr.,c) 69.60 •
5.26
1l.73 (Ord.)
-
50.77 TrQt !l'el'ritoZ'J'
(de.... )
ot
the PacU1c leladll
1964 1$169 1~
V1et-Ha
1969
9.00 15.00 1.70 2.40
-
-
Tabl" VI
AVAIUBILr1Y AND FJNC"I.'IOO OF PDBLIC OBIERAL HCllPlTAL BEllI BY ~ AMI) CIII'l'ADI lHDIClIS
N..... of COuntry
, _A. .l1IlM.. hIods! 1000 populatlan 1~
Qo·;upied bedsi 1000 population 1~
In-patlanta t,,"te4/ 1000 populatlCEl 11)611 1969
DlAratl_ ot patient at&)' (in daJs)
In-patiete u-te4/ available bed
In-patlente t~te4/ oc(lUpied bed 1~'
1969
11)69
11)611
11)69
11)611 22'• •
1969 26.50
1969 ".}O
Au.trall& (!leW SClQth
5.80 0.18 1.00
5.10
val.. -17) C!l1na ('l'al-.)
4.20 0.1}
11.20
131.90 2.65
1110.10 ,.00 72.90 11'.00 ~.49
10.10 11.",
10.70 10.80
,1.10
PiJl ~oh fo~. .1&
-
0.21 1.50 0.95 5.58
-
0.18 2.00
• 2.00
-
JII::q
Kane
JIIP8n
.\.C8
KhDel> Republic
I.~1a
,.2,
. -
}.CJIi!
-
.
· '.47 · 2.72 4.90
69.90 152.00
9.50 15.00 ~.OO
1.90 14.00 ~MIO
17.00 20.00
· • •
o.n 4.50
}2.94 24.88
2.48
-
.
2O.}5
11.70 51.70
6.40 ~.65
-
.
-
25.70 15.00 }2.}O
-
82.00
)2.011
7.20 Oeft. ~
8.110 ..... Hoap.
--
9.50
8.90
tll.at._llelp. Dlft..... ,M 100111
· 16.01 17.»
.
12.00 • 19..00
·
SO.OO U.,. )9.'70
18.10
-
•.
-
~ i
."
4-6 JI_7al8Id. l'I11l1ppSn. .
10-14 15.~
6.50
RepubU" of XoNa
Tanca 1'Nat 1'errlWIT ot the hettie Ialllllc!a Wlet.llul
1.~
.
6~
0.24 0.51 0.'-5 1.70
,.40
·
•
-
3.00
lO8.70
0.19
0." 2.09
65.16 105.60
-
-
115.90 14.18 '8.47
16.50
51.81 99.90 ~.110
10."
'.JO
.
-
5.!)} 1~.OO
8.00
.
· -
18.7. ~.Cle
2'1.110
2a.9D 711.Cle
14.90 0.16
0.22
-
211.1' 0.(17
·
e.50
2M.
...
-
-
-
JO.)o (196ft
10.00 (1967)
10.00
".90
-
".~
'fable i n
IXIIICILIAR'f SI!RVICI!S OF". POIILlC IIlINIRAL HaSPl'l'AL 8l8'1'1M Br COImR!
-
"
CCMltZ7 AlI8tral1a
Bllda1,.
IIIIm1DC +
M;tclw1teZ7 +
ADte-liatal Care + +
"""t-Hatel Care + + +
Pllbl1a Health
1/ur111n8
OoClllPllt1C11al ~10the.....,. "'Dl_ +
lIIcI1~lal
8...n_ + +
-~tr1o
PQah1atrlo
t-1n8i. IIt>O~l"Wo~
8an1terian
Health
I!duoator
Cb1JIa (Talwn)
ftJl ~ah Po~ia
IIanI
~
J~
m-r Jlepubllo lao.
Malelaia
_Zea1e4 ;)b1l1pp1Dea
+
+ + +
+
+ +
+
...
+
+
-
+ + + "
+
+
-
-
+
ljapablla ot
~
-
+ +
+
+ + +
+
+ +
+ +
-
+
-
+
• + + + "
".
M.A.
"!Net 'r.rr1tGZ7 ot the holt1o Ialanda
net-_
-
-
-
-
-
-
-
+
+
--
+
+ +
-
-
+
+ +
+ + +
-
+ + +
+
+
+ +
II.A. + + +
-
W.A. +
-
+
I
'cR
-
-
+
+ +
-
-
-
I
+ • Serotc. 1. aYa1Lable. - • Berota. 1. not aYa1Lab1e.
H.A. • Not answered.
-
- 5'7 -
iiJ ~
::sj I
:
+
+
+
+
I
I
I
+
+
I
I
+
I
+
"'fi :f~
.. .. ill & II
U
I
I
+
+
I
+
I
, +
I
+
+
I
+
+
I
I
I
+
I
+
•
I
, ,
..
tl · +
+
I
+
fiJ ij iii ::sl
I
I
+
I
I
I
I
I
I
+
I
+
+
+
I
+
+
+
I
I
I
I
I
I
+
I
+
+
,
'Ii II ~Q eo: J~ !!'
I
I
,
I
I
I
,
I
I
I
, ,
+
i! , I
+
I
+
+
+
, ,
I
,
I
+
I
+
+
+
.. Ii ~ f C
I
+
a~
•
I
,
I
+
+
I
• •
+
+
+
+
I .. i .. J
,
+
+
I
+
+
+
+
•+
I
+
+
+
•
•
"!l i .. JI .. 0
I
,
+
+
,
I
I·
+
,
I
I
I
+
+
+
., 0
ill .. ::1~
, +
+
+
+
I
+
+
+
I
, I
+
+
+
+
+
:IS + +
il Ja l J~ ~I
,
I
I
,
+
• +
+
+
•
+
+
! • ... !J +
j ~ i ,; ! II
.!I
. 0:1
i u i
+
+
+
I
+
+
+
+
I
+
+
• +
+
+
E .. I J .. • • • , •
3
+
•
+
+
+
•
+
+
+
+
+
+
+
+
J 'a J
t
:I
J
jIJi l.ilr Uj JJJ.J J j il Jj!! ~ ! i!
- 58 -
'!'able IX
Countl")" Austzoalla
Rehab111 tat1~ Teach1nc Serdoes .
R.earch + ..
U . . of ICD in Recorde + ..
-
CP1na ('l'a1wan) P:LJ1 Prench
+
+ +
+ +
Ole hoepi tal + + +
onl~
PolJD..a
..
+
+ + +
.Honc Japan
Kcng
+ + + + + .. .. +
+ .. + .. + + .. + N.A. + onl~
+ +
+
JlJ'aer Republic
H.A.
,.A.
lAo. Ma~ia
+ + +
M.A. + +
New Zealand
Philippines Republic of Korea i'onp
M.A. +
M.A. SOllIe hosplta18 + .N.A.
+ +
+ N.A.
'l'rwIt Terri tOl")" of the PaoUte Isl,enda V1et-Ham
+
+
+
+
+ .. Function i. carried. out.
- - JUnotion is not carried. out. ± _ JUnction varie. f'l'OIII hoepltal to hoepital. N.A. - Question . . not
answered. .
?alJle .
nmrcm Ha.~
OF GENERAL HC8Pl'rAL or c.o~t.:..·
C~'lS
BY' COON'l'RY
A.~
YEAR
of 1~
h'aturil
cO!1::;ider~d
country
Capital C<>8~ ~
Maintenance
:~st/cu':~Fat:~r.t -:"rea':=-!
A.ustral1a
240 beds (1972) A~ll 212 000 A$116 716 per bed (U8$f;J 768.)
•
(Us!"a~.63~ =.47 (US$25.<6)
~
@
1A$13.6')
China ('fa1_)
PiJi
(1967) 5 6 _ P$2 911./bod (US$} ~3.)
(1970) 12...... \IS 2.2 (lilt 2.5) 11113.4 (W~ 3.91 P$}-\ 8SO. lI$2 904 (US$} :m.)1
I
1I'I$l00. (ust 2.5) 11I'I$l60. (USS t.)
•
lI'renah Polynesia
-SO 000 000. ClIP Pr 1
125 OOO/bed (USSl2 532.) (1<)69) 76"..,.
!:iong Kong
IJII[$
(196) 1~_ JIC$ '7} 310 000. )7 162./bod (US$ 6 1)2.)
HK$II6. (D,$ 7.6)
iJClJ9-'.
(00$15.5)
IIK$555. (VS~1.!'Il
JIC$ 2 092 000. H!($?r
HK$71. (V'$117.8;
IIK$ 5.2<) (US$ 0.87)-
11l1<$
562./bed.
7 (US$ 1.)1)-
·9.
(VS$ .. 542.) (1970) 586_
JapUl
,:"'lil) .-00 beds ! 7'2.~ Yen l.::¥. Y'en/bed{;;3t<~711 ~.511 Y"""'(US$l36.Jl
(1965) 519 bods 664M ren
I 1
775 I!«U4296 158(11312 3)6. "~:S8 Yen 1 -422
(tIS! •• 2}l
11m 2 60~ (US$ 7.7<)
Yen 6s5 (VS$ 1.95)
Yen 1 401 (VS$ 4.17)
i Y.hHr Ib!-publlc
i c.os I ~~aya1a
i
II! 900 000/ oed (ust 16 216.)
R 450 000 DOO
(1960) IJ!S 500 """"
I~.
~':'.6
;:- ... ~-::: -:".') OOO/bed L .~-: .:. ;C~/bed
'::'. !:t. il00
(J(YJ/
~
1
I ,
oc oeQS
r~~!
15 OOG 000.
MS: 20 T76/bed. (Us., 85".) New Zealand
1'I1111RdDH
25 bOcIa 1}00 000. 112 ooo/bed. (US$ 1 9'>''-76)
I ' (1970-71) 25 bods. (;;3$2!) "1 .. )
&! beda (lIZ$l 060 621.) ::::;17 677/beO
IIZ$l.OS (I1S$12.06~ lIZ$14.8 (1);$17.03) iIz$l73.4(US$l99.54! NZ$227.8 (1l3_.14) 11}.22 (US$ 2.1)
NZ$ 1.'7} (us$1.8)
HZ$ 2.25
(us$2.'7})
Republ1e of Korea
I ,
I J-:/25 000. 1]5 ooojbed (m!\l96l!) ~50 becls
Won 2 lfOO (US:!t>.~)
T,jr.ga
, s: ... IIor, , _) :':'0 , 0""' ~.
4" I 150 OO'J ~:r,,.. ..;; "I.l':".5.000/bed. ~ -')fl
Won ,2 900 (US$88.92)
Won 49C (US$1.m
"OC.;
')00
oe-js OOC
1'l'fI V!et_N_
I T,,"~ c<;Cf""1 C :.k :> -:-:-5.00) m~ 20.
USlt 2.
(1<;66) 600 bedo \'N!200 000 000 '.1:~;~~
(-S-x-) 600 t-ed.~ '::1:'::.15 :;00 000 -~!"";-: ~-:"V'be·j
333/bed
(U8$ 1 212.)
(:.."S::: 1 7)0.)
..-
InJ"oftllation not o'.ailable • 1\."1
One cl1r.lc only as
eX8/lIple.
-60ANNEX 4
MODERN COOCEPl'S AND GUIDELINES FOR ADAPI'ING THE HOSPITAL
TO THE MEDICAL CARE DEMAND OF COtJNTRIE3 AT DIFFERENT STAGES OF DEVELOPMENT by Milton I. Roemer. M.D. Seminar Director Professor of Health Administration University of California. Los Angeles, USA The role played by hospitals throughout the world depends on two principal determinants within countries: (a) the level of economic development and (b) the prevailing political philosophy, especially with respect to health services. There are. of course. gradations along both of these dimensions. Economic development ranges from weak and heavily agricultural to strong and heavily industrial. Politioal philosophy ranges from private and localized to public and oentralized. Individual countries each fallon a certain point along both of these scales. But I think one can say from world-wide scanning that the general direction of almost all countries along both of these scales has been similar: that is. toward increasing economic (and industrial) development and toward increasing publio (and centralized) political controls. In order to present this account of hospital roles, in a manner that may higlllight the issues and provoke discussion, I should like doing it with an eye to the future, as I judge it. Thus, I will stress the role of the hospital as a public or governmental institution and one operating in a centrally planned system of health services.
These remarks will. then, examine the future hospital in terms of five features: (1)
Sponsorship FUnctions Controls Relationships
(2) (3)
(4) Financing (5)
Sponsorship There is a mixture of Ownerships or sponsorships of hospitals in most countries. but the trend is clearly toward greater sponsorship by units of government. There may well be different agencies within government responsible (e.g. Ministries of Health, social security bodies or military departments) and different echelons may be involved -- local. provincial and central. Even when local government plays a large role -- as ocours in the more industrialized countries -- central government has come to exert increasing controls, through legal standards and conditions asSOCiated with financial support.
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The governmental sponsorship of hospitals has important advantages, although it also oreates some problems. On the negative side, there is alw~s the danger of exoessive bureauoraoy, with the d~lays and irritations involved in awaiting approvals of various deoisions. There may also be some slowing up of innovations, sinoe an organization aooountable to the total population must be v.ry oautious. On the positive side,publio sponsorship permits rational planning. It enables a hospital to have aooess to large finanoial resources. It helps to assure equitable treatment of different population groups. Everywhere in the world there has been a rising trend in hospital utilization. Of all health servioes offered to people, a larger share of them are offered in hospitals, where teams of personnel and proper equipment oan be mobilized. '!hese trends are largely responsible for the inoreasingly PUblio sponsorship, sinoe private or charitable resouroes are no longer oapable of meeting the rising population demands and needs. Even when sponsorship is private, the direot and indireot oontrols are inoreasingly publio Cas will be discussed below). Among different agencies of government, however, there are many persistent problems of inoo-ordination. Ministries of Health, in my view, have a responsibility for oo-ordinating the policies of all governmental bodies offering health services, through various forms of inter-ministerial couneil. In the economioally less developed oountries, the sponsorship of hospitals is usually more heavily governmental than in the higj:l,ly developed ones. '!his is an advantage whioh, in my view, should not be lost as eoonomio resouroes inorease. Private investment and sponsorship tend to oreate many inequities in medical oare -- a two-olass system, one for the rioh and another for the poor. A small private seotor, within a publio hospital system, mB¥ be justified, but the prinoipal determinant of hospital servioe should be the medioal needs of the patient, and not his personal wealth or sooial pedigree. Functions The original funotion of hospitals was confined to the bed oare of the seriously siok. Unfortunately, many hospitals still restriot themselves to this funotion, but there is no doubt that the world-wide trend is toward a muoh broader range of health services. These may be olass1f:led as: (a) (b) Co) (d) Ce) In-patient oare OUt-patient servioe Domic1liary oare Education and researoh Health servioe responsibilities in a distriot
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Regarding all these funotions, a pervasive principle has evolved throughout the world: health service regionalization. lhis principle recognizes the different technological levels of health service, which require different concentrations of resources. lhus, we must think of health services as a network of activities, like a tree with its trunk, its large branches, ani its leaves. lhere must be continuous communication among the different levels, in both directions. Wherever a person lives, he should have access to a facility at any point in the network whioh his medical condition requires for proper scientific care. Most conditions, fortunately, can be well handled at peripheral units, but some require referral to more central echelons. Likewise, technical advice must flow continuously from the centre of the regional network to the peripheral units. In-patient care always has two aspects: a medical and a custodial. 'nle custodial or care-taking aspect is usually more important in poorer countries or for poor people in any country. Thus, the average length-of stay of hospital in-patients tends to be strongly related to their economic level; poor patients stay longer because their home conditions do not penn1t proper medical service (as well as because of the usual greater severity of their disorders). Beoause modern hospitals are expensive to build and maintain, it is always sound to reduce length-of-stay to a min1mwn, but this really depends on general socio-economic development. If general living conditions are poor, society must expect to pay the price by prolonged hospital stays for custodial reasons and convalescence. As social conditions improve and length-of-stay shortens, more patients can be accommodated in the same number of beds, so that the hospital becomes more of a medical and less of a custodial facility. In-patient hospital care has many oomplex requirements in way of diagnosis, therapy, and rehabilitation, which other speakers will be discussing. lhe technioal resources for in-patient care, however, should also be available for the out-patient and other hospital functions. Out-patient servioe was not originally a hospital function at all; the first organized ambulatory clinics for the poor in 17th century Europe were entirely unrelated to hospitals, and it was only in the 19th century that most hospitals developed out-patient departments (OPD). '!he importance of tl'l!! OPJ) has steadily increased. I t is a place for both diagnosis and treatment of the patient who cannot be adequately served by a health service provider (doctor or other type) closer to his home. Perhaps it is sometimes over-used because of the greater confidence of people in the hospital as a place for help. Like in-patient care, it is .reasonable for OPJ) services to be regionalized. In the large urban hospitals, one expects to have specialized departmentalization of out-patient serviceS -- for medical conditions, surgical, paediatriC, etc. In the smaller district or :rural hospitals,
- ~OPO servioes should naturally be more generalized. Emergencies. of oourse, oocur at any hour of the dq or night. and the modern hospital must be prepared to oope with them. While the routine hours IIIa1' be
om
in the morning or afternoon. a hospital doctor should be "on oall" at any t1nle. The patient coming to an OPO presents a valuable oppo1"tun1 'loy tor health promotion and prevention, as well as treatment. Health eduoat1on. iumunizations, screening for h1dden \Useue oan be and should be ottered, but the.e services require staffing. '1here are ObrtOWl eoonam1es in combining these preventive services with medical oare. in tems ot both the patient's travel and the cost of delivering the servioe.
. Domioll1ar;r care. or "home care'!· ~ inor.. ·"'c~ .oometo be :~oog., nized as a proper hospital responsibllit:r. It is onJ.:r reuonable tor patients who 11ve fairly close by. but for such persons a procr_e Dt home oare oan reduoe the unneoessary use ot hospital beds. Convalesoenoe or oare of the chronio patient oan be oarried out in the patient's own home. if skilled personnel from the hospital oan make period1o visits. A speoifio department of the hospital ouSht to be responsible for domioiliary oare. B.tt the personnel in this department should be tree to oall on any other department -- the laboratory, the pharmao:r. the equipment unit -- for help. 'lbe home oare department must also be able to instruot family members in how to take care of the pat1ent at home. Education and research are. to sane limited extent, proper funotions in every hospital, but they need be well developed onJ.:r in the larger urban faoil1 Ues. ~uoation in the health-related GOoupations requires both patients and teachers, and these are both found in hospitals. '!'he best eduoational programnes, however, require teaching of both theory and praotioe, and theory may be better taught in a school or oollege. Therefore, hospitals must often work in olose do-operation with sOhools to fulfill this fUnotion properly. Medioal research must be both laboratory-based and olinical. 'lbe latter type is best oarried in hospitals where oareful observations oan be made. If good patient reoords are kept, some research oan be oonducted . retrospeotivel:r by outs1de investig~tors, without an1 disruption of patient oare. Health servioe reSponsibilities in a distriot is a final funotion that maybe oarried out by the modern hospital. In this sense the hospital serves as an. administrative unit, with its staff exeroising supervision on%' other faoilities' in a geographio area. TYpioally these are pol:rclinios, health oentres or health stations.
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Since the hospital has a staff of relatively highly skilled personnel, it is reasonable for them to give consultation and take administrative responsibility for ambulatory services in satellite units. Thus. the specialist in paediatrics or obstetrics in the hospital would be in charge of child or maternal health services peripherally. Likewise for infectious disease. traumatology, or other specialties. Responsibilities should concern preventive as well as curative services. Thus, the hospital would be the hub of the wheel for virtually all health services to the population within its reach -- or in its "catchment area". To play this role, however. it is obv.1ous that the hospital must be directed by someone who is knowledgeable about total conmunity health services. Some people have resisted such a broad role for the hospital. on the grotmd that hospital doctors tend to lack a "conmunity viewpoint". Ent if so broad a role is to be played. the hospital director must be or become a public health leader, rather than purely a clinician. So broad a hospital function has implications for the total national organization of health services. Hospitals would become, then, not only centres of technical expertise, but also links in the chain of administrative control. from the national capital to the villages. Controls In many countries. espec1ally of Asia or Africa, the national control of health services is div1ded between a preventive or "health" side and a curative or "medical" side. The origin of this dichotomy is understandable. Hospitals and healing of the sick were much older than preventive strategies. When pre.ventive campaigns were started, therefore. they were set up separately and as both curative and preventive services developed they became associated with separate major branches of the Ministries of Health. Today, however, we realize that the prevention and treatment of disease complement each other. Much greater efficiency can be achieved if people are approached for both types of service at the same time. Health education, 1mmunization. disease-screening, health examinations, nutritional guidance, etc. can be best conveyed at the time and place where medical care is sought for some specific ailment. Such integration also yields economies of travel. The physician, moreover. can have the greatest influence if he constantly maintains a preventive viewpoint with his patients.
Therefore. I believe that the health services of the future in most countries will not be divided between prevention and treatment. Hospitals accordingly will be links in the "chain of responsibility" for all types of service. There may well be sub-diviSions for special disease problems -like mental disorder. cancer. etc. -- or for special age groups -- like children or the very old -- but not for prevention of the personal type. (Environmental controls may admittedly require specialized agencies of a different sort.)
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At the national level, aooordingly, standards would be necessary for both hospital construction ard operation. M1.n1mum levels should be set, which could be exceeded in looal oirawastances. Stardards should be applied to staffing of different hospital departments with doctors, nurses, technicians, etc. To implement the conoept of: regionalization, there should be standards on the type of care which may properly be treated in each level of facility (except, of course, for emergenoies). ~e SUIP~illance over standards required for polyclinics and health centres should be a responsibility of the hospital, to which each ambulatory unit is administratively attached. Manuals of hospital servioe procedures are useful in many sectors. It is helpful to have standardized policies on equipment, supplies, and drugs. Likewise the administration of departments of surgery, infectious disease, paediatrios, eto. as well as the supportive services (records, laboratories, feeding, launiry, pharmaoy, eto.) oan be provided guidelines through periodic bulletins issued by a national health authority. ~e planning of new hospital oonstruotion should be a responsibility of central authorities. In this way, equity can be best achieved among the different regions of a country. ~e supply of beds that may be provided for a population depends, of course, on national economic resources, and it is important to avoid over-building in one region, while another region has a bed shortage. ~e number and types of hospi tal be~ required depends also on the degree of attentian to prevention and ambulatory care. It has become increasingly appreciated that greater emphasis on ambulatorY services, both preventive and therapeutio, oan reduce the demand on hospital beds. This is probably more true in the developing countries, where so much illness is preventable, than in the wealthier industrialized ones where the chronic degenerative disorders are more prevalent.
Evaluation of hospitals and all health servioes is another responsibility of central authorities. This depends very much on accurate reoords of mortality and morbidity. It also depends on periodic inspections by experts. Only by detection of problems, can policies be modified to achieve greater effioiency. All these controls -- Qy way of standards, planning, and evaluation are more readily applied if the hosp! tals of a country are publicly sponsored. Even if they are not, however, or-if there are diverse forms of ownership and management, the aPRlioation of national oontrols is still feasible. Insofar as hospitals serve the whole population, they should be. subject to public controls. ~s becomes more obvious as the financial support for hospital service, or health services generally, is assumed by government or through other social mechanisms. . Financing The costs of hospital service for in-patients have been rising everywhere in the world, due not only to increasing rates of utilization (hospital days per 1000 persons per year) but to the increased technical
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content of each day of care. To meet these costs, the money has been derived increasingly from social sources -- mainly from governmental revenues and social insurance. Private payments and oharity have played a relatively declining part. The rising public share of hospital finanoing applies both to construction and operation. It has the benefit of facilitating systematio planning and equity to different sooial olasses. :a.tt it may lead to waste or extravagance if the meohanism of finanoing is not prudent. A oommon praotice, adopted from the private business arena in some countries, has been for hospitals to charge a government agency (or a social insuranoe body) for eaoh patient-day of oare rendered. This policy creates an inoentive for maximum use of hospital beds, in order to maximize hospital inoome. It is doubtless more sound to finance hospitals on the basis of a prospeotive budget -- that is, a monthly or periodic amount neoessary to maintain a given rrumber of beds. at an assumed oooupanoy of 80 or 90 percent. If there is a speoial need, due to an epidemic or a oatastrophic occurrenoe, additional funds oan be allotted. Blt there is no incentive toward overuse. Periodic budgeting also permits systematic planning of new services and it promotes equitable uniformity in the salaries of personnel. This mechanism oan only be used, however. if all or the great bulk of the oosts of hospital operation are met from a single souroe. No two hospitals are exactly alike and so the budgets must take aocount of varying local oiroumstances. The budget should be prepared by eaoh hospital, on the basis of approved standards, and be subject to review by a oentral authority. Only in this way can economy be protected. Through budget review, furthermore, the oentral authority can see to it that the full range of hospital functions (discussed above) are provided for, in proper proportions. Relationships The polioies and perspeotive suggested here for hospitals are oriented toward the future. They assume that the trends observable now in most countries will continue toward a time when systematic planning of heal th servioes will prevail. At suoh a time. hospitals will have a very different role from theirs today. With the scope of functions suggested above, the mechanisms of finanoing. and the exercise of various forms of control, tpey will be the key facilities in the whole network of personal health services. They will not be "workshops" for private medioal practitioners but channels for over-all social policy of health protection.
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'Because of the heritages of the past. and current political realities, the path of this future state will. of course. differ among countries. It is likely to be more rapidly traversed. in my opinion, in the developing countries, Where the hospital tradition is younger. By conscious leadership toda;y, the hospitals in developing oountries oan avoid some of the distorted or imbalanoed developnents that have marked the growth of health servioes in the industrialized oountries. Suoh leadership will emphasize the relationships of hospitals to all sectors of health servioe in their own 1Dmediate areas and the relationships to other hospitals in regionalized systems. All this planning would be motivated by a goal of health servioe. in which the ori teria for use of 8Il¥ resource would not be the 1ndividual's wealth or sooial status, but only his human needs (both pathologioal and personal) and the requirements of efficient medioal servioe.
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ANNEX
5
TO EXPIDRE MFANS FOR MOBILIZING RESOURCES AND THE ~E OF SlSTEM3 FOR THE DEVEIDPMENT OF EFFICI»rr MANAGEMI!m' OF HOOPlTAIB by R. Glyn 'lhomas, DPH Regional Officer for the Organization of Medical Care, EURO Introduction Disrael1 once said "the health of the people is really the foundation upon which all their happiness and all their power as a state depends". Hospitals are among the most important, complicated and expensive components of the system being provided by countries to ensure adequate level of health of the people. A large proportion of the financial, managerial and personnel resources assigned for health services is used in hospital care. The hospital equally, has evolved from a place set aside for the "care" of special groups of the community to an institution providing treatment. In consequence, many hospitals have become disease-oriented. Dr Edwin Crosby,l in his Ren~ Sand Memorial Lecture in DUsseldorf in 1969, described this situation as one in which there was an "emphasis on scientific quality within its walls, ignoring the needs without its walls". This constant pressure to develop acute services coupled with technological advances, perpetuates concentration on the disease situation, and there may be a tendency to leave to the community the growing problems in other fields of med1calcare. It seems therefore essential to develop the changIng role of the hospital as an essential part of a total health care system. As a social institution it is Involved and must be involved in studying the needs of the community outside its walls. Such study must include the interrelatIonship of health and sickness. as well as hOUSing, food, education, sanitation. preventive medicine and long-term care. The hospItal clearly has an essential part to play in maintaining people's health, which requires knowledge and understanding of all aspects of living. To develop a purely hospital-oriented system calls for the accessibIlity to other services. They too must be of high standard and efficient and it is perhaps appropriate even at the beginning of this paper to emphasize that the attainment of efficiency and effectiveness of service is in no way inconsistent with humane purposes of hospital or medical care. This point is made early in the paper to emphasize the need for greater knowledge of the communities which hospitals exist to serve. Indeed, direct involvement of the hospital in community affairs must ultimately increase the effectiveness of oare such hospitals give. lcrosby, E.L. (1969) Ren~ Sand Memorial Lecture, International Hospital Foundation Congress, Dasseldorf.
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Trends in the d.v.l0Jl!!ent of s.rvices In many oountri.s, due to the d.sire tor a more .ff.otiv. a.rvio., there is a ol.ar trend towards the srlldual re-ori.ntat1on of servic.s towards the cOlllUJl1ty. 'leobnolOS10al JDIId1cal d.v.lopaent and. the cost of such d .....lopaent 1s alao contribut1ng towards this trend. Pressure is b.ing brousht to bear by new so01al d..ands and. prioriU.a. In the d.....loped. oountri.s, th.re s .... to be a furth.r factor. that of the ohanI1ng . . . .truoture of the coa.unity and the dift.rent patt.rn of d1 ..... 1n the 00lBWl1t1.a be1ng ••"ed. Aa cOlllllUllioabl. di...... are brousht IIOre and IIOre und.r oontrol, th.y are beina replaced by the di ......, par.t1oularl;v the d.gen.rath. d1s....s, characteriat10 of later I1fe. '!he 1nore..ina 1nc1dence of aoc1denta, .. populat1ons move from a trlld1tionally rural to an urban soc1.ty, gives ria., not n.oessar1ly to h1gh mortality, but to 1ncre..1ng IIOrbidity, mak1ng in consequenoe, inore..ed d_and.s upon total medioal and 1!I001al .erv10•• , not only ho.pi tal treatment for acut. 0.... but also, oontinuina oare, wh.ther this be in hoapital or outaid•• Wheth.r the 1108pital prorid.s the care and treatment for the aout.l;v ill or injured, it IIhould be r.cogn1sed that a proportion ot such c ...s require oontinuing oare and to maintain such oare at hoapital lev.l, can result in the hosp1tal abaorbina an undue proport1on of the reaourc.s aVailable for the maintenanoe of a total h.alth oare s;vatem. It s .... therefore that the reoosn1 tion ot trend. 1n an:v oountry in the patt.rna ot h.alth oare, allows a olo..r und.ratancling of the relationship bet• •n the needs of the oammmity and. the d--.nd. it plac.s on s.rvio.s. 'lh. d.v.lo. .ent ot the t • • ~ach to match the multi pl. d..anda being mild. by 1ndividuals fl'Oll the o~ty beccaes also a matt.r of consid.rabl. iIIIportanc. by the d.vel~t of Sl'OUP practio., h.alth o.ntres. _ 'lh. eduoation and training of aulti-d1s01plinar;v t .... by a mult1-d1sc1pl1nar;y approach 1a equally important in the ultimate evolut1on of cO!lPreh.na1 v. a.rvic.s. R.sourc.s available Before attempt1ng to cons1d.r wqa in which resouro.s can be more .ff.ctively and .ff1cl.ntl;v used, 1t may be of value to Identify the rel!lOurc.s that for the purpos.s of this paper will be consid.red. 'lhes. a• • to be under four main headingst
(1) Knowledge, (2) (3)
Physical Resources. Personnel,
(4) Economic.
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Probably the IIOst important ot all our resources is knowledge coupled with the words "intol'llation" am "data". It is 1Jnportant to emphasize that the planning am eValuation am orsanization of service depends on the enstenoe or reliable intol'llation. partioularly on the eztent. kind or ill health. in the oOllllllWl1ty that the service is being devised or established to serve. The recosni tion that intol'll&tion is required not only
ot what
exists - by th1a~ WlIOrbidlty· - but also in the changing health needs of the oa.lWl1ty. am obang1ng d_ams, as the sooial structure of the ~ty alters. ineT1tably altering the delivery or care required. 2. Phlsioal resources
'lhese rellOUroes cover buildinga~ equipaent am will be dealt with IIOre tully by other collessues at the Sea1nar. It is essential to reoosmze that the desi8n and prorts1on ot such Jlb7sioal resources oan have very marked ettect upon the ultillate use of other resources. particularly those ot personnel. ,. Personnel
In any health care syate.. resource availablli ty am allocation is 110810 important. We are dealing with a serTioe which is personneloriented ancl theretore not only the 1f81' in which such personnel are USed~ but their reoruitaent, beoc.ea a'lIOst 1IIIportant oonsideration. An Alllerioan worker. Ginabers. in 1967. said that "'lbe one sure way to waate akills, to dlsoourap trained people. to disenchant statf ~ is to have enoush people for all the work that needs doing. A lean orsanization is the beat - i t there is a ahortap ot people. then and only then~ w111 the latent undeveloped potentials ot people be tully utilized". In .'-ing this quotation at this stap it se.s to 118 that we are dealing with a situat10n in II&nY' countries where the ahortap of people alre~ ensta. and therefore the Utilization of personnel to a III&X1mum desree is a sine qua non.
4.
BcoJ1Oll1c resouroes
It baa been said that the evolution of any service depends pr1llar1ly on two factorsl availability of finance. availability of IIal'lpoWer. I t baa alrelldy been said that hoap1tals are probably the lIOat complioated and expensive oomponents of the health servioe. and there is olear evidenoe in II&nY' oountries ot the conoern of the rising cost or the health sernoes pnerally. particularly those having a
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hospItal-oriented systea. 'lhe.e hospital costa qlpear to ri.e in direct proportlon .. hoapital. concentrate an acute di...... and It ahould be recop.ad that ho.pltala deal nth a "d-m" altuatlon which Is net nece.sarUy s1m1lar to the true "need" ot the cOlDWl1tlea they .erve. Hoapitala tend tblretore, for various reuona. to be .electln, and It is clear that in so doing, the hoQital. to deal nth thi. d_and altuatlon - tends to utllize - in ter.. of personnel, building and equls-ent - up to ~ of the total available resource.. leaving only ~ to deal nth the extra-wral care .errice.. '!he fipre 1. even IIOre disconcerting when one considers. e.pbaai.ed by oertain atudie•• that the hospltal only deal. nth approx1llate17 ~ of the tNe *>rbidity of a oountr.v. 1'he lIOdem hospltal provide. all the recognised IIIOdem facilitlea, such .. tor ex.ple. laboratoriea, rlid101og-, operating theatre, otten net fI1l17 utUised by the uJorlty of the hoapltal populatlon, and theretore problaa of operational coata need to be solftd, so that these facUltiea are uaed to their -m-a potentlal, and the ndening gap between the potential ranp ot sophistloation of .adem care and that which ia economicall7 te..ible can be reduced to a II1n1J11wa.
Pressures for change Before IIOVing to the 1IIportant part ot the paper, where I ahall attempt to define the future needa and the .etboda tor opt1ll1zing reaource.. it i. pem.pe wortlndl11e to identIfy what the pre.surea are on the a"teaI. (1) to control rapidly increuins coet.,
(2) to 1Iaprove quality o,t care, ~
(3) to extend the .cope of co.un1 t,. .ervlce.,
(4) to utll1ze manpower *>re eftectively becauae of shortases,
to expand and modemi.e phy.lcal resource. to .et Increased d_and., , (5) to plan future .ise and functions of a ho.pital and to define the f~nork of the total plan. agreed tor the area, (T) . to redefine the hoapltal '. functIons and bl'O.ten It. reaponalbUIty.
'1.'hese are b7 ne _ana cOllPJ'8henalve but at leut .et a beokground against which we can nowllOTe to oonaider the probl_ of our future needs and demands.
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It has already been stated that arrr health care or hospital &yst. abould be ollPable of developing altiple objectives. 'l'h1s is ap,inst a period ot ohanp lIhere the ho.pi tal wi thin the sy.t. is changing and sbould be looking outwards towards a co.uunity-oriented &y.t.. !he•• multiPle objective. should therefore be olo.ely .tudied. Puture needa '!he.e oan be oonsid.red under the following head.1np t 1. Renew of the infolWation be1nl u.ed and required.
As mentioned .arlier. info1'llation and data are of fund...ntal 1IIportanoe. not only in planning but in the on-so1D8 qtpreoiation of any .errioe. It i. e ••ential to consider the infol'llation b..ed on the . total needs of the oc.un1ty. eYen when o01UJidering the hoapital .ituatlon and therefore. neoe.sary infomation will oover dellOsraph1c data of the population. oatola.nt area being .erved. surv.y of the .xisting resouro.. available. levels and types of morbidity. the medioal care re.ouroes available outside the hospital. the health polioy wh10h has been defined and decided for the area. .. well &8 speoifio infonaation dealing with lIdaIi.aion, di.charge. demand and supply, and the social ooncH.tions of the area. Infomation on personn.l will be dealt within great.r detail ~en we consider personn.l requi~nts.
2.
Personn.l
l'!9,u1~nt.
Great.r study Of the inter-aotion and inter-relationahip of various .eotors of health oare. for ~le, acute, preventive, rehabil1tation. and long term oare. Althoqh thi. has been .aid ~ t:laes. it is •••ential to consider in the develo)ll8Jlt of JHd10al oare .ervio•• the relationship betwe.n prevention and trea1aent. 'lo illu.trate by point. of specific interest the d.velo,..nt ot rehabilitation .errioe•• it it is reoognized. that rehabilitation i. in itself a preventive ••rrio•• well-orsanized - Oan prevent the developaent of ultiaate di.abillty 111 th its oonsequential d.ands upon long-tel'll oare. therefore 1IO~ of sreater and sreater oonsideratlon, apart troll belng 110" .oonoaioal in the us. of pb;ysloal and manpower reaouro... PQ1Hnt of pension without at the .... tim•• ocaprehen.1v. rehabilitaUYe ••rrioe•• oan l.ad. to the perpetuation of a di.ability rather than It. oure. S1a1larb. recoptlon of .arbdi..... IUY result in prevent1ng . edIIluion and so the coI18UllPtion ot acut. and co.tb hospital resources. Developaent of oOllllllUll1.t}'-based servio••• requiring as th.y do, fewer personn.l. and v.ry ott.n 1 ••• hishlY-trained personn.l can lead not only to prevention of .arly lIdIIi••ion. but allow also for earlier disobarse of patients •..no by their illness require hospital oare.
t
I
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3.
'!'he quality and
outc~e
of 1I8d10al oare provided
We are really oonsideri~ the effectiveness and efficiency of medical care servioes. Also one should introduoe at this stage a word otten forgotten - adequacy. '!'his paper began with the statement of Disraeli - and whilst many countries, if not all, acoept man's rigbt to health, it is extremely difficult, at times impossible, to ensure that everyone enjoys his rignt - to benefit ~ medical oare services provided. Seleotion is bound to take place, based otten on eoonomio faotors, distance and. availablli ty of resources. It is important to define these criteria of seleotion and also to define and identity how effective and efficient or even how adequate the services are. The World Health Organization defines the quality of care as consisting of three components, adequacy, effioiency, arXl technical and. scientific level of care. Adequacy is concerned with the performance of the health service in relation to its stated obJeotives; efficiency. the relationship of the degree of adequacy to the resouroes employed; and the technioal and soientific level is ooncerned with the production of health services. The purpose of this estimation of activities of a hospital should be to obtain obJeotive information for a correct evaluation based on ohang1ng needs and demands of the populatio n being served, and the ultimate planning of the development of the system of hospital health care, and in so doing, inoreasing its service effioiency. Therefore, it is necessary to bear in mindl (1) The ohang1ng demographio and epidemiologioal characteristics of the oOlllllUllity, for example, birth rate- increase in proportion, aged _ deorease in prevalence of some diseases - increasing prevalence of others, (2) '!'he sooial progress and increasing availability and acoessibility of health oare servioes. (3) '!'he scientifio advanoes and technioal progress, for exa.ple, availability of new proPQTlaotic, diagnostio, therapeutic and rehabilitation methods. No doubt, during the period of the seminar greater opportunity will be taken to oonsider the estimation of the effectiveness or efficiency of medical oare. 1
Even if this is not so, the mOdel which oould be used in the formulation of any activity I (1) (2) .(3)
the definition of aim the planning of aotion the organization of manpower and. material resources deployment and
their
~orld Health Organization, Effioiency of Medical Care, Report on a SYIIlposium, Copenhagen, 1966 and 1967.
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(5)
the realization of the appreciation of service activities,
(6)
the e.timation of th••e activiti•••
Organizational probl. . '!his s.ction can best be d.alt with b7 posing a que.tions can the pre.ent Q'stems be ~ .uily' and bow do the7 relate to the .pecific innovations being ••tablished particularly' at ho.pital level, such as int.nsiv. oare unit., progressive oare, or even daJ servio.s' It ..... • ••ential, Whether on. is oonsid.ring regionalization of .ervioe., siz. of hospitals, oa.plex1ty of hospital., the e.tablishment of intensiv. oare units, the e.tabliahlllent of progressive oare, or even dq .ervioes, that .ach of th••e abould be ident1fied apinst the background of the defined model before being .stablished. It ..... obrtous that for ex.pl., to .stablish an intensive oare unit 1JIIplie. that ons will provide servioes for relatively' few people but at high cost in tems of lIIanpower and lIIaterial resourc.s allooation. iIle priority d.cision, therefore, as asa1nst whether it 18 possible to provide such servioe before on. bas e.tablished sel"'lioe. for the maJority i. one of f'undaIIIental 1JIIportano.. On the other lwld, to establish dq services,
whether the.e be ot a _ therapeutio or of a oare .ervioe. are equally' 1m.portant in that th87 oon~ tewer personnel and PhY.ioal re.ources and will offer greater .ervice. to III&n7 rather than to the few. Man;y .tudies have been und.rtaken on the que.tion of patient hosp1tal1zat10n. In lIIany instano•• the decision to hospital1z. has not been tor a olinical reason, but rath.r tor a .ooial reason. ih1s 1JIIplies a par.x in that the patient adJI1tted 1s otten subjeoted to llUIIIerous invest1gations which. had th.re not be.n the sooial reason, weNld not have been und.rtaken. It is 8ssent1al th.refore, that the total needs ot the pat1ent relative to hi. ol1n1oal oond1t1on should be Identified and that the inve.tigation end the requ1rellents are diotated 1II0re by what the pati.nt requIres rather than b7 the pby.ioal looation. Pattern of tra1n1¥ It . . . . in III&Il7 instano.s a .trange paradox that ever,yone beoause of pressures indioated .arlier in this paper, oonsid.rs 1t n.ce.s&r7 to train people and to redetine tasks of h.alth personnel based on the oOlllll\U11ty. It s..us however .trange that the c~ty is rarely' used for the purpos.s of such tra1n1ns. ill. ho.pital 18 used 1II0re and 1II0re for the training of personn.l,
I.
bued on a morbId1t,y whioh is not nec.ssarily Charaoterist10 ot the oommunity servioe.. .urse train1nS i. usually' hospi tal-orientedJ med10al tra1n1ng 1s hilbly hospital-oriented. 'l'be teal approach is usually looked upon as being a hospital prerogative. whereas the cont.nt of teal and activity of telllll deaand dift.rent att1tudes in a community .ltuat1on.
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It . . . . therefore •••ent1al that we aboul4 be(l1n to det1ne !DOre and more the tunction of 1Ibat people are requ1re4 to do rather thaD 1Ibat
t.be7 are 401118. It abould be reoosnised that we are tra1n1ng for a liven d.fined prrpo•• rather thaD tor Ul act1vlt,' lIb1eb hall been undertaken for a consid.rable period of ts... '1t1e nHC1 to d1.t1np1eh quite clear17 between 1Ih&t 1• •pec1al1Ation aDd pneral1Atlon beo••• 1IIportant. aDd i t one recop1z•• that the a&in probl_ 18 bow to deplOJ' perIIODnel to the great.st IdVUlt.... then the DMd to UDd.rtake invesUptlon ot tun~lonal anal7.18 of actl'9'1tie•• to define 1Ih&t a patient requires in te1W8 of ••rvic•• beccae• •ven acre aDd aore 1aportant. Recent17. in J':lnlaDd. Ul interest1n8 atud7 baa been undertak.n in Ul atteapt to detine the I t . . of ••rvio. c~ bT patlents with particular dia.... s1tuations. '.lb. 1Dvelltlptiona required are 1dentit1ed aDd allow medical personn.l to define the therQT wbich OUl then ult1a&te17 be co.ted. In it ..... that to defin. II4equacy and efflc1enOJ'. it i. neoeeear;r to quant14 factors !molved in patient care. At this atap 1n t1ae, III&n1' factors IU1' . .11 be non-quant1tiable.
"-&17.
Relat10n of cap1tal eooncm.e. to lQDI-tezw rennue .conome. off.red relat1onah1p between c91tal inveataent aDd re'9'8l11l8 c~taent
bl
Und.r thi. sect1on, it 1. n.ce.sUT to consider that when, for .lWIPle, in a laborato1'7 fl.ld. autoaated equ1JII8Dt 1. introduced. then the l.vel of .tattins of- aueb autc.&ted proc...... both in tezwa of D\llllbers end tra1n1nc ahGuld be related to tbe equ1,.ent. It 1. impract1cal to ...,107 hi gbl 7'-trained labordo1'7 tecbn101ans to supervi•• autoaated equiJII8Dt, oapabl. 1ts.lf of S1v1ng reault. w1thout the need for h1shl7-tra1ned per.onn.l.
De.11D of pbJ'alcal re.ourc.. IIb8uld al.o be related to the ult1lllate need and ita avulabillty. De.1sn ot ward unit•• for eX.pl., needs to be related to the available aaDpower aDd the tra 1n1 na facillU... '1'0 chaDp a ward d ••1p. wltbcNt at the . _ ts.. conaid.rtna the avulabll1ty ot auralns personnel. oov.ld leld to conald.rable d1tt1oultl••• Def1n1tion of lllne•• At the pre.ent IIOIIeDt, one define. aDd provide•••rv1c•• baaed on a dl....e or 11lne•• d.f1n1t1on. Cona1deratlon should be slnn to the d...nda of croups of pat1ent. and the def1n1tlon of cue 1<*1 IU1' be more important to the cOl18\1llptlon of .ervic... Illne.s.. IU1' th.refore be srouped baaed on th. d they IU1' have on ••rvices. If this 18 po•• ibl., in turn 1t IU1' then be oapable ot being Ident1tied in tams of oo.t. of ••rvioe.
M.
- 76 -
Size of facility It is important to consider the proJeoted possible new struotures of hospitals and. hospital services. i'here are a number of choioes. If it is acoepted that there should be large hospitals for acute oonditions then. even in the present system. some are short of one faoility of another. A hospital system usually corrects this omission by diluting its oase load and ultimately what happens i8 that a hospital. designed primarily as an aoute hospital. dilutes its oase-load to such an extent that the facilities of radiology. laboratory. etc. are not used to their full capacity. The patients. by extending their length of stay are not really oonsuming facilities made aVailable to them. Larp mixed hospitals for aoute oonditionswith possibly a hi8her number of intensive oare units are required. but at the s ... time. a hospital requires faoilities to whioh patients no longer requiring assooiated faoilities of the hospital oan be transferred as soon after admission as possible. Suoh units require a different fOnD of staffing - a different form of training of their personnel. Within the hospital itself. length of stay as an index of the effeotiveness of the hospital is not adequate any more than averase oooupanoy. It is neoessar,y. and this in itself is not a difficult problem. nor does it require hi8hly-sophistioated information systems. in oonsultation with olinioal staff. to define olearly what each bed. in a given speoialty can produoein terms of "through_put" per patient. i'his varies enormously from specialty to speoialty but experienoe has so often shown that a surgioal unit in one hospital differs from another. or even within the same hospitals. for the same olinical oonditions. i'his is not in itself an economical or praotioal use of the resources. Effioienoy has often or frequently 'been associated with stringent and often ill-oonoeived oost-control measures. Equally. the delegation to physioians of complete freedom to presoribe and oarry out treatment which they feel in their patient's interest. is not a wholly satisfactory situation. It is essential that there should be some fom of feedbaok of information on aotivity of individualS. If one is to provide facilities whioh are hi8hly oostly in tems of oapital investment suoh as radiologioal and laboratory servioes. then not only must they be used to their maximum capacity. but the users of suoh servioe must be constantly infomed as to how they are using them. Use of managerial methodology We now oome to the most important part of the paper. We have attempted to define oertain problems. How oan one now use servioes to improve the situation? Management requires possibly three skills - technioal (knowledp of the particular problem at hand); human (the ability to cOlllllUll1oate); and oonoeptual (the &bility to see things as a whole).
-77-
It 1s necessar.y to see and trr to define what the probl.m 1s and to define what .ball be done, and to IIOve to a st... , siven the problaD, of what the solutions are and how theJ' IIIQ" be iIlpleMnted. 'lhia can be defined . .&in as four phaseal planninS, organizing, IIIOt1vat1ns end controllinS. The hospital s .... to bav. two maJor re.pona1bilit1es~ to define the best wq of providins a reasonable and aecure therapeutic environment, and al.o to defin. the be.t wq of deploying 1 ta akilla and resource.. 'D1.1a impli•• that without .ff.ctive organization and leadership, the dec1aion-lII8k1na. which i. 1'undaental in JII8lUIPMIlt. ia 11ke17 to be inadequate.· '!'he manaptrial process" th.refore ..... to be (1) consid.ration of an id.al future; (2) formulation of an obJ.ctiv.;
(3)' ••ttiq of a target; (4)( allocatine of reaources;
(S) follow-u~ and evaluation. and "tarpt". l.t
So that there IIhould be no contusion between the words "obJectiv." 118 take a ve1'7 ailllple UMPl.:
CarcinOlll& of the luna - consequ.nt upOn lIIIIOking, the id.al i8 that there .hould be no d.aths. 'l'ba obJ.ctive 1s to atop people amokins. 'D1.e target 18 the health education of children to prevent their ever tekins . up amok1nl. 'l'ba allocation of re.ourcea and the follow-up i. a normal manaptrial procedure. '!'he use
ot varlOW! tecbnologies and technique. can be identifiech
(1) dellOsraPh1o _thoda in t.1'III8 of e.tlmatins manpower" (2) funotional anal7aia of at4f'f actiVities, (3)
aDulation of hospital aotivity and ita .f'f'icienoy" identification ot quali t7 oontrol b1' the us. of .imulation prooedure., the
(4) (S)
application of operational. re••arch.
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At this stage. it should be emphasized that operational research is not really a technique in itself. It has been described as a sclence in support of the practioe of management. The other techniques referred to are often used in operational research because similar types of problems arise in many different situations. However. it would be a mistake to identify operational research as being the totality of these techniques. 'lbe purpose of operational research is that action needs to be taken and operational research is specific to the managerial. technical ani social situation. Conclusion Many countries. if not all. have a genuine concern over the increasing problem of defining and designing a comprehensive medical care service. In the period of the Seminar therefore. one may identify the approaches that are required. These seem to be as follows:
(1) Definition of the methodology which takes into account the
total health care system. the hospital being only a part of this. (2) A critical review of the infomation being used and needed. (,) A study of the interactions and inter-relationships of the various sectors of health oare systems.
(4) Identification of measures which can be used to detemine the quality. adequacy and effectiveness of the medical care delivered. desired and planned. (5) Valid comparisons between the resources and the demands of the various sectors of health oare and the appropriate allocation of resources to each of these sectors;
(6) A funotional analysis and/or definition of the roles needed for the deiivery of such services as well as the identification of goals and priorities for the education and training of health personnel. Change in the methodS and attitUdes within a medical care delivery 2 system are oocurring. Change occurs only when:
(7) Need exists (perception of a "gap' or of a" crisis") ;
(8) Opportunity exists (there is existence of different methods and new ideas);
~se of Operational Research in Health Services. WHO 1970.
(l!X1R> 0408 (1».
- 79 (9) (10) Resources are available to iIIpl_ent new methods; '!'hat there is motivation of appropriate people to act.
All thes. tour factors are necessar,v tor change and they must all coincide. Unfortunately. they rarely do. What is 1JIportant to reoopize 1s that unless they coincide. ckaDp 18 unlikely to occur.
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ANNEX 6
Ha3P1'1'AL CONSTRUCTICIf:
REASCIf AND METHOD OF DESIGN
by Donald A. Goldfinoh l'BIBA. Dipl. TP (Leeds). Dip. H. Eng. FflSH. HON FAPHA 1.
'!'he oOJl8Ultant in hospital p!ann'ns and oonatruotion
In such a vast territory as the Western Paoific Region many oountries will be faoed with a rap1dly expand1.ng building prosra-e for health and medioal servioes u a general 1DIprov.ent of world economy takes plaoe. while others will have to taokle the probl.. of aohieving and maintaining a satisfactory level of building on a budget whioh is ever d1f1ndltns in purohasing power. All oountries planning for the satisfaotory health care of their peoples need to ascertain the most up-to-dste trends and to seek the skills that can app17 those trends to the many unsolved problems. 'l'here are very few part. of the world where this oan be done unaided. There are the larger oentres of oivilization both in the East and West. the North and the South. where great disooveries in medicare have been developed. OOWltri. whoae individual needs have been on such a scale that learned men and women in the medioal anel nUNing, architeotural and the engineer1nl profes.iona have set th...elv.. apart to specialize in the field of hospital and health institution design and requirements. In sOlIe areas it m&7 not be neoessar.r to seek help tram abroad as one reoalls the research work of hoapital oOIlllUltanta who have oCllle to the fore in Japan. Australia and New Zealand. Countries in both hemisphere's contain examples of buildings designed to solve the m&nJ' special problems; and yet this is one field of developaent where reference to an example is not enough. It takes many decade. of prof• •ional experienoe in this field to achieve the skills neoeuar.r to stud7 the backcround and peoples. medical risks and possible solutiona, to enable one to give sound advice or to be able to respond to CDIlsultation b7 a developing country-. In such cases, the open mind with no preconceived ideu ls essential, if the advice given is to be truly that of a friend with the one purpoae to help his neighbour find the right answer to his probl•• Advioe 18 -an opinion siven or ottered as to aotion". And so to publio health authorities there 18 the opportunity "to seek or receive a profe.sional op1n1en u to a OOUNe of aotlon", and in the true aplri t of definition, that op1nion oan be acoepted and aoted upon. or rejected at will by the reoipient. 0nl.7 he will benet1 t rr. or sutter the oonsequenoes of . that decislon. 'l'he oonsultent to mOIl one turna has pl'Clfesaional skills. uperience and wide knowl.:lge of' a particular field, which equip him to give pereonal and prof• •lonal advioe or expre•• an opinion. His integrity. knowlqe, acral and profes.ional .tanding are such that it matters not to him -nether h18 advice is acoepted or rejected. Reaponsib1lity for that deo1.ion retlt8 with the reo1pient alone, be it individual. miniatry- or govel'!lllen.t.
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thilt. that b)' exchange of vieW. and probl.... it ia posaible to uaesa the degree of advice that mat be aousht. and learn the .thodll whereby it can be applied to the individual probl_. I shall therefore t17 to set out the sequ~ce of elaente requiring studT and leadine to a functional plan tor hospital d..isn and construction to . e t the particular needs of the terri to17. 2. Preventi ve and curati va medicine
I t is in the course of WHO a.-1nal'11 such u
Health services and education intermingle. Nurser" schools are a form of preventive .edicine closely allied to clinics dealing with II&ternity u part of general medicine and with health centres that are district branches of the general· hoapi tal out-patients' department. There has been a progressive change tro. the purely preventive care for the local population. with curative hospital care being separately located at a greater distance, into a new pattern of combined preventive and curative medicine in a single establishment. The size of the cOlB\mity served m&7 well V&l7 frOID one count17 to another. A certain indecision is noticeable u regards the curative functions to be entrusted to a rural hea~th centre; some cOYQ~ries do not hesitate to provide for a wide range of activities. including materni ty services, emergency care, in-patient treatment for COlllllon and contagious diseues, and out-patients' clinics. Others realize the difficulties which May reault frOID excessive decentralization of rural hospitals, and prefer to limit the curative functions of such establishments to out-patients' clinics. In these countri.. , hospitalization begins at the level of small town hospitals where proper facHi ties and qualified medical staff can be ..sembled. There is general agre_ent however on the need for transport and communications facilities between town and count17.
3.
Health services development plan
I t will thus be seen that the preparation of a national plan for the developllent of health services IllU8t clearly indicate the pattern and the extent of care to be provided .and this will be influenced not only by geographical conditions, popal.ation trend and distribution, developllent plana for industry, agriculture, mining, etc. but alao b)' the rural and urban pathology. These latter medical data, together with the fact that distribution of specialists in various branches cannot be as regular as that of general practitioners, ldll dictate the overall plan, h08pi tal type and location. for econOlllJ' or skilled manpower must receive equal consideration with that of financial resources.
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The teaching of medicine and scientific research also play a decisive part in the distribution of specialized services, and they have profound influence on the hospital of today. The few specialists of the past passed on their learning and \:)onducted' their research wi thin the medical schools. Today. specialized training necessarily comprises a very large part of the curriculum of medical studies, and, in all, a student spends more time in the specialized departments than in the general hospitals for patients suffering from common ailments. This applies with even greater force in specialized diploma courses and post-graduate teaching. Now. the rarity of certain diseases tends to favour the concentration of patients in urban centres possessing medical schools. The planning of a hospital system at government level after consultation with various ministries (including the Education Ministry) is bound to be profoundly affected b,y these considerations. The geographical element, and relatiV'1tyof the centres of population, will have a great bearing ontha number of relatives and friends that accompany a patient to hospital, on the length of the patient's stay, and on the need for patient self-care, accommodation, or even a hostel type accommodation for relatives. 4. Seek the right solution
In many countries, proVision of health and hospital facilities still fall very far short of the needs of the people, not always because no provision has been made but because it is of the wrong pattern, in the wrong place. and is functionally unsuitable for the country. So often 1t is still thought that a hospital is a luxury building that brings prest1ge - it 1s not and must not be. Each country must consider the tradition of a hosp1tal service as its own personal problem. the solution to be made to measure. The mode of life, which is an expression of the economic and cultural structure of a country, varies completely from one region to another. In areas where general farming is carried on and the farmer is self-sufficient. Journeys to town are rare, because the town. in developing its activities, has managed to extend the range of its commercial and banking services over a considerable distance. The famier has but few occasions for travelling, and going into hospital in a distant town is for him an adventure that arouses certain fear and hostility complexes. He will consent to go only when his doctor assures him that the. town hospital alone can provide the treatment he needs. Furthermore. the fear exists that, in the event of death and, unfortum te1y. the death rate of such cases is high because hospitalization is accepted only when the patient is seriously 111 there may be serious obstacles to the celebration of funeral rites and the return of the corpse.
Nevertheless, it is interesting to note the str1k1nS rapidity with which an uneducated populat10nLbecOllles accustOllled to hospital services. Hospital attendance would inorease rapidly i f hospital capacity permitted. In Southern Rhodesia, the rural hospitals have an attendance of 14 inhabitants per 1000. In Egypt, hospitals have clearly become popular, and their requirements seem to correspond to starnards generally accepted for Western hospitals. 'lb1s points to the fact that a hospital system, correctly planned, would very soon be ut11ized by populatiOns hitherto badly provided with health services. In the Western Pacific Region the approaoh to hospital provision and design pattern must be varied in order that territories can be embraced both with and without financial resouroes, although, fortuitously, many are good. for those which lie within the tropics as
well as for those outside. Climatic conditions differ from one part to another, and likewise the degree of develop!l8nt. The result of established trade with other parts of the world has given to many a regular source of exchange of ideas, sk111s and knowledge to help in solving, . inter alia. their own public health and hospital problema, but unfortunately this has also created further insuperable difficulties. In the past, some developing countries have built ~xtremely costly hospitals, patterned after those of Western Europe or tbeUni ted States of Amerioa (USA). Not only has the oost often proved so exoessive, wan applied to local oonditions, that buildings have been left inoomplete, but even when oanpleted ·it has been found impossible to afford the maintenance and operational oosts and staffing pattern involved by the design. I have alreed7 referred to the growing utilization of hospital facilities when these are made available but proper use is another matter. Hospitals must be designed for a particular pattern of staffing, of organizational ability, of supply and maintenanoe and, not least, of the type and degree of disoipline obtainable fran patients and staff alike. The pathology of different areas, and urban, differs greatly as medical surveys have revealed. It is true to sq that you cannot merely copy a hospital design or pattern fram another territory having a different religious and cultural background, financial resources, and staff of different backgrounds regarding medioal education, etc. Each and every territory must adopt 1ts own "tailor made" operational policies for all elements of the health servioe and hospital, cliniCS, etc.
rural
5.
New site - the develOpment plan
The Health Servioe DeveloJl1lent Plan shai.u.d be expanded into actual health arxi hospital requirements, setting down the extent of medicare (basic or other specialties) to be accoamodated. and either
the population to be served (with population trend envisaged over twenty years) or an indication of the out-patient oonsultations,
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casualty admissions, radiological examinations, and the number of surgical operations to be perfomed. over a given period. The operational policy and departmental organization, with proposed staffing establishment, with .reference to any particular locally developed methods and practices should be clearly set out, bearing in mind an operational budget cost both for quality of bu1lding, economic use of staff, and future running costs. It is futile to plan for three X-ray rooms if X-ray film is going to be limited by budget to ten per week! From this information, either prepared or supplied by the hospital authority, or drafted with the aid of a hospital consultant team, the hospital architect can prepare Schedules of Acconmodation to meet the need.
6.
The deSign stages
The next stage, and not until these other matters have been clarified, is the desfgn and. preparation of the outline of the specification of the buildings to provide a functional unit in which the care of patients in the manner prescribed can be accomplised with maximum efficiency and economy. The architect, apart from concentrating on comfort, health and design, should remember that in the tropics lnDnan safety can be just as important a factor, where the hazards of climate are as catastrophic as they are occasional. High winds of hurricane force, tornadoes, floods, earthquakes and severe lightning all occur in varying degrees, apart from the rapid deterioration of certain materials as damage due to structural movement. All these factors must be taken into consideration in order to minimize mistakes which can be countered to a great extent by careful design and. detailing. 'lh1s again leads to a careful study of the local environment and planning to meet the need. Facts revealed are of paramount importance in the choice of bu1lding materials. Surfaces with "thermal inertia", such as mud, absorb and release heat far more slowly than, say, metal, and. as a result. in the hot dry tropiCS, surfaces which heat up the quickest and are the hottest during the day become cool quicker at night. In the humid zones, where the diurnal temperatures range is small by comparison, due largely to water vapour in the air and considerable cloud formations, choice of materials is not so greatly affected as it ss by rapid temperature changes. The damp, lnDnid climate, the prevalence of insects and fungus growths do, however, influence the choice of materjala.
-85 ..
'!he effect of the shadCllfS cut by sunlight fallins em to a build1ng and the podt10n of the sun at d1fferent times of the day w1th 1ts degree of penetrat10n into a bu1lding are definite and pred1ctable. Instruments exist, of which perhaps the Healidon 1s the best known, by means of which orientation" the desisn and effect1veness of sunshade devices and the measurement of day-l1Shting and reflect10n from adJacent services may be determinad. '!here are also special Sbadow-angle protractors and Charts for given localities wh1ch may be used in order to arr1 ve at correct orientation and sun shade dev1ces. It 1s not ourselves only who are affected by dryness and heat; bu1ldins materials are ccmpletely stable and in the hot, dry climate there may be a change in their temperature due to suc1den storn or diumal of t.aperature of as much as 1000 • They are indeed subJect to expansion and contraction at a rate unknown elsewhere. It is the land of craoking and buckling, of sand and wind, erosion and seneral building defomation" for whioll reason great care must be tUen when detailing" especially when dealing with materials which have not, like brick or mud" low temperature inertia.
rsnpe
In addit10n to this the7 must stand cons1derable wind strain; how to allow roofs to move underthemal stress and yet hold them down when hish winds blCllf such is the problem. On the other hand, stabilized earth, especially if coated with lime plaster or other white-reflecting . surface can be used here, and materials such as O,ypsum plaster, coral and limestone are useful since h1sh plasticity and themal interti. are valuable attr1b11tes, as are cool pemanent colours and SIIIOOth surfaces. Paints and plastics in the dry, tropics generally behave badly and undergo photo oham1cal changes. Glass is subject to abras10n. Wood dries and splits, as does asbestos, and roof felts tear in the hish winds. Steel, althoush it moves, does not corrode unless there is sOme chemical present in the air. I t will" therefore" become clear that it is not only ftnanoial resouroe., and. functional plann1na requirement. that make 1 t neces.ary to investigate fully the .structural plan and. the material. themselves when oreating a solution for the des1sn of a particular hospital in a particular location. Having studied the need and organization. the arahi tect must reflect upon this, and the economy of building cost" 1n his design. Undoubtedly in manr oountries locsl resources and. looal methods of construction are both cheaper and more efficient in meeting the conditions imposed. otten the s"tudT of such 100&1 traditional methods and materials oan lead the aroh1tect into creating. new solution ~luenced by western ide.. 1Nt more directly related to the surroundings and the 100&1 probl_. The7 should not be lightly dismissed in favour glus and conorete, or tndustr1alized building components of new materials. Seldom can the additional cost of buildings in excess ot three to four storeys in he1Sht be J1Btified when financial resouroes are l1m1 ted, and where land for more open type planning is available.
.r
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Not only must relativity between the different departments of the hospital be considered in relation to circulation and cross traffic, but principles of airflow without risk of cross infection, advantages of orientation and solar shade, must all play their part in creating the design in the mind of the architect. 7. Departmental planning
I t !DUst be evident that those areas of the hospital to be used for sophisticated diagnostic investigation and some forms of highly
technical treatment are most costly. It is here that the type of material used in the surface finishing of walls, floors am ceilings, ani the type and nature of built in equipnent must be of a higher stamard than elsewhere. T.he fact that the size of an out-patient department proper can be reduced i f a filter clinic of simple type is provided at the entrance am that X-ray and laboratory services can be concentrated to meet both in-patient and out-patient need conveniently, effect both the capital cost and the running cost. In-patient accommodation must be related to the likely availability of nursing staff' and the average rate of occupancy, although it may be possible to design for an ~iate nursing unit with responsibility for some 45 to 60 beds, so designed that when future staffing problems can be overcome (by reference to a long-term training progr8lllDe), i t can be reorganized as two nursing units of more manageable bed complement. However, in-patient accolllllOdation requires ancillary facilities such as treatment rooms, clean and dirty utility rooms, duty rooms and ward kitchen. T.hese all add to the capital cost. Where, because of for example, long distances from home, patient stay must be prolonged into the convalescent stlige, there is a great economy to be achieved by the erection of simple self-care patient accommodation, from which the patient may readily attend a treatment room, but which more resembles the standard of accc:mnod.ation to which he is accustomed than that of the hospital proper.
8.
Staff
T.he aim oJf a well designed hospital building is essentially to ensure the comfort of the patients and create conditions under which the worit of the doctors am nurses can be carried on most effectively. T.he skills to be attained by nursing staff are considerable in relation to the general level of education to be found in many parts of the territory and it is therefore essential that, when the hospital develop-· ment plan is prepared, consideration should be given to the numbers of staff that are likely to be required in the future years. Where the Training School Curriculum requires several years of training and where recruitment is difficult, the training programme for the hospital penomel should be taken in hand even before the construction period of the hospitals cOlllllence. 'lhe design of accommodation for the staff
-ft7 -
is an essential part of the hospital tradition and consideration should be g1 ven to the location of' such staff quarters more or less independent of' the hospital. so that the staff can get away from the working atmosphere onae duty hours are over.
9.
Modernization
Whereas it 111 generally true to sq that a building erected for one purpose becomes a costly uperlment when attempts are made to adapt and alter that building for a totally different use, the same is not true when applied to sound hospital building structures. Medicine has advanced over the years and has reaulted in many changes of' requirement in hospital accommodation. many are the defioiencies of ancillary rooms to be found in older buildings. but also the principles of hospital proviSion and organization have advanced full circle and In many cases by simple modernization. with f'ew additions. existing hospital buildings that are sound can be made to plq their part in the hospital progr8lllll8 without the necessity of demolition and ~placement. Indeed I am aware of examples where changes and alterationa have been carried out throughout the years which have so changed the original intended organization and method of use that they have become a burden to the maintenanoe cost of the service. By reoonatruction back to the orSinally intended use of' the buildings and b.r minor additions to meet deficiencies in ancillary accommodation not only was greater efficienay of' use achieved but a considerable saving of upend!ture b.r wq of replacement building was avoided. 10. Conoluslon
It is not possible, nor indeed desirable. to submit in this dooument a complete and rational approaoh to the design of a hospital f'or reasons that have become lIPP~t •. In the oourse of the Seminar problems will arise, the oonaol1dated. country report will be studJ.ed and opportunity will be taken to apply the outlines refe~ to .above in respect of the differing probl.s that must relate to such a large area as the Western Pacifio Region.
- 88 ANNEX 7 PAPER ON THE RESPonsIBILITIES OF THE NON-MEDICAL HCBPITAL A~~ATOR ~ENTJm AT 'mE SECOND RJ!X}ICIlAL Sm>mlAR ON HCBPITAL AI»1INISTRATION AND PIANNING Manila. 18-29 November 1971
by
J. Dur1ez Hospital AdII1D1strator Former Director of the School of Roapita1 Administrators in the Democratic Republic of the Congo (1962 - 1970) School of Higher Technical Training (WHO Project) WHO Staff Member
1.
INTROOOm'ICIl
The subject on which I have the honour of speaking to you today would require a lengthy technical development wh1ch unfortunately oannot be done in the 11mited t1me available for th1s presentat1on, 1.e. 45 minutes. However. we should first examine the subject of' hospital admin1stration wh1oh, in the framework of public health,. extends its'ram1fications into unsuspected and even hidden domains. -, When speaking the language of "public health" we should first of all agree on a precise definition for the term "administration". It seems that at present there are two slightly different concepts each of which is perfectly valid in its context.
own
Under the first concept. hospital administration is viewed as a problem of technical organization to be dealt with by specialized medical officers while the second concept is closer to a broad administrative concept meaning that management problems should be handled by administrators. < ' -,
In additian. in this field of hospital adm1nistratian there should be no confUai(ll\ between onpnization and administration' since these
are
two complementary yet distinct Bciences. In fact. while organization because of its medical objective is a policr preroptive which belongs to pbz!iciane. hospital administration 1s now a new acience which falls sl1sht17 outs1de the scope of the medical f1eld in the l1m1ted senee of the word. HOirever. it should be emphasised that these two sciences are not to be dis.oclated and that they complement each other in the pursuit of the one
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and only objective namely medical care for the patients. It is in this spirit of permanent cooperation between the "hospital administrator/physician" that hospital administration functions are to be carried out with a view to giving adequate support to the physician in his provision of medical care. The provision of medical care is in fact partially conditioned by the performance of administrative functions which provide the required material facilities. This is what is generally called "the management of care". We feel that the physician is above all a "scientist", a man of high intellect, who guides and implements the over-all health policy of the country which in turn will condition the administrative organization of services entrusted with the implementation of this policy. In order to attain the obJeotives of this policy, the ph:vaician will need the close cooperation of administrative staff specialized in and wellacquainted with medical problems.
This is where the "non-medical hospital administrator" comes in, workinp; as the number one collaborator of the medioa1 director of the hospital who will thus be relieved of managerial problems. Before considering the preoise and detailed role of administration let us review briefly the various problems concerning hospitals and hospital functions.
2.
GENERAL ASPEal'S
The role of the hospital, its position in the over-all infrastructure and its general organization are related to the internal structure of the supervisory body, i.e. the Ministry. These institutions have underione some c~es over the past few years in line with political developments or with mOdifications in policy in the field of public health. In fact, newly independent cmmtries have had to ,adapt former structures to their resources, to reconsider .the ldlo1e set-up and to restore a proper balance by advocating a policy of "health cooperation" based on existing foreign assistanoe (bilateral and multilateral).
2.1
W1th1li the t'riiIiIiwork or thIs new trene!
Need for revaluation and stand.ard1zatiQ.n of hospital administration
Although there is a cmon and tmiversa1trend in the health technical field, the same does not hold true for health administration. In fact. for the latter there is a framework of general administration of public finances and general legislation the concept of which may vary
- 90 from one state to another. Therefore, it is necessary to start from a common system adjusting it to the regulations and policies applicable in each local administration. SUPERVISORY INFRAS'l'RUC'lURE
The supervisory infrastructure of hospitals may vary from one country to another. The management team may- include the following: <a) A Medical Director assisted working in olose oo-operation; by
a hospital administrator
(b) An Administrative Director who, under the authority of an Administrative Committee, is responsible for the management of all servioes and co-operates with a Consultative Medical Committee inoluding representatives of the hospital medical staff; (c) An Administrative Director in charge of administrative. accounting, eoonomic and general services. A Technical Director (physician) in charge of medical and technical services. The first of these three alternatives is the most common and we believe it is the best as for developing countries as exercise has shown. The third alternative which oa11s for a dual leadership is a permanent source of conflict of prerogatives and is not to be recommended. In the present hospital organization the basic prinCiple which is to be borne in mind is that of the re nderance of the medical aspect as the final objective <which conditions the entire existence of the hospital over the administrative aspect. (See the organizational chart given on page 103). 4. CLASSIFICATION OF HOSPITALS
A hospital oonsidered to be an efficient medical oentre for cure of disease must make it possible for a limited number of staff, sometimes in a limited space as well as with limited sophisticated equipment to have a maximum of efficiency. This hospital must include a oertain number of essential faoi1ities to meet specific and precise needs. There are two types of ori teria to be applied to the organization of hospital servioes: technical and adJainistrative. In view of this duality
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which is found at every stage of the operation of health services. it is necessary to ccnalder the structural set-up on two levels: (a) (b) Technical level Management level.
On the technical level the following structure, Is generally found: (each hospital category corresponding to a specif1c population area)
4.1
Hospitals for "acute cases" (rapid tum-over of patients with a limited length of s~)
4.1.1 First catesory General hospital which III&T be used for tra1nlns purpoe.. or hospital (capital cities _C?r large towns) (a) Medicine.
!!!!l
(b) .. ?ae~:tatrics.
(c) (d)
Surgery, Maternity.
(e) Speclaltie~.,,<dlrectors of vocational schools, professors of the facultY'_9~medlcin~~ t!tc.). ' (f) (g) Technical departments, OIlt-patlent depart:lant.
4.1.2 Second category Secondary or local hospital·(province - district - circle): (a) (b) (c) (d)
Medicine, Paediatrics, Surp17
MatemltJ',
(e) 'rriteotloua diseases and a fewspeolaltles (eme or two), (r)
Technical departments, OIlt-patient department.
(g)
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4.1.3
Third category Rural hospital (sub-division, rural zone): (a) (b) (c) (d) (e) (f) Medicine, Maternity, Paediatrics, Surger.y (optional), Infectious diseases. Out-patient department.
(This list has an indicative value only; other departments may be included). 4.1.4 Hospital - health centre Health centre - preventive services - health education, etc. 4.2 Establishments for "chronic cases", i.e. specialized hospitals (longer length of stay and slower turn-over) Sanitoria and mental hospitals Leprosaria and hypnoseria (endemic services). 11. ~.l
structural set-up on the management level The important factor in this connexion is the source of financing. The following breakdown is given here as an example: (a) Central hospitals: These are provided for under the general budget of the state - therefore, they may include all central hospitals and all specialized establishmen+s (acute conditions, first category and chronic cases). (b) Regional or provincial hospitals: These are provided for by the local administration. However. they can be subsidized under the general budget of the
bt> i
I t is important to note that the geographical distribution and the capacity of the various categories aa well as the number of hosp! tals 17' each category depend on the follow:!ng: It. -~
administrative and political set-up of the country. geographical distribution and degree of ~orbidity.
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-
localization and importanoe of eduoation. financial resources (construction - equipment - personnel).
From the technical point of new u well u for management, it is desirable that all hospitalabe subject to m1n1sterial control. The latter would simply. Come above .that of the ~ooal_ adnIinist~tion in the cue ot regional hospitals which ~ fr9m .the ope1"l11:i~ point ot view, wouldl'!"Jllain under the auth~rity of the, §!feral health'1.1slat1on and would have to abide by the regulations applicable for the lUI'lyement ot publiC finances
4.4
Ddfferent1ation
It should be pointed out that hospital serTices in industrialized countries are not the s . .e u in developing cO'.mtries.
4.4.1 In industrial countries, the hospital intrutruoture has gone through a lang evolution emerging now in a mOdern concept based on advances in technology as well u on econom10 and sooial changes and, f'rcm the purely teclmical point of new, th1s new concept seems to be close to perfection. However, thesllllle ooncept, men tnmapo••d in the geographioal context and espeoially the socio-eoon0ll1o oontext of developing countries, is no longer appl1cable. In trop1cal oountries, the provision of hosp1tal serTioes has special characteristics and in addition, p%'Oblema and solutions may be rather un1que and will differ trora one region to another of the same continent. '!hiB is due essentially to the oomponents of the Bocio-economic and cultural patterns, i.e. populations oonoentrated in the oities and l1ving in over-crowded condit1ons ft1'SUl!l '\:hoee living in sparsely populated areas (bush or rural. areas) J populations tamiUar with the modern concept of medicine versus populations reacting with reluctance or indifference. I t should be emphasized that in the developing oountries the core of the problem u regards hospital ,services is not so much the retinement of hospital teclmiques but rather the basic concept of the role ot the hospital.
4.4.2
1 fetl that the 1deal hosp1tal, to be renamed "Hosp1tal-Health Centre", ,should have 4 bas1c roles: DIAGNaSlS - 'l'REA1!tIEl'lL' - ritEVEh'l'IClN HEAIlI'H EOOCATIW ~
,
II
Ii I
I
5.
1illOIPMlIi'I.I.' AND SUPPLIBS FOR H(5PITAIB
As far ueQu1i1Hat and auppl1e. are concerned a number of countries have kept the tOnier oentralized procedures which meet best with the needs of economy for the two oent~l souroes.
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5.1 5.2
Central supply pharmacy (medicaments, dressings, medical or surgical preparations, etc.) Central supply store (maintenance products and equipment, various other supplies)
A pharmacist is in charge of the central pharmacy and he may be assisted for the administrative tasks by a hospital administrator. The responsibilities of the central store can be entrusted to an administrator with special competence in the field of purchasing and who may also have hospital qualifications. Each of these bodies plays an identical role according to its own specialty: Stocking of products Periodical supply to health services Provision of supplies to new establishments.
6. HOSPITAL ARCmTECTURE (BRIEF OUTLINE) FROM THE POINT OF VIl!)J OF FINANCIAL IMPLICATIONS Existing hospital services can be outlined according to the following three groups: Pavilion-type hospital: This type of hospital with a maximum of two levels has been in use for a long time and continues to be in favour with populations of newly independent countries. The patient does not feel lost, he feels at home and he can move around free1y. However, operational costs are relatively high and supervision is difficult. 6.2 Block-type hospital: Centralized construction, numerous stories. Although it is more economical because of the reduction in volumes, circulation routes and a rational division of services (care units, etc.) it is expensive to build and highly qualified personnel is required. For example, the technical and maintenance problems arising with vertical communications should be taken into account. In addition, in developing countries it is difficult to ensure the proper operation of this type of facility in view of the lack of qualified staff and of funds to meet operational requirements.
6.1
6.3
Block system: With a limited height, this is a compromise between the first two systems and it does not require any type of elevator.
liThe hospital architeCJture should be a picture of integration with the environment and not one of domination. II
-95·
In the oase ot n..,ly independent oO\mtries where the hospital is an expensive facilit,y# What 1s needed is a sturdy oonstruotion with a simplified maintenanoe requiremente and built aooording to the modular technique using standardized unitll repeated vertically and hOrizontally acoording to plans for expansion when fUnds are made available.
F1nally, whichever system is adopted# the general lay-out of the hospital is as fOllows: (a) Hospital facllities as INch including the medical and technioal units 'Idrlch belong to the basio section of the hospital. (b) Adm1nistrative services. Econam1c and general services.
(c) start housing, lf available. Such housing facilities should be .located a small distanoe away from the hospital so that the staf'f' may have a change of atmosphere.
7.
lUiBP<H!IBILlTIES OP THE JePl'l'AL
The responsibilities ot the hospital may be summarized as follows: to provide medical care. The hospital 111 a place where med1c~ care is provided and where the following facilities are made available: in-patient services, medicalteohnical services, out-patient servioes, examinations, ambulatory treatment, etc. The provillicn of medical oare implies a number of oomplex activities. Although efforts should not be spread apart in too many and too specialized fields each of which could be an end in itself, efforts should be ooncentrated on the following three major £\mctions: curative services, institutional servioes and administrative and accounting servioes. 7.1 CUrative services - These inolude all highly speoialized actiY1tieR related to diqnoe1a and therapeutics. 7.2 Insti tuticnal servioes - These inolude all the requirements tor handling in-patients. 'fiie. hOspital ill pr1mar11y ccnceived to provide hospltal1ty: f'ood# lodging,. bed, _ter, proper BUl'TOImd1nge and adequate service .•
7.3 Adm1niatrati~ and acoounttns servioes - These include all operational and servicing procedures •. 'Bles. haft a oa.aercial aspeot (purchases, acoO\mting, pa7lllents)# !Z' indwstr1al.~ot (oanatruction, equlpment#, maintenanoe) and a 1'1NIIioial upeat dgete, aooO\mts, and other t1n8ncial procedures, e t o . ) . . . .
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8.
TERIvf3 OF REFERENCE OF THE MEDICAL DIRECTOR (alternative (a) under section 3)
As we can see from this title, this official is both a physician and a director. As the hospital director he is responsible for running the establishment end his terms of reference are as follows: (a) (b) General leadership of the hospital. Supervision of all staff and nomination of personnel.
(c) Coordination of activities of various services and supervision of care provided. (d) Leadership for the training of student nurses in his hospital and supervision of work performed by students, trainees, etc., when necessary. (e) Preparation of periodic statistical reports (morbidity and mortality data). To fulfill this responsibility he should have adequate secretarial assistance and someone should be in charge of the maintenance of medical records. (f) Responsibilities as senior official, etc.
(g) Submission on required dates of proposals concerning the budget prepared by the non-medical administrator. (h) (i) Control of the economic management of the hospital for the Ministry. Implementation of ministerial decisions.
(j) Weekly inspection of the hospital with the administrator. A different aspect may be chosen each week for the purpose of this inspection. (Offices: out-patient department; hospital services; accounting section, etc.).
(k) Responsibility for proper management and general discipline. Organization of periodical meetings with other physicians and other categories of staff in order to assess the situation and the various activities, hear complaints and provide guidelines and advice. (1) Maintenance of excellent relations with the local authorities and request for their assistance whenever his own training proves insufficient. Finally, the medical director must have an office as close as possible to the main entrance and to the office of the administrator; as a physician he can have an office in-the department where he works but these offices must never be in the same place.
- CJ7 -
As a medical officer. and especially in the newlY' independent cOWltries where physicians are laoking. he should. whenever this is possible, has a hospital function. 'n1is is in no W8.y' incompatible with his duties as director of the hospital. on the contrary. since. this helps him improve his lmowledge of the needs of the hospital and hence be in a better position to carry- out his functions as director.
9.
'1'ERM3 OF REFERENCE OF '.l"HE NON-MEDICAL HOSprrAL ADMINJBTRATOR
<alternative <a) Wlder section 3) Basically this official must be a man of' high intellectual value having personal qualities of tact and Judgement. SecondlY'. he must ensure continuitY' in the implementation of the ideas and policies formulated by- others and which beoome his own objective.. He oooperates in the definition of' this policY' at his own level. He summarize., ~rizes and controls and envisages all activities whioh concern the past. the present and the of the hospital. His functions are manY' and varied and tend to diape1'8e his attention. In order to avoid the congestion of details and ;ret not neglect more important factors, .it is necea8&1'Y' he be a man of' bperience and have a strong - - that -.discipline of mind. The hospital administrator is the first and closest collaborl'ltor of the medical director whom he relieves of management duties and with whom he studies On a daily basis all the general problems of the hospital, not onlY' 'f'rom the budgetary- and finan.c1a!_ po~~ of' view but also as regards the psychological aspects. ~_'!!Il:! as extemal relat~ona. As an example, let us consider the various activities which the nonmedical hospital administrator is asked to perform: Ca) Financial - financial administration - financial statements budget - statements and acoounts. (b) Insti tutional - food for the patients. lodging, reception, premises, communications. (c) CoImJercial - purohaaes, stocks, distribution. economic studies.
(d) Industrial - maintenance of equipment. control, repair, use of mechanioal equipment. (e) Agricultural - market gardening, noral decorations, maintenance of gardens and grounds. (f) Architectural - 'n1is ia one of the h_viest responsibllities. 'n1e cooperation ot physicians. administrative staff, moneY' lenders, archi tects and engineers depends on the authoritY' Shown by- the administrator whioh depends on his technical knowledge and the constant attention he devotes to matters related to construction, control, network of conmnmications as well as plans. progranllles, maintenance, etc.
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(g)
Administrative and accounting: Manpower management Manpower - Salaries
General administration
Record-keeping. labour legislation Promotion Vacations Miscellaneous
9.1
Work relationships requiring personal contacts and oorrespondence (a) (b) ( c) (d) (e) (f) Administrative and supervisory f'Lmctions Patient - families - visitors Medical and phanuaceutical staff Non-medical hospital staff Individuals and companies with debit accounts Other administrations or institutions Authorities (elected or appointed) Mlmicipal sanitation
(g)
(h) Security service. Firemen. polioe. services. Suppliers. Contractors. etc.
He is both a manager and an acoountant and. as such. he represents the administration and assumes leadership for the general services. He has financial responsibility for all matters related to stocking and consumption of supplies and various products used in the hospital. When he takes his post as administrator he becomes responsible for all the equipment indicated on the inventory as well as for stoaks of products in the supply stores and he must be able to produce justifications for their use at any time (accounting on a quantity basis). In the field of accounting his duties
are as follows:
(a) Collection of receipts. where applicable since this is not the case in all countries. (b)
Ddsbursements Accounting operations - daily accounting PQIIIent of personnel. etc.
-99-
9.2
Technical tra1n1ng ot hospltal adIII1nl.trators
At present. non-cpl&l.lt1ed otticia18 are stl11 entrusted with the administration of hoapitala in too manT instances. This transitional si tuation due to the lack of spec1alized personnel should graduallT g1 ve way to the appointment ot well-trained statt. The -.in obJective is to give TOOatlcmal and solctit1c training to those who will be in charge ot the .....n'atration ot hosp1tal sernces. This training 'llhould. prov1de the hoepltal adII1n1atrator with an understand1ngot the place androle of the hoep1tal in the health and soc1al infrastructure and give him an insight in the health and med10al reallt1es and needs. He should acquire a lmowledge of finance. statistics. public accounting and hospital "8.0counting. managel'1al ald.118 and ..peoial1:y purchaSing. inst1tut1onal ~t and all other bu1c procedure. conduc1ve to a high qualitT serVioe in .. publ1~L1tlat1tut1on. Nowada1'8. hosp1tals have becca_ a modem establishment the orpn1zatlon of which differs aocordL'lS to the so01al and eoon~io conditlcma obtaining in each oountr:y. A hosp1tal's movable and 1DIII0vable ..sets I are the toundat1on for the provision of med10al sernces. It 1s theretore essential that managerial responslbilities be entr'll8ted with an offlcial espeoia11:y trained tor this purpose.
I !lID convinoed that hospital servion should have a oompetent administration and that qualit1ed staff should be put in charge so that. while giving due oonsideration to local ciJ'9Wll8tances. theT will tollow a poliCT geared towards a general stanc!ard1zation ot administrative procedures at the reglonal level and towards universal medioal cooperat1on. I feel that it would be dn1rable to set up a training centre tor hospital adain1strators in each Res!on. Such a reg10nal training centre would make It poes1ble to prortc!e training in the area and to adapt it to the local conditiona. and this would 1IIp1:y a ccDaic!erable reduotion ot expenses oonnected 1dth tellOW11hlPlLtor atudles abroad.
9.'
1telitions between the' Medio&l Direotor and the Administrator ...
-
- . -
The i.ed1cald1teotor andth. adad.n1strator should tOnD a ver:y, 010.811'1mi t teu. 'l'he:y should show a sp1rit of understanding end cooperat1on. til spite ot his ,Nzogativn .. director of the hospital. the phJa10lan should retratr1:trcD ndxtng in oonetantlT with'the- ~t ot the eatabl1ehment sinoe suoh an attitude would be oontrar:r to the notlon ot oontrOl and would b8.oonstrued .. an inelegant and un1lU"1'llritable intertermoe. (h the active inteNt;Sn the eooncia1c aapecta and pronde cOntrar:r he should take the neoeasar:y ~ ~or th~ hoIiplta1 ' . dnelGplll8nt. A. tor the hoep1tal admin18trator. he ahoald not Sn1;lertere with the treatllent ot the patients.
.n
Their weU-toundedunit:y of aotlan .at be telt in relation to doctors. personnel and authol":~i_ .. 811 .. ezternal taotore in. view o~ ach1ev1ng the ane and anlT objective o~ the hoep1ta1. the well-beg ot the patient.
-100
In addition, such a closely-knit team at supervisory level will have much greater room for action and hence a greater chance of working in the interest of good hospital operation.
Each member of the team. medical director and hospital administrato'!' having been assigned specific responsibilities they now need a common tool. This tool is the "Handbook of Procedures" of the hospital or in other words the manual of official rules and regulations setting out in detail all operational procedures such as internal organization of the hospital, administrative functions. distribution of responsibilities and discipline of staff. operation of medical and technical services. public worship in the hospital. conditions of admission of patients. catering services. police measures. etc. This body of regulations is approved by the Minister and it provides a trame of reference for the staff sinoe it includes job descriptions, professional duties and responsibilities, and a clear outline of the horizontal and vertical lines of communication in the entire hospital infrastructure. To conclude this very important section of my paper. I might say that g1ven a closely-knit, well-qualified and responsible supervisory team and a strictly enforoed "Handbook of Procedures" the end result is botmd to be a satisfactory operation of the hospital. What remains to be done is to provide those responsible with the necessary authority as well as resources in terms of funds. supplies and equipment. and qualified staff.
10.
CONCImION
We have just gone over very quickly an outline of the duties and functions of a profession in which each and everydetall is of highest importance although an over-all view and genenl interest in favour of a cont1nued progress must be used as a standard of reference for all activities. This is a delicate task, one where contacts with ind1viduall!l or interests which are varied or of a contradictory nature require firmness and tact and' where it should never be forgotten that the basic responsibility is above all the "care of patients". This is the underlying principle.
It 1s with this principle in mind that discussions become meaningful and must lead to their logical conclusion, whether it be a matter of finances. architecture. discipline or medical organization. The necessary cohesion must be centred on the patient and preserved by .the attentive and devoted efforts of the medical director and the administrator.
- 101 -
11.
l!U'l'URB '1'H!N1B
'lbrough thi8 very complete bird' 8-eye view we have 8een how the nonmedical hospital administrator aees the hospital. At times, Whether it is justified or not, hospitals are subject to oritioi8111S. '!he hospital is .!!. ret'lecticm ot a 80ciety and its objeotive8. its orpnizaticm and 1ts act1vities will var,r aooording to the.1Ocal s001al and,eoonom1c circumstances.
'!he main factor to be bome in mind is that a hospital is an expensive enti ty- all the more so when 1ts ~t is unsatistactory and unorthodox. A reelar source ot f'1nanc1n,s is eS8ential to proper operation. As t1me goes b)r, the oost ot 1nBtituticmal1zed treatment tollon an upward curve due to the progress ot medioal .cience and the development ot hospi tal teohniques. Hence, in practioe, the hO!ll)ita1 adIII1nistraticm a11!!l8 finds itse1t in a di1enma: between. two obJeotives and two necessities: (a) Constant demand for high quality- oare, which is a1WQ1!1 expensive; and (b) Need tor econom;v and reduction ot operational costs.
Therefore the hospital 1s a1WQB in ccmt'lict either with the consumers of hospital services or with those who IIIWIt ensure its financing.
, - . Awareness of' authorities A
Adequate resources to meet the needs Revised financ1al s78tems giving each hospital "manageriall autonw"
A
12.1
Formulatlcm of a policy- for hospital 8ervioell through national and provinoial planning
No matter how beautiful or modem a hOBPita1 1s it will be useless i f it is not harmoniousIz related to the other oOlllJ)(!1ents ot the health infrastructure. '!he hospital must oooperate tree1l" nth other hospital services as well as with health centres, dispensaries, sanitation servioes, etc.
- 102 -
12.2 Humanization of hospitals snd improving the atmosphere Arrangements should be.made for local training adapted to the local circumstances in order to produce good hospital administrators for the large centres and managers for the smaller services. The level of hospital administrators should be upgraded (post-graduate) so that they may not suffer from an inferiority complex in their dealings with physicians and so as to avoid their being considered simply as clerks or small department heads as unfortunately still often happens in many countries. Nevertheless. they would still have to be given full recognition as partners and team members working towards a COlJlllon goal. It should not be forgotten that hospital administration is closely related to general administration and it would certainly be premature at this stage to try to apply radical solutions to the administrative problems of the hospital health services. Furthennore, as far as the int'rastructure and the role of the hospital services are concerned, it is necessary to take into account traditional aspects with which the population is familiar. Changes can actually take place only af'ter the implementation of a system of education and vocational training which go beyond the scope of the hospital. To summarize. the first step should"be to standardize operational procedures in hospital services so as to obtain a maximum yield in operation and efficiency. Once this is achieved, it will then be possible to consider the fundamental doctrinal issues, especially as regards balance and hannony between the curative and the preventive aspects which should gradually be inversed. Let us not forget what was said in the last century by lavoisier: "Hospitals are to some extent a reflection of the civilization of a people".
ORGANIZATIONAL CHAR'r OF HOSPITAL SERVICES ( General 0utI..Iu)
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Note: The GeIleral SUperv1lar 11 not mclicated 011 thla clwt since the need far th1a pGIt. itl posid.OII and tbe supervlaory and operationalllDe, of commUDlcatiClll are left at the discretion of the hoapital authority.
[
MORrUARY~
- 104 -
ANltEX 8
INFO:AMA'1'IOH mum.'IN NO.5
lDr ,our intor.at1om tbe tollow1ag pub11catlona tor backgrOund rea41q are suppl1e4:
Brld SMB n , R.P. AD Internat10nal StudT on losp1tal Utilization. Comslderatlons at Methods ot Co11ectlas .eces.ar,r Data tor IItt.atlag HOfpltal Be4 Requ1reullt. u4 tor PlaaD1D11 a IOlpltal Serrie.. QeD..... : World Health Orsanlzatloll. 39 p. Br1dp1Ul, R.P. 1II1ral loaplta1; It. structure and. Orpnlzation. World lealth Qrsaaizatl01l, 1955. 162 p. Geneva:
Llevel.7D-Dart.. , R. and H.M.C. Macaulq. Hoapita1 Plaulag and. AdaiIl1Btratlon. QeDnat World H ••ltb. Org&lllzatton, 1966. 215 p. Hospital A4a1nl.trat1on. Report ot a WID Expert eo..1ttee. Organ1zatlon 'feclmlcal aeport Senes, 395. 29 p.
.0.
World Healtb.
VI.
ANNE:XE3 - BIBLIOGRAPHIC
- lOS -
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No.3. 49-52;
No.4
Nalon, P.F. a: Ballinger, R.I. Cr1t1oal path method of soheduling and finanoing tor hoapitala. Hospital Mpt. 196/1.. 21. No.5. 40-42.
N.well. D.J. - Emergenc;r adld.ssiona and. the pre-disoharg. nrd. Hospital (London). 1962. 2!!. 13-15. - Provis1on ot ."rsenol' beds in hospitals. Brit. J. prevo 800. Med. 1954. 8. 17-80. - statistioal aspects of the de...nd tor _ternit;r beds. J. ro;yal statist. Soc., Series A (Gen.ral) 196/1., 127, Part 1. 1-40. Nuffield Provincial Hospitals Trust studi.s in the functions and d.sign ot hospi tala. Universi t;y Press. 1955. 192 p. London, Oxford
-- - -, -------
- 114 -
Nuffield Provinoial Hospitals Trust. Operation Research Unit. Waiting in outpatient departments. A survey of outpatient appointment systema. London. Oxford University Press. 1965. 69 p. Operations researoh helped shape this hospital design. Mod. Hosp. 1966. 107. No.5. 122-125. Oxford Regional Hospital Board. Operational Researoh Unit. - Coverage analysis. Oxford, 1967. 12 p. - Hospital or regional stores? ..; Hospital out-patient services. - Measurement of nursing oare. Oxford. 1966. Oxford. 196'. Oxford. 1967. 26 p. 81 p. Oxford. 1962. 6 p. + 54 tables •
- Nursing oare in a modern hospital.
·Optimu. purcha8ing policy. a supplies officer's guide to the . .thematics of ordering and maintenance of stocks. Oxford. 1962. 10 p. - OptimUDI purchasing tables; extended tables for asoertaining reorder quantity and minilDWll stock level. Oxford. 1962. 26 p. - Out-patient servioes for orthopaedio and oasualty patients at Princess Margaret Hospital. Swindon. Oxtord.g96Jj. 14 p. - Scheduling of student nurses with the aid of a oomputer. 1965. 7 p. - Computer simulation of a maternity hospital. Oxford. 14 p.
Oxford. 1964.
Pelletier. R.J. The future for programming and planning complex faoilities. Canad. Hosp. 1967. 44. No.ll. 66-70. Petrakov. B.D. New forma of organization and methods of ambulatory and polyolinio medioal services for urban population. Sante publ. 1962. ,2, 197-215. Pike, M.C. et al. Analysis of admiSSions to a oasualty ward. Brit. J. prevo soo. Mad •• 196" .!I, 172-176. Pol'a-enIco. V.I. o metodike opredeleniJa moll!nosti raJonnyh bol'nio. ,LMethod of det.ermining the oapacity of district hOSPitals..:! Sovetsk. Zelra voohr. 1962, ~, No.2, 27-,0. Popov, G.A. - The planning of inpatient services in the USSR. Copenhagen. Regional Of'tioe for Europe. Wol'~ Health Organization, 1962. 21 p. Unpublished working dooument EURO - 1'7.2. - The problem of hospital bed requirements. Copenhagen. World Health Organization. Regional ot'l'ioe for Europe. 1965. 9 p. Unpublished working document EURO - 295/1.
~
115 -
Reed, R., Jr. & Stanley, W.E. Optimizing control of hospital inventories. J. Indust. Engineering, 1965, 16, 48-51. Revans, R.W. - The hospital as an organism. Inl ProceedingS of the Second International Conference on Operational Research. Aix-en-Provenoe 1960. London, English Universities Press, 1961, pp.l04-114. - The hospital as an organismJ A study in communioations and morale. In: Management sciencesJ models and technigues, proceedings of the sixth international meeting of the Institute of Management Sciences, Paris. 7-11 September 1959. Oxford. Pergamon Press. 1960. Volwae 2. pp. 17-24. Rice, R.G. Analysis of the hospital as an economic organis•• Modern Hosp. 1966. 106, No.4, 87-91. Robin, J.P. La notion de ooOt. de rendement et de productivit~ en fonctionnement des ~tab~ements hospitaliers. Rev. Hyg. Ned. soc. 1959, I, 667-693. Robinson, a.H •• et ale Prediction of hospital length of stay. Hlth Serv. Res. 1966, 1, 287-300. Robson, D.M. Hospital activity analysisl its use in hospital management. Hosp1 tal (London), 1967, 22, 388-391. Rosenfeld, L.S. Quality of medical care in hospitals. Amer. J. publ. Hlth, 1957,.!!I, 856-865. Rosenthal. G. The demand for general hospital facilities. Hospital ASSOCiation, 1964. 101 p. Sando, F.A. Crit1cal path is road to better building. Mod. Hosp. 1963, .!Q1, No.5, 91-96. Scheidler, K. - Die GeWlnnung wissenschaftlicher UnterlaBen fur Planung und Le1tung des Gesundbeitsschutzes durch die Krankenhausstat1ltik, erll~tert am Beisp1el e1ner Totalerhebung 1m Demokratischen Berl1n. Inl Erler, H. et a1., eds, Das stationire und ambulante Oeeundhelts"sen. PlanUDI, Organisation Bau unci Betrieb. BerUn, '9EB Verb& Vak und Gesundheit, 1963. Band 4, pp. 41-112. - Zu einigen OruncUagen wi.8ensohaftl1cher Planuns: des statioMren Gesundheitswesen. San~ publ. 1961. i. 365-386. Chicago, American mati~re
de
- U6-
Schne1der. J .B. Measuring the looational ett1ci.nc7 of the urban hospital. Hlth Serv. Res. 1967. 2. 154-169. Skrbkova. E. K problemat1ce zkou.an! a stanov.n!" vtdecq zd4vodnlnC§ potl-ebu n.mooni~nr pele. LInvest1sat1ons and as......nt of .oientifioally founded needs of hospital oare~ 1. FaktOr7. ktere v,yraznf ovlivtn1J! potrtbu nemocn1~n1 pe~e. LFactors Wh1ch 1nfluence the needs ot hospital care in an important way~ 2~ Metod1ka stanoven! pot~by nemocni~n1ch l«lek. LMethods of assess1ng the need of hosp1tal beds~ Cs. Zeirav. 1965.~, 170-176; 242-248. Sleight. R.E. S7stema analysis smoothes conversion to disposables. Hospitals, 1967, 41. No.21. 84, 88-92. Slllalle7, H .E • ProfesSional methods improvement i8 ultimate path to IIOre .fficient hospitals. Mod. Hosp. 1965, 105, No.}. 107-110. Smalley. H.E., and Freeman, J.R. Hospital industrial engineering; a guide to the improv••ent of hospi tal management systau. New York, Reinhold, 1966. 460 p. d'Econom1e .t de Mathematique appliqu~.s. Fondements de l'activitC§ hospitali~re. - Demande d'hospitali.ation. - CoGt des soins ho.pitaliers. Etude realis~e PQur le M1nist~re de la Sante. Rapport de synthhe. LN'eulll)'- sur- Sein.!?, Soci~te pour l' Avan.£ement et l'Utilisation de la Recherche operationnnelle civile, ~o dat~. 27 p. Soo1~te pour l' Avancement et 1 'Utilisation d. la Recherohe operationnelle civile. - Les facteurs de d1mens1onnement des h8p1taux. Prem1~re partie I Analy.e et methode. Etude "alis~e pour le Minist~re de la Sante publique. Neu111y-sur-Se1ne, AUROC. 196}. 60 + 6 p.
Societ~
- Les facteurs de dlmenslonnement des h6pitaux. Deuxihle partlel Etude des coats de fonct1onnement. Etude realisee pour le M1nist~ de la Sante publ1que. Neu1lly-sur-Se1ne. AUROC. 1964. 47 p. Souder, I.J. et al. Planning for hosp1tals; A systems approaoh us1ng oomputer-aided techniqu••• Ch1cago, Amerioan Hospital Assoc1at1on, 1964. 166 p. Sor1ano. A. On the problem of batoh arrival. and it. application to a scheduling system. OperatiOns Re •• 1966, li, }98-408.
~tiOh. Z. New methodologioal approaches in estimating the number and the distribution of hospital beds. Copenhagen. World Health Organization, Regional Oftice for Europe. 1965. 22 p. (Unpublished working dooument EURO - 295/6) Thompson. J.B. et a1. How queuing theory works for the hospital. Modern Hosp •• 1960. ~, No.3, 75-7B. Thompson, J.D. et al. - Computer simulation of the activity in a maternity sUite. Ina Actes de la 3~me oont4renoe internationale de recherohe oe!rationne11e, Oslo, 1963. Paris, Dunod. 1964. "pp. 213-223. - Use of computer simulation techniques in predicting requirements for maternity faoilities. Hospi tals, 1963. E. No.4, 45-49. 132. Thompson, J .0. ct Petter, R.ij. The ~onom1cs of the maternity service. Yale J. Bio!. Mad. 1963, ~. 91-103. Ullmann. L.P. Institution and outcome; a comparative study of psychiatrio hospitals. Oxford., Pergamon Press. 1967. 197 p.
United Hospital Fund of New York. Training. Research and Speoial Studies DiviSion. Systems analYSis and design of outpatient department appointment and information "systems. A special study in hospital systems and prooed~es. New York. 1967. 95 p. Uni ted states. Publio Health Service. Division of Hospital and Medical Faoilities. - Areawide planning for hospitals and related health facilities. Washington, 1961. 56 p. (Publio Health Service Publioation No.BS5) - Hospital administrative researoh. Washington, 1964. Servioe Publioation No.930-C-B). 48 p. - Procedures for areawide health facility planning. agenoies. Washington, 1963. 118 p. (Publio Health Servioe publication No. 93o.B-3) (Public Health
AgU1de for planning
United States. Publio Health Servioe. National Centre for Health Statistios. - Comparison of hospitalization reporting in"three survey prooedures. A study of alternative s~ve7 metbods for oolleotion of hospitalization data from household respondents. Wuhington, 1965. 48 p. (Publio Health Service Publication No.1OOO - Series 2 - No.8) - Computer simulation of hospital disoharges. Washington. 1966. (Publio Health Service Publioation No.1OO - Serie. 2 - No.13) '5 p.
- 118 -
Un! ted States. Public Health Service. National Centre for Health Statistics. - Development and maintenance of a national inventor,y of hospitals and inst1tut1ons. Washington. 1965. 25 p. (Public Health Serv1ce Pub11cation No.1OOO - Series 1 - No.3) - HosP1tal ut111zation in the last year of life. Development and test of a method of measur1ng the effect of omitting decedents from a survey of hospitalization. Washington. 1965. 30 p. (Public Health Service Publicat10n No.lOCO - Series 2 - No.lO) Wagner. G. Bibliogra~hy on mechan1cal and electronic medical record proces.1ng. LCopenhage]V World Health Organization. Regional Office for Europe. 1968. (unpublished 1«lrking document EURO 3(92) 32 p.
Watts. S.P. & Acheson, E.D. Computer method for der1v1ng hosp1tal inpatient morbidity statistics based on the person as the unit. Brit. med. J. 1967. 1, 476-477. Weckwerth, V.E. Determining bed needs from occupancy and census figures. Hospitals, 1966. 40, No.1, 52-54. Welch, J.D. & Bailey, N.T.J. Appointments systems in outpatient departments. Lancet, 1952, 262, 1105-1108. Wh1tston. C.W. An analysis of the problems of scheduling surger,y. Hosp. Mgmt, 1965. 22. No.4, 58-66; No.5, 45-49. Whitehead, B. & Elders. M.Z. An approach to the opt1mum layout of single-storey buildings. Architects' J. (U.K.) 1964. 1373-1380. Williams, W.J. et ale Simulation modeling of a teaching hospital outpatient clinic. Hospitals, 1967. 41, No.21. 71-75, 128. Wing, P. Automated system for schedu11ng admissions. Hosp. Mgmt, 1967, 104, 4, 53-56. Wolfe, H. & Young. J.P. Staffing the nursing unit. Part I. Controlled variable staffing. Part II. The multiple assignment technique. Nurs. Res. 1965, 14. 236-243 and 299-303.
-mWorld Health Organizatlon. Reglonal Offlce for the Western Paoifio. A study of nursing aotivities ln the outpatlent department. Phillppine General Hospltal. by the partioipants of the flrst reglonal nursing study semlnar WPRO. Manlla. PhIlippines. August 16 to 21. 1965. 108 p. Unpublished working document w~/65. Yoshitake. Y. Determination of length of stay in hospital by a survey day census. LGene~ World Health Organization. 1967. 10 p. (Unpublished working document OMC!WP/67.5) Young. J.P. - A queuing theor,y approaoh to the oontro1 of hospital InpatIent oensus. A dissertation submitted to the Advisor,y Board of the School at Englneerlng of the Johns Hopkins University In oonformity With the requirement. tor the degree at Doctor ot Engineering. Baltimore, Johns HoPklns Unlverslty. 1962. 198 p. - Sta~lzation ot inpatient bed oooupanoy through oontrol of admiSSion. Hospitals. 1965. l2. No.l9. pp. 41-48.
- 120 ANNEX 10 REFERl!NCES AVAIIABIE IN 'l!JE WPRO r..tBRARY FOR 'l!JE 8!Jt1INAR
ON HCSPrrAL AmINm'l'RATION AND PLANNING HOSPITAL AIlmfISTRATION & PLANNING
AUREOUSsu.U, P. and CHEVERRY, R. L-I·h6pital de dell81n; principes d'organisation, no:nnes architecturales, structures f'onctiOJlD8lles. TaDe 1. L'h8pital d'adultes. Tome 2. L'ft&pital d'enfants et la maternite. Paris,· Maaaon et cie., 1969. BELL, George B. (edi tor ) Hospital and medical school design. International s1JDPOaium held at Queen's College, Dundee, July 1961. Vol. 1. Papers and discuesiOll8. Vol. 2. Architectural plans and diagr8JllS. Edinburgh, B. & S. LiviDgstone, 1962. BRIIXIUB, R.F. i'he rural hospital,; its structure and organ1zation. WHO Monograph Series Ho. 21. Geneva, World Health OrgaDization, 1955.
BURLING, T. and others. The give and take in hospitals. A .,tudy of human organisation in hospitals. Hew York, G.P. Putnam's Sons, 1956. HAMILTON, James A. Decision maldng in hospital adJn1n1stration and medical care. book. Minneapolis, University of' Minnesota Press, 1960. HUDENBURG, Roy Planning the community hospital. 1967. .l case-
Hew York, McGrav-H1ll Book ec.pany,
INTERNATIONAL lIlSPITAL FEDERATIOH - INTERNATIONAL UNION OF .lRCIII'rEC'l'S International seminars on hospital architecture and techniques. First seminar - Geneva, 1957.
JACKSON, Laura G. Hospital and cOJlllllUn1ty. Studies in external relationships of the aciD1n1strator. Hew York, M.cmillan Company, 1964. JEliSIN, D. M. liard adllin1stration.
St. Louis, C.V. Mosby, 1952.
LLlWELYN-DAVIS, R. & MACAULAY, H.M.C. Hospital p1anniDg and adm1nistra tion. WHO Monograph Series No. 54. Geneva, World Health Organil5ation, 1966. McGlBONI, Jobn R. Principles of hospital administration, 2nd ed. G.P. Putnam's Sons, 1969. Hew York,
MIUlE, J .F. and CHAPLIN, H.W. (editors) Modern hospital manag8llent. London, Institute ot Hoepital Adm1n1stra~rs, 1969. OWEN, J. K. (editor) Modern concepts ot hospital administration. W.B. Saunders, 1962. Philaclelphia,
- 121 PERRY, E.L. Ward administration and teacbing. The work ot the ward sister. London, Ba1lli~re Tindall and Cusell, 1968. SPENCER, J .A. Management in hospitals. WORLD HBAL'lH ORGANIZATION
London, Faber and Faber, 1967.
Role of hospitals in programmes of community health protection. WHO Tectmical Report Series No. 122. Geneva, WHO, 1957. WRLD HJW.TH ORGANIZATION Role ot hospitals in 8IIlbulatory and doIII1cUi817 _dical care. WHO Technical Report Series No. 176. Geneva, WHO, 1959.
WORLD HIAL'lH ORGANIZATION Hospital Administration. Report of a WHO Elcpert COIIIIIittee. WHO Tectmical Report Series No. 395. Geneva, WHO 1968. WRLD RIlL'l'B ORGARIZATlClf. RBJlafAL OFFICI FOR EOROPI s,mpos1_ on hospItal and doII1cIliary care. A1IIaterdam, 19.2& Bovee.r 1962. Copenhagen, WHO/EtJRO, 1962. .
WORLD HlALTB OHWIIZATlOB. RmIOKAL OFFICII: FOR EOROPI The organization of ieneral. hospitals. Report on a con!erence. Oxford, 14-19 NOftIIIber 1966. Copenhagen, WHO/EUlfO, 1966. WORLD HEALTH ORGANIZATION. RmIONAL OFFICE FOR THE WESTERN PACIFIC Report on the First Regional Seminar on the Role of the Hoapi tal in the Public Health Progrlllllllle. ManUa, 13-20 May 19S5. Selected Periodical Articles BINKS, F.A. - The functions of a hospital.
Lancet,!t 1085-1086, 1962. Hospitals, 35, 42-44, Med. J. A~t.
BROWN, R.B. - Evaluating hospital adm1rU.stration. 1961.
lJJQDlLB, A.B. - A method of assessing hospital efficiency.
-
2, 1087-1091, 1970.
.
FAIRLBI, J. - Administration of teacbing hospi tala.
Lancet, 1, 323-324, 1967.
GOOAN, I. - 1he role of the hospital in the prnention of di.ease. Can.d. J. Publ. nth., 52, 431-436, 1961.
-
LUCAS, A.O. - The role ot the aoclern hospital in the ccwnm 1ty health sen1cu of deftloplna countries. Papua' R. Ou1he. lied • .1., !!r77-80, 1970. . . MARTDf, D.L. - x.m.c-ent dnelo.-nt in hospitals. 38-42, 19M. MAroGA, P. - b Med. Assoc.,
-
Canad. Hoep. 41, -
!2,
d...1~t of hOspitals in the Philippine.. 825-836, 196&.
J. Phil.
HAYUGA, P. - ~le of the hospital in the Philippine publ1c health SJBtem. J. PIlU. Ked. Assoc., ~,e7o-e74, 1963.
- 122 McCARTHY, B. - Job Evaluation in the hospital. McKILLOP, ment. Canad. Hosp. 2,., 53-54, 1960.
w. -
Hospitals,~,
Hospital administrative services: keener insight for manageSO-53, 1964.
MacMAHON. R.P. - Administration and the IHA: some considerations. Hospital (Lond.). 61, 296-298, 1965. NEWKIRK, D.R. - Hospitals in Brasilia: Hospitals, 2,.. 69-71. 1963. modern facilities in a planned city.
QUERIDO, A. - ~e changing role of the hospital in a changing world. Hospitals, ~ 31-35, 1962. RIEKE, F.E. - Public attitudes toward hospitals in Europe and America. Hospitals, ~, 54-57. 129-130. 1965. ROBSON, D.M. - Hospital activity analysisl its use in hospital management. Hospital (Lond.) §2., 388-391. 1967 ROmER. M.l. 8: FRIEDMAN. J.W. - Medical staff organization in hospitals a new typology. Hosp. Manyement. 105 (4) 58-60. (5) 41-44. (6) 56-59.
1968.
SAINT, E.G. - Hospital and the community.
Med. J. Aust.
g.
1221-1224. 1970. Pub. Hlth. Hosp.
SHAIN, M. 8: IDEMER, M.L - Hospitals and the public interest. Rep. 76, 401-410, 1961. SHEE, W.A. - British hospital developnent. Management. 31. 421-425.
Contemporary trends. Hospital.
SHEl'MIN. S. - ~e hospital service in Israel.
58.
667-671. 1962.
STEWART. R. - Chinese hospitals: some aspects of their organization. Hospital. §2., 425-429. 1967. STICKNEY. D.W. - A vietnamese province hospital in the war zone. 41, 67-71. 1967. STONE, P.A. - Administration and costs of hospital maintenanoe. 60, 411-415, 479-484, 1964. Hospitals. Hospital. a
TAUEENHAUS, L.J. - Community health services in a voluntary hospital: service director's point of view. Med. Care, ~, 247-251, 1970. TAYLOR, K.O. - Trends in hospital use.
Pub. Hlth. Rep. 84. 1037-1042. 1969.
TOOMEY, R.E. - Setting objectives: a guide to efficient management. Hospitals, ~, 48-51. 1963. 'l'ZE-K'UAN, Chang - '!be developnent of hospital service in China. Chin. Med. J. (Peking), §i. 412-416. 1965. WOODRUFF, P.S. - The hospital's role in the community. ~ 1050-1053. 1966. Med. J. Aust.
- 123 MEDICAL CARE AMERICAN PUBLIC HEALTH ASSOCIATION A guide to medical care administration. Vol. II. Medical care appraisal. New York, American Public Health Association. 1969. BERNZWEIG, Eli P.
Legal aspects of PHS medical care. USPHS Publication No. 1468. Washington, D.C., U.S. Government Printing Office, 1966.
BROWN. R.G. & WHYTE. H.M. (editors). Medical practice and the conmunity. Proceedings of a conference convened by the Australian National University. 26-30 August 1968. Canberra. Australian National University Press. 1970.
DODGE. J.S. (editor) The organization and eValuation of medical care. Proceedings of a postgraduate seminar held at Dunedin, 22-24 July 1970. Dunedin. University of Otago Medical School. 1970. GALLACHER. J .R. Medical Care of the adolescent. 1960. New York, Appleton-Century-Crofts.
GREENLICK, M.R. (editor) Proceedings of a conferenoe on oonoeptual issues in the analysiS of medical oare utilization behavior, Portland, Oregon, 29-31 October 1969. Washington, D.C., U.S. Public Health Servioe, 1969. HAMf.10ND, K.R. & KERN, F. Jr.
Teaching comprehensive medioal oare. A psychological study of a change jn medioal education. Cambridge. Harvard University Press. 1959. INTERNATIOFJlL LAOOUR ORGANIZATION The cost of medical care. Geneva, International Labour Offioe, 1959. KING, Maurice (editor) r·iedical care in developing countries. A symposium from Hakerere. A primer on the medicine of poverty. Nairobi, Oxford University Press, 1966. KLOTZ, S.D.
Guide to modern medioal oare.
New York. Charles Scribner's Sons, 1967.
MICHIGAN, University of. The economios of health and medical oare. Proceedings of the conference on the eoonomics of health and medical oare. May 10-12, 1962. Ann Arbor, Michigan, University of Michigan, 1964. PAN AMERICAN HEAL'IR ORGANIZATION Administration of medical care servioes. New elements for the formulation of a continental policy. Scientific Publication No. 129. Washington, D.C •• Pan American Health Organization, 1966. PAN AMERICAN HEALTH ORGANIZATION Coordination of medical care. Final report and working documents of a study group. Washington, D.C., Pan American Health Organization, 1969.
- 124 QUERIDO, A.
The efficiency of medical care. A critical discussion of measuring procedures. Leiden, H.E. Stenfert Kroese N.V., 1963. READER, G.G. and GOSS, M.B.W. (editors) Comprehensive medical care and teaching. A report on the New York Hospital - Cornell Medical Center Program. Ithaca, Cornell University Press, 1967. BOI!MBR, Milton I. The organi zation of medical care under social securl ty. A study based on the experience of eight countries. Geneva, International Labour Office, 1969. SAUND!RS,
Lyle
CUl tural difference and medical care. The case of the Spanish-speaking people of the Southwest. New York, Russell Sage Foundation, 1954.
u.s.
DEPARTMENT OF HEALTH, EOOCATION, AND WELFARE Medical care for the American people. The final report ot the CCIIIIIi ttee on the costs of medical care. Chicago, University ot Chicago Press. 1970.
U.S. DEPAR'lMENT OF HEALTH, EDUCATION, AND WELFARE Legal aspects of PHS medical care. A programmed instruction course. Washington D.C., U.S.Government Printing Otfice, 1968. U.S. DEPAR'DoIENT OF HEALTH, EDUCATION, AND WELFARE Medical care in transition. (A compilation of reprints trCIII the American Journal of Public Health from 19&9 to 1966). U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Studies in medical care administration. What thirteen local health dppartlllents are doing in medical care. Washington, D.C., U.S. Government Printing Office, 1967. Periodical articles (Selected)
BTESH, S. - International research in the organization of medical care. Medical Care, ~, 41-46, 1965. COTTRELL, J.D. - The consumption of medical care and the evaluation of eficiency. Medical Care, i, 214-236, 1966. !!MERY, G.M. - New Zealand medical care. FOX, T.F. - Medical care in China today. 28-35, 1960. Medical Care
i,
159-170, 1966.
Amer. J. Pub1. Hlth. 50 (Suppl. 6) A review and cOJllllen-
GILLES, H.M. - Medical care in developing countries. tary. Lancet,!, 718-719, 1967.
KLARMAN, H.E. - Approaches to moderating the increases in medical care costs. Medical Care, 2, 175-190, 1969. KLO!KE, A.H. - Medical care in the Tropics. LAST, J.M. - Evalution of medical care. Lancet,!, 1336-1338, 1961.
Med. J. Aust., 2, 781-785, 1965.
MARCOS, P.B. - Coordinated and integrated medical care services for the Philippines. J. Phil. Med. Assoc. ~, 555-560, 1967.
-
· .. 125 MAlUOA, P.N. - Medical care system in the Philippines. ~., 41, 2BO-:~83, 1965. J. Pbil. Med. J. Phil. Med.
MAIOOA, P.N .... Scheme ot I18dical care in the Philippines. Assoc., S8, 52-56, 1962.
ROBMBR, M.I .... A coordinated health Service and the problem of prior1ties. Israel J. Med. Se., !, 645-548, 1965. ROJIMIR, M.I. - Medical care adm1nistration in the United Statest Personnel needs and goaJa. .Amer. J. Publ. Hlth., 52, 8-17, 1962. ROIMIR, M.I .... '!he need tor medical care spec1al1sts in state and local health departments. Pub. Hlth. Rep., !!., 4155-440, 1967. TADMI, T.... A histol'7 of medical Care in Japan and the ob.1ect1Tes tor activities by the Japan Medical Association. Asian Med. J. 1:2. 1-28,
1987.
lIRBY, .A.S. - Medical care in the Soviet Un1on. 1985.
Medical Care,
!,
280-285,
Doc__te ABEL-SUTH, B. - Medical care 1n relation to public health. A 'tudf on the
coste and lOureN of finance •• Doc. aro/ClfC/SO Rev. 1, 1958.
ROIMD, M.I. - Medical care in Latin America.
Stud1es and MonOll'apba, III. Prepared tor the OAS General Secretariat, Pan .American Union, 1965 •
. . . . .,M.I .... Medical care in relation to Public health. A studT of relationships between preventift and curatift health ,erdc.. throughOut· iIhe world. ·Doc. WlO/ClfC/25 Rev. 1, 1956.
ROIIII>, H. ... An approach to the probl_ of coete and t1nancing of 118dical care servicea. Doc. WHO/(JoIC/26, 1956. WORLD BlALTR OROAllIZlTION .. 'l'he cost and services. Doc. MHO/PA/77.52., 1962.
Mana
of financing mecl1cal care
WORLD HlAL1H OllWfIZlTI<If, Regional Otfice tor Barope ... 'l'he e1'ficiency ot medical care, Report ot a SJmpOSiUIII, Copenhagen, 4-8 Jult1966. Doc. 1DRO-294-2, 1967.
- 126 -
ANNEX 11
CO'UNTRY QUPSTIONNAIRE ON HOOPlTAL INFORMATION
Notes for the guidance of participants 1. Cleneral
There is oonsiderable variation in the sooio-economio development of the countries and territories of the Western Paoifio Region. There is likewise considerable variation in administrative systems and the availability of vital and other statistios. As the same questionnaire is being sent to all participants some questions 1'Tt II be relevant in one oountry rot not in another. It is not expected that the questionnaire will be completed in full b,y all partic1pants.
If a country has a federal system of government, e.g. Australia, and to a certain extent Malaysia, it may not be possible to answer some of the questions on a country wide basis. In such instances supply the information for one state or area, specify the state or area and clearly indicate that the answer given does not apply to the country as a whole.
- 127 -
;.?
Specific
2.1 A copy of the country questionnaire is enclosed to be completed and returned to this Office by air mail. 2.2
Please use a typewriter in completing the questionnaire. T,ypescript must be double spaced.
2.3
2.4 One of the working languages of the seminar must be used# i.e.# eithe:' English or French. 2.5 When a "Yes" or "No" answer is required clearly delete the answer which is ~appl1cable. Do not ring or tick.
2.6 In questions where a number of alternatives are offered tick those alternatives which are applicable. 2.7
If the information asked for is not available please type not available.
2.8 Please complete the questionnaire to the extent that the inf'ormation asked for is available ani return it as soon as possIble to: WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Philippines Attention: Regional Adviser on Organization of Medical Care
2.9 Completed questionnaire must reach the Regional Office no later than 1 September 1971.
- 128 -
Country Date
COONTRY' QUESTIONNAIRE
1.
Demographic. socio-economic and health situation: A. Population: 1.
Total population at latest census. 19
(If no census state estimated population 1970 ____________)
At census prior to latest.
19 _:
(If no census state estimated population 1965 __________________ ) Population density: __________________ per square mile/ or ___________________~per square kilometre
2.
3. 4.
Percentage of population under 15 years of age Vi tal and health statistics:
--------------~% •
Crude birth rate Crude death rate
---------------------------------------------------------------------
Annual rate of population increase Infant mort ali ty rate*"
-------------------------
Maternal mortality rate** ______________________________
*Infant mortality rate = No. of deaths under the age of one year per 1000 live births per annum.
**Maternal mortalit,y rate = No. of maternal deaths per 1000 total births per MOum. (Mate1"tlal is defined as caused by complication of pregnancy childbirth and the puerPerium).
- 129 -
1bree leading cauaea ot JIIOrtal1ty and morb1d1ty (all age groups) Mortal1ty Morbiditl
1. ______________________ 2. ______________________
1. _____________________ 2. ______________________
}.
----------------------
}.
--------------------------
*Child (toddler) death rate (1-4 years) ______________________ 1bree 1ead1ng oauae. ot Want and oh1ld JIIOrtal1ty and JIIOrbid1ty* Mortal1ty Morbidity (appro.x1mately)
Infant 1 lear 1. ________ 2. _______
Child 1-4 ll'8.
Infant 1 year
Child
1-11- ll'8.
}.
----------
*Ch11d (toddler) death rate (1-4 years) 18 the lIP .pecific rate 1-4 lears - No. of deaths in sse groIlP 1-4 lears per tboua8Dd children 1-4 lears.
- 130 -
B.
Socio-cultural aspects: 1.
Major ethnic groups:
- 131 -
C.
Socio-economic aspects: 1. Main economic base: agriculture*/ind.ustry
*If agrioulture is there evidence of beginning industrialization? Yes/No 2. National income:
1964 ___________________ 19~
__________________________
3.
Range of annual per capita inoome in country' s ourrenoy (state year).
(Average income ___________________________ per capita per annum) State the range of inoome level per annum in your oountry which is regarded as: Upper range ____________________________________ and above Middle range from _ _ _ _ _ _ _ _ _ _ _ to ____________ Lower range _________________________________ and below
Approx. percentage of population in upper range ________________~% Approx. percentage of population in middle range _ _ _ _ _ _ _ _ _....% Approx. percentage of population in lower range _________________~%
- 132 -
II.
Health services of the country: Please attach an organizational chart of the health services of the
country from national down to local level. 1. (a) Manpower (Total)
Number of doctors (state category) _______________
Number of trained nursing personnel - professional
------- -- --
assistant ____________
- categories of nursing personnel and numbers:
Number of midwives (state category)
------------------------------- trained -----untrained
Number of traditional birth attendants
------
Other professional personnel category (e.g. phySiotherapists) Number
-1" 1. (b) Manpower in GovelillD8nt ani simil ar emplo yment . Total number of Gover nment -empl oyed/m edical perso mel: (inclu de emplo yees of hospi tal board s. muni cipal ities or equiv alent . i.e. total of non-p rivate lY emplo yed: Conve rt part-t ime to tull-t ime equiv alent s). Number of docto rs (state categ oI7) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Number of traine d l1IU'B ing perso nnel - profe ssion al
----------------
assis tant ___ ___ ___ ____ - oateg ories of nursi ng perso mel and numbe rs:
Number of midw1ves (stat e oatego r,y) _ _ _ _ _ _ _ _ _ _ _ _ __ Number of tradi tiona l birth attend ants·
---------- trained ---------untra ined ____ ____
Other profe ssion al perso nnel categ oI7 (e.g. physi other apists ) ____ ____ _--::-:- -:-___ ____ ____ ____ Number
- 134 -
1.
(c)
Manpower of the public hospital system.
Total number of medical persormel employed in pub110 hospital system (convert part-time employees to full-t1me equ1valents) Number of doctors (state category) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Number of trained nurs1ng personnel - profess1onal _ _ _ _ _ _ _ _ __ assistant _ _ _ _ _ _ _ _ _ __
- categor1es of nurs1ng persormel and numbers:
Number of midwives (state oategory) ___________________
Number of trad1tional birth attendants _________ trained _______ untrained _______
Other professional persormel category (e :.g. phys1otherap1sts) Number
- l~-
1.
(d)
Manpower of the private sector. (Convert
Total rnunber of medical personnel in the private sector:
part-time to full-time equivalents). Number of doctors (state category) ___________________
Number of trained nursing personnel - professional _ _ _ _ _ _ _ _ __ assistant ____________________
- categories of nursing personnel and numbers:
Number of midwives (state category)
Number of traditional birth attelidants _______ trained _ _ _ __ untrained _ _ _ __
other professional personnel category (e.g. physiotherapists)
--------~N~um~b-e-r----------------
- 136 -
2.
Medical and other professional eQ.ucation:
Number of medical schools (state category) annual output ____________________________________________________________________________
Number of nursing schools:
Category
Number
Annual Output
Number of midwifery schools ___________ annual output _ _ __
Number of schools for other professional workers such as Schools, physiotherapy, number _~______
annual output _ _ _ _ _ _ __
Medico-socia,).. workers, number __________ annual output _ _ _ _ _ _ __
Health educators, number _________ annual output _ _ _ _ _ _ __
Others (specify), number _______________ annual output _ _ _ _ _ __
- 1Yf -
III.
National Gove1'l'llll8nt e:xpenditures on health services of the country (a) National income.
1964 ___________________ _________________________________ 1 ~
(b) National budget. 1964 1~
_________________________________
(e)
National budget for health and medical 1964 c~.
______________________
1969 __________________ (d) National expenditure on
public hospitals (capital & maintenance) 1%4 _________________________________
1969 _________________________________________ (e) (e) as a ~
of (b)
1964 ____________________________
1969 __________________________________ (f) (b) as a ~
of (a)
1964 _______________________________
1969 ________________________________ (g) (d) as a ~
of (c) 1964 _________________________________
1~
________________
~----
___
- 138 IV. Legal status and control of the public general hospital system
Please submit as annexes. national legislation and/or regulations state legislation and/or regulations (where appropriate) and municipal ordinancp.s which relate to the control of public general hospitals. If there is no such legislation and there are no regulations or ordinances. please state: (Give critici~comments
on salient points - not more than 10 lines)
- 1'9 -
v.
Legal status and control ot the private hospit.al syst.em
Please subDit as annexes. national legislat.ion and/or regulat.ions, st.ate legislation ~or regulations (where appropriate) and municipal ordinances which relat.e to control of the private hospital system. If there are no private hospit.als please st.ate. If there are private hospitals but there is no such legislation and there are no regulations or ordinances. please state. (Give brief crit.icism or comments on salient. points - not more than 10 lines)
I f private hospitals exist is their role included in the overall planning
of hospital services as a whole within the national health plan if one exists? Elaborate briefly.
- 140 -
VI.
If there is a private hospital system
Is finanoial assistanoe given to the private hospitals or patients entering private hospitals b.1: National Government State Government The Local Authority Yes Yes Yes No No No
If the answer is "Yes" elaborate briefly: (e.g. assistanoe may be oapital (to build or extend a hospital) b.1 either interest free or low interest loans; or e.g. the maintenanoe oosts of the hospital may be subsidized; or e.g. a benefit may be paid to either the patient or the hospital).
- 141 -
VII.
Organization of the publio hospital system
Is there a national polioy whioh is effeotively bringing about regionalization* of the publio hospital system Yes No
Does ultimate responsibility for the oontro1 of the public general hospital system lie with (a) (b) (c) (d)
a national "authorit.y a state authority a local authority other.
I f several systems operate within the oountry please speoify briefly and elaborate on how they relate t.o each other.
*Regionalization is placing under unified. general administrative oontro1 the hosp!t.als and health servioes of a wide area which m~ oontain a population of up to several million people. The provision of hospital services can thus be related with reasonable accuracy to the population they are intended to serve gaps and overlapping can be avoided. and new hospitals oan be sited in the most strategically suitable positions with regard to population density and means of oommunioation.
- 142 -
VIII.
Management of public general hospitals at a local level
Is there a local management board, representing the public, which takes part in managing a public hospital or group of public hospitals within a local authority area? Yes No
It "Yes", are members elected or appointed.
If appointed, by whom -, specify.
Any other important relevant information:
- 14, -
I~~.
.~~i_n1strat1on
of the individual public general hospital oount~J
(a) Is it a policy in your the hospital in the hands of:
to place the administration of
- a lay administrator - a medically-qualified administrator
(b) If there are lay administrators in charge of some publio general hospitals and medically-qualified administrators in charge of others, please co~ent briefly.
(c) If public general hospitals have lay administrators state briefly the training and qualifications required.
- 144 -
(d)
If public general hospitals have medically-qualified administrators
- Does the size of the hospital determine whether the doctor in charge nrust be a full time employee? Yes !'G If "Yes", what is the size.
(e) Some directors of hospitals also have clinical responsibilities especially in small hospitals. Is there ~y size of hospital which determines when the director shall have no clinical responsibilities? If so please specify.
(f) In hospitals, if any, in which the director has no clinical responsibility are any special qualifications needed for appointment to the pest, e.g., Master's Degree in Hospital Administration or DPH (Hospital Administration).
- 145 -
x.
Funding of public general hospitals
(a)
Are publio general hospitals funded by:
(a) (b) ( c) (d) (e)
National Government State Government Local Authority Patient contribution Other - speoify.
Where there is a combination of souroes of finance. indicate the proportion.
(b) If part of the finance comes direct from patient contribution indicate the method or methods used: - Pay beds
- Charge for medicines. etc. - Request for donation from the patient. - Other (specify).
- 146 -
If more than one method of patient contribution please indicate the proportion of total patient contribution from each method.
•
- 147 -
(c) If some public general hospital bedS are 'pay beds' what is the proportion of 'pay beds I to total general public hospital beds?
What are the charges for pay beds per dq?
Do these charges include the cost of drugs and medical and nursing
oare.
(d) I f some public general hospitals have 'pay beds' or if there is a charge for all beds. even if small. oan the publio take out private insuranoe against the oosts of hospitalization? Yes
No
If yes, what percentage of the oharges will be reimbursed by the insuring organization?
•
- 148 -
XI.
Availability of hospital beds (all typeS) Number of beds per 1000 population ~ !2§2.
12M 1.
Number of beds
~
Publ1a general hospital . (inalude maternity if this is austomary). Public geriatric hospitals. hospitals (do not inolude psyohiatric beds in general public hospitals)
2.
3. Publia psyahiatric
4. Publio maternity hospitals (only if not inaluded in 1 above)
5. Public leprosaria 6. Other special public hospitals (specify) Sub-total
7. All types of private
hospitals (excluding missions) Mission hospitals Any other type of hospital (specify)
8.
9·
Tot a 1
- 149 -
XII.
Distribution of public general hospital beds only
In most. if not all countries. there is a variation in the distribution of available public general hospital beds from one area of the country to another. In order to give some indication of the range of this .variation in your country and if there has been change over recent years please complete the following table. No. of general public hospital beds/1OOO population
No. of people
No. of general public hospital beds
Administrative area. 1964 with the smallest number of available general hospital beds/1000 population in the year 1969 1969
Administrative area. 1964 with the greatest number of available general hospital beds in the ye at' 1969. 1969
- 150 -
XIII.
No. of public general hospitals in the country and the size of the hospitals Complete the following table. No. of beds in the pub1io general hospitals
No. of hospitals
1 -
49
50-99 100 - 199
200 -
299
300 - 499 500 - 799 800 +
Tot a 1
=~=~==============~===
- 151 -
XIV.
Utilization of public general hoapitals Complete the following tables: Average No. of beds available per day per 1000 population
(bz
in-patients)
Average No. of beds available per day
Average No. of beds occupied per day
Average No. of beds occupied per day per 1000 population
1964 1969 In-patients treated in public general hospitals In-patients treated Number Number per 1000 population
1964
Average duration of patient stay in days
1964
Average number of patients treated per available bed per annum
1964 1969 Average number of patients treated per occupied bed per annum
- 152 -
:cv.
Availability of public general hospital out-patient services
(a) Do all general public hospitals in your country have an out-patient department (as distinct from an accident and emergency or casualty service). Yes If "No" state briefly ~
No
(b) Is 'a general practitioner' service available from out-patients for patients who present seeking it. Yes No
(c) If a general practitioner service is available do patients have to be referred by a doctor or nurse? Yes (d)
No
Is a specialist service available at out-patients Yes No nurse.
(e)
If "Yes", do patients have to be referred by a doctor or
8
Yes
No
- 153 -
XVI.
Utilization of emeraJ. f!:1blic hosntel out-patient services Number of out-patient services rendered per 1000 population per annum
NUmber of out-patient service. rendered
1964 1969
Number of out-patients inveatiptecl or treatecl
Number of out-patients inveatigatecl or treatecl per 1000 population per annum
1964
1969
~
154 -
XVII.
Cost.s of general publio hospitala (a) Capit.al oost.s
Give the capit.al cost of the most recently constructed general public hospital in your country stating the number of beds and date of completion. Do not include the cost of furnishings non-bu1l t in furniture and non-built in equipment.
Please state if the oost includes, land, nurses' home. kitchen, laundry, bollerhouse. eto. or if the hospital speoified is an extension of an existing hospital with supporting servioes previously made available.
If possible give the figures for a comparable hospital oompleted five years previously. Briefly supply any additional information of importance.
- 155 •
(b) Maintenance coats Costs of in-patient care Average coat per occupied bed per da.v
1964
Average cost per in-patient treated per ann\DII •
Coats of out-patient care Average cost per out-patient service per annum
Average cost per out-patient treated per annum
- 156 -
• XVIII. Domiciliary services of the public general hospital Indicate which of the following domiciliary services are available from your public general hospitals. 1. 2.
Bedside nursing Midwifery Antenatal care Post natal care
Yes Yes Yes Yes Yes Yes Yes $ Yes Yes Yes
No No No No No No No No No No •
3.
4.
5. Public health nursing
6. Physiotherapy 7. Occupational therapy 8. Medico social
9. Psychiatric nursing 10.
Psychiatric social worker '!he services of a sanitarian or sanitary inspector Health education b.1 a health educator
11.
Yes
No
12.
Yes
No
If it is necessary to amplify any of the above, do so:
.
- 1';7 -
• XIX. Rehabilitation service
Is a comprehensive integrated rehabilitation service part of your public hospital system? Yes
No
•
If "Yes", describe briefly:
- 158 -
•
xx.
Preventive services
Indicate which of the following preventive services are routine in your public hospital system: Antenatal clinics Post-natal clinics Family planning Well-baby clinics Medical exminat10n of sohool ohildren Inmunization Case finding in tuberoulosis Case finding in venereal disease Environmental sanitation Public health nursing Health eduoation Nutrition and dietetics Mental health Public health laboratory Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No
• •
No No No No No No No No No
..
If "NO", state briefly why not.
•
- 159 -
XXI.
Use of the hospital system in education and training
Give summarized information on the role of your public hospital system in the education and training of professional staff; (post-graduate, undergraduate) doctors, general nurses, psychiatric nurses, midwives, occupational therapists, physiotherapists, radiotherapists, others •
•
XXII.
Use of the hospital system in
re~~h
and evaluation
Give brief information on the above. State whether or not in your system of hospital records the ICD is used and if so in such a manner that the information can be readily retrieved for such surveys as the epidemiological study of hospital admissions.
- 160 -
•
XXIII.
Critical evaluation of the public hospital system in your country
Restricting yourself to the space available below (typing double space) critically evaluate the system of your country and make any recommendations you think are desirable.
I
...