SNR District Hospital: Delivering Quality to the Poor
Public authorities and legislative bodies have accosted the government for failing to ensure primary health care to those below the poverty line. This article uses the SNR Hospital of Kolar as an example to study what ails government hospitals. Recommendations for improvements have been presented in light of the SNR Hospital case which would also apply to any other government hospital.
The Government of India has the responsibility of alleviating poverty concerns and promoting healthcare, while ensuring that there is equality in all its operations. In the past, successive governments have failed in providing basic healthcare facilities to the poor, especially to those living below the poverty line. A number of accusations have been levied against the government citing inadequacies in staffing and infrastructure, corrupt officials, inefficient bureaucracy and a lack of basic sanitation facilities. This article attempts to study the inadequacies of one government hospital in particular, located in Karnataka and provides recommendations to improve its operations and deliver its goals of providing quality primary healthcare at affordable prices to those below the poverty line.
SNR District Hospital
Sri Narasimha Raja District Hospital is a 70 years old hospital in Kolar, a small town in Karnataka. The hospital is funded by the World Bank and has a sanctioned capacity of 400 beds. It is meant to cater to a population of 0.12 million each year. The hospital receives a grant from the National Rural Health Mission (NHRM) and generates most of its revenues from clinical fees and user charges. The average out-patient (OPD) inflow is 800 everyday of which 10-20% come from Kolar and the rest from nearby villages for general ailments, including diabetes and viral infections.
In November ’08, The Hindu, a national daily reported that the hospital had become the red herring in public eyes owing to the lack of facilities and certain operational inefficiencies. The State Human Rights Commission had expressed its anguish over the state of affairs in the hospital1. Field visits to the SNR hospital and focus group discussions with the staff and the patients reveal the inefficiencies in the system, some of which have been detailed.
The issues were visible at different critical points that the patient travelled at the hospital. They are listed below in the order of severity.
There is a chronic understaffing of nurses. There were 8 doctors in the OPD and they treated roughly 100 patients a day! Considering a call time of 5 minutes per patient a doctor would have to spend at least 8 hours in the hospital. Moreover, all doctors were ‘On call’ – available anytime during the day for an emergency.
Lack of Information Systems
The hospital has a record keeping room where data is maintained diligently and systematically, but manually. Internal & external communications systems were absent.
The hospital offers free services to people belonging to the Below Poverty Line (BPL) income group. The Resident Medical Officer (RMO) has to identify who the right beneficiary is through a ration card issued in the name of the house owner.
The District Superintendent (DS) runs the show and is the supreme authority at the hospital. There is no proper delegation of authority.
Poorly Equipped Front Desk
Though courteous, the staff at the desk lacked professionalism and were not trained in handling the queries of patients.
Sanitation and Other Facilities
The condition of toilets, both in OPD and wards, was abysmal. The hospital suffered from power shortage.
Shortage of Equipment
The equipment at the labs was not upgraded in number and quality for a long time. The physiotherapist at the hospital showed us outdated instruments.
The administration dissuaded the public from offering bribes by printing messages in local languages. But the patients complained of the existence of brokers, who ‘guarantee free and quick service’ to their ‘customers’.
Inadequate Knowledge & Resource Management
Preliminary enquiries with the medical staff revealed that the physiotherapist had no clue of the new technology available in the market. A qualified surgeon at a high position had not held the scissors for years. There was no system in place which would tell the doctors the availability of medicines at the pharmacy. To add to the patient’s misery, there was no register in place to collect and review feedback.
Recommendations for Improvement
The hospital is being funded by the Ministry of Health and Family Welfare, Government of Karnataka. The bulk of the expense incurred is due to the free services provided to the BPL patients. Hence, to ensure its self sustenance, it ought to provide services in a manner that decreases cost and increases effectiveness. With that objective, a few procedures that could be implemented to ease the inadequacies in the system are noted.
The administration requires improvement both from the Organizational structure and human resource point of view.
The DS and the RMO are responsible for the supervision of administrative activities including cleanliness, identification of BPL patients, scheduling work for doctors, accounts, security etc. Research indicates that the DS, who is the most experienced doctor in the hospital, spends 70% of his time doing administrative work. A delineation of the administrative and medical functions was mooted. The administrative work could be outsourced to third party companies – security, housekeeping, accounting agencies etc. The DS would head the doctor’s hierarchy and facilitate high quality health service quality and smooth transfer of knowledge to junior doctors. A liaison could be introduced to interface between the 3rd party administrative company and the medical fraternity.
The sanctioned staff is a number that is linked to the number of beds in the hospital. This is the standard recommended by the government. This policy needs to be rationalized - the number of medical personnel should be in resonance with the number of patients rather than the number of beds.
Human Resource Initiatives
The doctors at the SNR hospital work with commitment and deserve to be incentivized for the exemplary work done. The same cannot be said about the technicians at the hospital. It is mandatory that best practices need to be recognized with awards and performance based bonuses. The introduction of performance appraisal systems like the 360 degree feedback mechanism can be used to motivate the workforce.
The hospital needs to graduate to technology based systems to ensure efficient record keeping. It would also help in optimal use of staff resources.
Building the IT Infrastructure
The patient record-keeping activity needs to be computerized. Though the hospital provided basic data needed for the work, a computerized system can provide valuable insights to future consultants who work with the hospital. This can be used to keep track of the medical staff attendance as well. The hospital needs telecom connectivity to minimize physical movement of staff thus ensuring availability in cases of emergencies.
The ration cards are an inefficient medium to identify beneficiaries. The RMO’s intuition and intervention is required to award these benefits. This creates opacity in the process and provides scope for corruption and appropriation of benefits illegally by fake card holders. A biometric signature would act as a unique identification system with complete biometric information about every customer. This eliminates fraud and increases transparency at the identification level. Also the complete medical records of the patient can be stored in a database. Such a system would also benefit in monitoring developmental activities in the region.
Delivery of Service
Quality of service can be increased manifold by putting in systems in place to connect with the potential customers by ensuring two way information flow.
Formal Feedback Collection
A simple feedback mechanism in the local language must be put in place. This is needed for a system in pursuit of quality.
Educating the Public
The opportunity to serve the community goes beyond the medical needs. Initiatives like anti-AIDS campaigns, anti-polio drives as well as personal and community hygiene improvement can be put in place to increase public awareness.
De-isolating Medical Staff
The medical staff at the hospital are cut off from the rest of the fraternity in the private hospitals. An exception here is the District Surgeon who is connected to the internet. The idle time of the technicians can be utilized (with controlled usage of internet) in completing online training programs so that they are adept in their knowledge of the cutting edge in medical technologies. Subscription to e-journals and medical libraries of various government colleges in India and abroad will add a lot of value to the doctors in the hospital. The medical fraternity could also keep abreast with the latest in the academic world by inviting students from nearby medical colleges to collaborate with the staff in carefully devised programmes.
Patient Grievance Cell
There is a help desk that functions effectively but not efficiently. There should be professional staff support as part of the administrative structure that has already been recommended to guide the patients during their visit. A patient grievance cell would also facilitate the implementation of any feedback from the patients.
Service Quality Parameters
The SERVQUAL2 system of measuring differences between the expected quality and the delivered quality could be implemented. The patients at the hospital are from a rural background and obtain the service at little or zero cost. This discourages them from expecting that the services rendered would entail quality. In all probability, this could be a fall out of the fact that most patients are ‘used to’ the apathy of government service over time. Some parameters that could be used to measure patient satisfaction are speed of service, responsiveness of doctors, cleanliness. Simultaneously, employee satisfaction can be quantified on certain parameters, which include the learning potential of the job, salaries, quality of work amongst others3.
Self Financing Options
Various self financing options can be explored. Some of them are:
Wards with Differential Charges
In Tamil Nadu, such a system is in place to tap into the rich urban population. This could be used to provide relief to the poor, in terms of subsidies.
Public Private Partnership
PPP models are being extensively used in infrastructure, education and health in India. But, the success of the model depends on finding a viable compromise between the money-making objectives of the private enterprise and the public health delivery objective of the government4.
Super-specialty Arm as a Public Venture
A viable option is to setup the super-specialty arm using government capital only. The premium earned could be used to subsidize the services offered to the poor.
The current model of health service delivery would not achieve its objective of delivering primary health care to people below the poverty line unless the government puts in place certain operational measures, to improve the infrastructure and the administration of the Sri Narasimha Raja District Hospital. Research studies have indicated a number of gross inadequacies in the current operational model of the hospital. Improving the technology, a proactive role in engaging the community and training the medical personnel would ensure that the hospital is sustainable in the long run and the poorest of the poor are provided basic health facilities.
S. Nayana Tara is a Professor in the Public Systems Area at the Indian Institute of Management Bangalore. She holds a PhD in Education from the US and is also a member of the Karnataka Knowledge Commission. She can be reached at firstname.lastname@example.org
Prahalad Mukundan (PGP 2007-09) holds a B.E degree from SSN College of Engineering and can be reached at email@example.com
Krishna Chaitanya Raghav (PGP 2007-09) holds a B.E degree from PES Institute of Technology, Bangalore and can be reached at firstname.lastname@example.org
Nikita Sood (PGP 2007-09) holds a B.E degree from Thapar Institute of Engineering & Technology, Patiala and can be reached at email@example.com
Venkateswaran K. N. (PGP 2007-09) holds a B.E degree from Indian Institute of Technology Madras and can be reached at firstname.lastname@example.org
Healthcare, Public policy, IT, PPP, Organisation Behaviour, Human Resource
- Vishwa Kundapura, 2008, ‘Kolar District in need of major surgery’, The Hindu, Nov 28, 2008, http://www.hindu.com/2008/11/28/stories/2008112851770600.htm. Last accessed on December 6, 2008.
- Babakus E and Mangold W G, 1992, ‘Adapting the SERVQUAL scale to hospital services: An empirical investigation’, Working Paper, 2/1997, Department of Marketing, Memphis State University.
- Shainesh, G and Mathur, Mukul, 2000, ‘Service Quality Measurement: The Case of Railway Freight Services’, Working Paper, 9/2000, Central Railways, Nagpur, Management Development Institute, Gurgaon.
- Raman, Venkat A and Prof. Bjorkman, JW, 2004, ‘Public Private Partnership in Healthcare services in India’, Working Paper, Institute of Social Studies, The Hague, Faculty of Management Studies, New Delhi.