Keyur D Vasava

Pharmacy+MBA

Dist.Narmada

"ACCEPT EVERYTHING ABOUT YOURSELF -- I MEAN EVERYTHING, YOU ARE YOU AND THAT IS THE BEGINNING AND THE END -- NO APOLOGIES, NO REGRETS." ( 14/03/12)

SUBJECT-PHARMACEUTICAL AND HEALTHCARE SECTOR KEYUR D VASAVA

Module.1 OVERVIEW OF HEALTHCARE SERVICES IN INDIA:

1. AN INTRODUCTION TO HEALTH SERVICES IN INDIA THROUGH FIVE YEAR PLANS

Eleventh Five-Year Plan, 2007–2012

Health

Reduce infant mortality rate to 28 and maternal mortality ratio to 1 per 1000 live births Reduce Total Fertility Rate to 2.1 Provide clean drinking water for all by 2009 and ensure that there are no slip-backs Reduce malnutrition among children of age group 0-3 to half its present level Reduce anaemia among women and girls by 50% by the end of the plan

Eleventh Five Year Plan with the following Terms of Reference: (i) To review existing scenario of Public Health Services (including Water & Sanitation) in urban and rural areas considering regional & inter district disparities and with a view to provide universal access to equitable, affordable and quality health care which is accountable at the same time responsive to the needs of the people and also achieve goals set under the National Health Policy and the Millennium Development Goals. (ii) To review the goals, objectives, strategies and expected outcomes of the National Rural Health Mission by the end of the eleventh five year period (2012) at all levels. (iii) To review the implementation of major health and family welfare programmes, functioning of infrastructure and manpower in rural and urban areas, and suggest measures for rationalizing/restructuring the infrastructure, strategies for improving efficiency and for the delivery of services with a special focus on women & children. (iv) To review the challenges of the immediate future such as aging population increased disease burden on account of new infections and non-communicable diseases that have the potential to impoverish the poor. (v) To review the mechanism for screening and referral of patients, so that they receive appropriate care at all levels. (vi)To review disease control programmes and disease surveillance mechanism in the country, its capability to provide up-to-date information for effective timely response to prevent/limit disease out breaks and to provide effective relief measures.

(Vii) Identify year-wise quantifiable goals and specific road map of the NRHM and also suggest method of concurrent evaluation of NRHM. (viii) To suggest modification in policies, priorities and programmes during 11th Plan period in relation to: (a) Priority areas of research to investigate alternative strategies; (b) Mid-course correction of ongoing activities; (c) New initiatives; (d) Strategies to improve quality and coverage of services at affordable cost, to cope with existing, reemerging and new challenges in communicable diseases, emerging problems of non-communicable diseases due to increasing longevity, life style changes and environmental degradation; (e) Provide all these services through NRHM and secondary health care system in an integrated fashion; (f) Improve disease surveillance, HMIS, effective timely response. (ix) To indicate manpower requirement and financial outlays required for implementation of these programmes during the 11th Plan period; (x) To deliberate and give recommendations on any other matter relevant to the topic.

2. HEALTHCARE SYSTEM IN INDIA

A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations.

Healthcare in India features a universal health care system run by the constituent states and territories of India. The Constitution charges every state with "raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. However, the government sector is understaffed and underfinanced; poor services at state-run hospitals force many people to visit private medical practitioners.

Government hospitals, some of which are among the best hospitals in India, provide treatment at taxpayer expense. Most essential drugs are offered free of charge in these hospitals. Government hospitals provide treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one of the best hospitals in India) costs a onetime fee of rupees 10 (around 20 cents US) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on financial condition of the patient and facilities utilized by him but are usually much less than the private

sector. For instance, a patient is waived treatment costs if he is below poverty line. Another patient may seek for an air-conditioned room if he is willing to pay extra for it. The charges for basic in-hospital treatment and investigations are much less compared to the private sector. The cost for these subsidies comes from annual allocations from the central and state governments.

Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses. Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals).

In recent times, India has eradicated mass famines, however the country still suffers from high levels of malnutrition and disease especially in rural areas. Water supply and sanitation in India is also a major issue in the country and many Indians in rural areas lack access to proper sanitation facilities and safe drinking water. However, at the same time, India's health care system also includes entities that meet or exceed international quality standards. The medical tourism business in India has been growing in recent years and as such India is a popular destination for medical tourists who receive effective medical treatment at lower costs than in developed countries.

OR

A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations.

There is a wide variety of health care systems around the world, with as many histories and organizational structures as there are nations. In some countries, health care system planning is distributed among market participants. In others, there is a concerted effort among governments, trade unions, charities, religious, or other co-ordinate bodies to deliver planned health care services targeted to the populations they serve. However, health care planning has been described as often evolutionary rather than revolutionary.

Goals

The goals for health systems, according to the World Health Organization, are good health, responsiveness to the expectations of the population, and fair financial contribution. Progress towards them depends on how systems carry out four vital functions: provision of health care services, resource generation, financing, and stewardship. Other dimensions for the evaluation of health care systems include quality, efficiency, acceptability, and equity. They have also been described in the United States as "the five C's": Cost, Coverage, Consistency, Complexity, and Chronic Illness

Providers

Health care providers are institutions or individuals providing health care services. Individuals including health professionals and allied health professions can be self-employed or working as an employee in a hospital, clinic, or other health care institution, whether government operated, private for-profit, or private not-for-profit (e.g. non-governmental organization). They may also work outside of direct patient care such as in a government health department or other agency, medical laboratory, or health training institution. Examples of health workers are doctors, nurses, midwives, paramedics, dentists, medical laboratory technicians, therapists, psychologists, pharmacists, chiropractors, optometrists, community health workers, traditional medicine practitioners, and others.

Financial resources

There are generally five primary methods of funding health care systems:

1. general taxation to the state, county or municipality 2. social health insurance 3. voluntary or private health insurance 4. out-of-pocket payments 5. donations

Management

The management of any health care system is typically directed through a set of policies and plans adopted by government, private sector business and other groups in areas such as personal health care delivery and financing, pharmaceuticals, health human resources, and public health.

Public health is concerned with threats to the overall health of a community based on population health analysis. The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). Public health is typically divided into epidemiology, biostatistics and health services. Environmental, social, behavioral, and occupational health are also important subfields.

Today, most governments recognize the importance of public health programs in reducing the incidence of disease, disability, the effects of aging and health inequities, although public health generally receives significantly less government funding compared with medicine. For examply, most countries have a vaccination policy, supporting public health programs in providing vaccinations to promote health. Vaccinations are voluntary in some countries and mandatory in some countries. Some governments pay all or part of the costs for vaccines in a national vaccination schedule.

The rapid emergence of many chronic diseases, which require costly long-term care and treatment, is making many health managers and policy makers re-examine their health care delivery practices. An important health issue facing the world currently is HIV/AIDS. Another major public health concern is diabetes. In 2006, according to the World Health Organization, at

least 171 million people worldwide suffered from diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2030, this number will double. A controversial aspect of public health is the control of tobacco smoking, linked to cancer and other chronic illnesses.

Antibiotic resistance is another major concern, leading to the reemergence of diseases such as tuberculosis. The World Health Organization, for its World Health Day 2011 campaign, is calling for intensified global commitment to safeguard antibiotics and other antimicrobial medicines for future generations.

Special health care systems

Occupational safety and health School health services Military medicine

Health care by India

In the greater India, the hospitals are run by government, charitable trusts and by private organizations. The government hospitals in rural areas are called the (PHC)s primary health centre. Major hospitals are located in district head quarters or major cities. Apart from the modern system of medicine, traditional and indigenous medicinal systems like Ayurvedic and Unani systems are in practice throughout the country. The Modern System of Medicine is regulated by the Medical Council of India, whereas the Alternative systems recognized by Government of India are regulated by the Department of AYUSH (an acronym for Ayurveda, Yunani, Siddha & Homeopathy) under the Ministry of Health, Government of India. PHCs are non-existent in most places, due to poor pay and scarcity of resources. Patients generally prefer private health clinics. These days some of the major corporate hospitals are attracting patients from neighboring countries such as Pakistan, countries in the Middle East and some European countries by providing quality treatment at low cost. In 2005, India spent 5% of GDP on health care, or US$36 per capita. Of that, approximately 19% was government expenditure. OR Indigenous or traditional medical practitioners continue to practice throughout the country. The two main forms of traditional medicine practiced are the ayurvedic (meaning science of life) system, which deals with causes, symptoms, diagnoses, and treatment based on all aspects of well-being (mental, physical, and spiritual), and the unani (so-called Galenic medicine) herbal medical practice. A vaidya is a practitioner of the ayurvedic tradition, and a hakim (Arabic for a Muslim physician) is a practitioner of the unani tradition. These professions are frequently hereditary. A variety of institutions offer training in indigenous medical practice. Only in the late 1970s did official health policy refer to any form of integration between Western-oriented medical personnel and indigenous medical practitioners. In the early 1990s, there were ninety-eight ayurvedic colleges and seventeen unani colleges operating in both the governmental and nongovernmental sectors.

10 ways to improve India's healthcare system

1. Develop and implement national standards for examination by which doctors, nurses and pharmacists are able to practice and get employment.

2. Rapidly develop and implement national accreditation of hospitals; those that do not comply would not get paid by insurance companies. However, a performance incentive plan that targets specific treatment parameters would be a useful adjunct.

3. Obtain proposals from private insurance companies and the government on ways to provide medical insurance coverage to the population at large and execute the strategy. It is healthy to have competition in healthcare, and provide health insurance to the millions who cannot afford it.

4. Utilize and apply medical information systems that encourage the use of evidence-based medicine, guidelines and protocols as well as electronic prescribing in inpatient and outpatient settings. This is possible though the implementation of the EHR; this will, in time, encourage healthcare data collection, transparency, quality management, patient safety, efficiency, efficacy and appropriateness of care.

5. Perverse incentives between specialists, hospitals, imaging and diagnostic centres on the one hand and referring physicians on the other need be removed and a level of clarity needs to be introduced.

6. Develop multi-specialty group practices that have their incentives aligned with those of hospitals and payers. It is much easier to teach the techniques of sophisticated medical care to a group of employed physicians than it is to physicians as a whole. It is also important that doctors are paid adequately for what they do.

7. Encourage business schools to develop executive training programmes in healthcare, which will effectively reduce the talent gap for leadership in this area.

8. Revise the curriculum in medical, nursing, pharmacy and other schools that train healthcare professionals, so that they too are trained in the new paradigm.

9. Develop partnerships between the public and private sectors that design newer ways to deliver healthcare. An example of this would include outpatient radiology and diagnostic testing centers.

10. The government should appoint a commission which makes recommendations for the healthcare system and monitors its performance.

3. LEVELS OF HEALTH CARE, PRIMARY, SECONDARY AND TERTIARY HEALTH CARE HEALTH CARE is the diagnosis, treatment and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, dentistry, nursing, pharmacy and allied health. The exact configuration of health care systems varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; and well maintained facilities and logistics to deliver quality medicines and technologies.

What are the 3 levels of health care

Primary health care is about preventing illness or disability. This would include Well Women's Clinics, child immunization programs, malaria prevention and that sort of thing.

Secondary health care is where a patient is ill and is treated, usually by nurses and doctors. Treatment of diabetes, high blood pressure, bronchitis and minor fractures are some examples of secondary health care.

Tertiary health care is where things have gone wrong and long term care and rehabilitation programs are used, for instance if someone had a double amputation, they would need artificial limbs and physiotherapy and possibly adaptations to the home.

4. REVIEW OF PRIMARY HEALTHCARE IN INDIA

“PRIMARY HEALTH CARE” means “...essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individual and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s overall health system, of which it is the central function and main focus, and the overall social and economic development of the community. It is the first level of contact Of individuals, the family and community with the national health system bringing care as close as possible to where people live and work, and constitutes the first elements of a continuing health care process.” Primary health care is provided by city and district hospitals and rural primary health centers (PHCs). These hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses. Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluka headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals).

PRIMARY SERVICES Health care facilities and personnel increased substantially between the early 1950s and early 1980s, but because of fast population growth, the number of licensed medical practitioners per 10,000 individuals had fallen by the late 1980s to three per 10,000 from the 1981 level of four per 10,000. In 1991 there were approximately ten hospital beds per 10,000 individuals. For comparison, in China there are 1.4 doctors per 1000 people.

Primary health centers are the cornerstone of the rural health care system. By 1991, India had about 22,400 primary health centers, 11,200 hospitals, and 27,400 clinics. These facilities are part of a tiered health care system that funnels more difficult cases into urban hospitals while attempting to provide routine medical care to the vast majority in the countryside. Primary health centers and subcenters rely on trained paramedics to meet most of their needs. The main problems affecting the success of primary health centers are the predominance of clinical and curative concerns over the intended emphasis on preventive work and the reluctance of staff to work in rural areas. In addition, the integration of health services with family planning programs often causes the local population to perceive the primary health centers as hostile to their traditional preference for large families. Therefore, primary health centers often play an adversarial role in local efforts to implement national health policies.

According to data provided in 1989 by the Ministry of Health and Family Welfare, the total number of civilian hospitals for all states and union territories combined was 10,157. In 1991 there were a total of 811,000 hospital and health care facilities beds. The geographical distribution of hospitals varied according to local socio-economic conditions. In India's most populous state, Uttar Pradesh, with a 1991 population of more than 139 million, there were 735 hospitals as of 1990. In Kerala, with a 1991 population of 29 million occupying an area only one-seventh the size of Uttar Pradesh, there were 2,053 hospitals.

Although central government has set a goal of health care for all by 2000, hospitals are distributed unevenly. Private studies of India's total number of hospitals in the early 1990s were more conservative than official Indian data, estimating that in 1992 there were 7,300 hospitals. Of this total, nearly 4,000 were owned and managed by central, state, or local governments. Another 2,000, owned and managed by charitable trusts, received partial support from the government, and the remaining 1,300 hospitals, many of which were relatively small facilities, were owned and managed by the private sector. The use of state-of-the-art medical equipment was primarily limited to urban centers in the early 1990s. A network of regional cancer diagnostic and treatment facilities was being established in the early 1990s in major hospitals that were part of government medical colleges. By 1992 twenty-two such centers were in operation. Most of the 1,300 private hospitals lacked sophisticated medical facilities, although in 1992 approximately 12% possessed state-of-the-art equipment for diagnosis and treatment of all major diseases, including cancer. The fast pace of development of the private medical sector and the burgeoning middle class in the 1990s have led to the emergence of the new concept in India of establishing hospitals and health care facilities on a for-profit basis.

By the late 1980s, there were approximately 128 medical colleges - roughly three times more than in 1950. These medical colleges in 1987 accepted a combined annual class of 14,166

students. Data for 1987 show that there were 320,000 registered medical practitioners and 219,300 registered nurses. Various studies have shown that in both urban and rural areas people preferred to pay and seek the more sophisticated services provided by private physicians rather than use free treatment at public health centers.

PRIMARY HEALTH CARE It has been defined as an essential health care which should be based on practical, scientifically sound and socially acceptable methods and technology. It should be made universally accessible to the individuals and the family in the community through their full participation. It is to be made available at a cost which the community and the country can afford to maintain at every stage of its development in a spirit of self-reliance and self-determination. Primary health care is the first level of contact of the individuals, the family and the community with the national health system bringing health care as close as possible to where the people live and work. It constitutes the first element of the process of continuing health care, and this should get full support from the rest of the health system. This support would be required in the following areas: (a) consultation on health problems; (b) referral of patients to local or other specialized institutions; (c) supportive supervision and guidance; and (d) logistic support and supplies. For achieving success in HFA development, at least eight essential components of primary health care need to be properly implemented. For this the cooperation and support of other social and economic development sectors, such as education, social and women's welfare, food and agriculture, animal husbandry, water resources, housing, rural development, energy, environmental protection, industry, communication, etc. would be vital.

HEALTH SYSTEM INFRASTRUCTURE The country is divided into 22 major States and 9 smaller union territories which inturn are divided into administrative districts. At present, there are 431 districts. Each district is divided into sub-districts or talukas, under which are situated the community development blocks. There are about 6,000 community development blocks in the country. As mentioned earlier, over the past three decades the health services infrastructure and health care facilities have been expanded considerably. It is aimed to further improve the facilities as noted below

Facilities at Village Level In a village, for about 1,000 populations, there will be one health guide and one trained dai or traditional birth attendant (TBA); both will be selected from the community. They will be tra;ned at the level of the primary health centre (PHC) and the sub-centre. These two village level functionaries are to receive technical support and continuing education from *he multi-purpose health workers (male and female) posted at the sub-centre. Other administrative control and supervision should ideally be carried out by the village health committee or the village panchayat.

Facilities at PHC Level At present there is one PHC in each community development block, which covers about 1, 00,000 or more, population. It is aimed to establish one PHC for every 30,000 population by the year 1990. Many rural dispensaries are being upgraded to create the subsidiary health centers or these new PHCs. Each new PHC will have one medical officer, two health assistants - one male and one female, and the health workers and other supporting staff. For strengthening preventive and promotive aspects of health care, a new non-medical post called community health officer (CHO) will be provided at each new PHC. To date, there are about 11,000 PHCs (both old and new combined).

Facilities at Community Health Centre For a successful primary health care programme, effective referral support is to be provided. For this purpose one community health centre (CHC) will be established for every 1,00,000 population, and this centre will provide the main specialist services. The CHCs will be established either by upgrading the subdistrict /taluka hospitals or some of the block level PHCs, or by creating a new centre wherever absolutely needed.

Facilities at District Level District health organization is to be appropriately strengthened to cater to the needs of the expanding rural health and family welfare programmes. Not only the planning and implementation and monitoring of health and family welfare programmes are to be carried ou* at the district level (preferably on a decentralized basis), all the referral services from the periphery i.e. PHCs. community health centers and taluka hospitals, are to be attended to satisfactorily.

ESSENTIAL COMPONENTS OF PRIMARY HEALTH CARE In the Alma Ata Declaration, it is stated that at least the following components should be included in primary health cars: 1. Education of the people about prevailing health problems and methods of preventing and controlling them. 2. Promotion of food supply and proper nutrition. 3. Adequate supply of safe water and basic sanitation. 4. Maternal and child health care and family planning. 5. Immunization against major infectious diseases. 6. Prevention and control of locally endemic diseases. 7. Appropriate treatment of common diseases and injuries. 8. Provision of essential drugs.

5. NATIONAL RURAL & URBAN HEALTH MISSION

National urban health mission

The NUHM will meet health needs of the urban poor, particularly the slum dwellers by making available to them essential primary health care services. This will be done by investing in high-caliber health professionals, appropriate technology through PPP, and health insurance for urban poor.

Recognizing the seriousness of the problem, urban health will be taken up as a thrust area for the Eleventh Five Year Plan. NUHM will be launched with focus on slums and other urban poor. At the State level, besides the State Health Mission and State Health Society and Directorate, there would be a State Urban Health Programmed Committee. At the district level, similarly there would be a District Urban Health Committee and at the city level, a Health and Sanitation Planning Committee. At the ward slum level, there will be a Slum Cluster Health and Water and Sanitation Committee. For promoting public health and cleanliness in urban slums, the Eleventh Five Year Plan will also encompass experiences of civil society organizations (CSO) working in urban slum clusters. It will seek to build a bridge of NGO–GO partnership and develop community level monitoring of resources and their rightful use. NUHM would ensure the following:

• Resources for addressing the health problems in urban areas, especially among urban poor.

• Need based city specific urban health care system to meet the diverse health needs of the urban poor and other vulnerable sections.

• Partnership with community for a more proactive involvement in planning, implementation, and monitoring of health activities. • Institutional mechanism and management systems to meet the health-related challenges of a rapidly growing urban population.

• Framework for partnerships with NGOs, charitable hospitals, and other stakeholders.

• Two-tier system of risk pooling: (i) women’s Mahila Arogya Samiti to fulfil urgent hard-cash needs for treatments; (ii) a Health Insurance Scheme for enabling urban poor to meet medical treatment needs.

NUHM would cover all cities with a population of more than 100000. It would cover slum dwellers; other marginalized urban dwellers like rickshaw pullers, street vendors, railway and

bus station coolies, homeless people, street children, construction site workers, who may be in slums or on sites.

The existing Urban Health Posts and Urban Family Welfare Centres would continue under NUHM. They will be marked on a map and classified as the Urban Health Centres on the basis of their current population coverage. All the existing human resources will then be suitably reorganized and rationalized. These centres will also be considered for upgradation.

Intersectoral coordination mechanism and convergence will be planned between the Jawaharlal Nehru National Urban Renewal Mission (JNNURM) and the NUHM.

OR

Union Minister for Health and Family Welfare Ghulam Nabi Azad on Wednesday said the government was in the process of formulating the national urban health mission.

"We are now in the process of formulating the national urban health mission which will take care of infrastructure needs of district and subdivisional level besides divisional headquarter and state capitals," he said. He was speaking at the inauguration of a two-day conference of state health ministers.

There has been improvement in health infrastructure, referral transport and augmentation in human resources. Under the Janani Suraksha Yojana, the coverage of beneficiaries has increased from 573,000 in 2005-06 to 10 million in 2009-10, said Azad.

Presenting his ministry's report card for 2010, the minister said institutional deliveries had gone up from 47 per cent to 72 per cent during this period.

Highlighting the success of the polio drive, the health minister said that with the introduction of the biovalent polio vaccine, only 42 cases were reported in 2010, versus more than 700 cases in 2009.

Speaking on the occasion, Chief Minister of Andhra Pradesh, N Kiran Kumar Reddy said his state government intends to boost expenditure in the health sector.

He said the health budget of his state was Rs 1,680 crore in 2004 which has now gone up to Rs 4,300 crore. The Andhra Pradesh government, Reddy said, was concentrating on strengthening government hospitals and staff by giving more incentives to doctors and paramedics, he added. Over the last six years, the government has provided Rs 53,000 crore to the states under National Rural Health Mission. The utilisation of funds in all states under National Rural Health Mission has gone up from Rs 4,873 crore in 2005-06 to Rs 14,264 crore in 2009-10.

National Rural Health Mission

THE VISION OF THE MISSION

To provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. 18 special focus states are Arunachal Pradesh, Assam, Bihar, Chattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur , Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa , Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. To raise public spending on health from 0.9% GDP to 2-3% of GDP, with improved arrangement for community financing and risk pooling. To undertake architectural correction of the health system to enable it to effectively handle increased allocations and promote policies that strengthen public health management and service delivery in the country. To revitalize local health traditions and mainstream AYUSH into the public health system. Effective integration of health concerns through decentralized management at district, with determinants of health like sanitation and hygiene, nutrition, safe drinking water, gender and social concerns. Address inter State and inter district disparities. Time bound goals and report publicly on progress. To improve access to rural people, especially poor women and children to equitable, affordable, accountable and effective primary health care. To achieve these goals NRHM will: Facilitate increased access and utilization of quality health services by all. Forge a partnership between the Central, state and the local governments. Set up a platform for involving the Panchayati Raj institutions and community in the management of primary health programmes and infrastructure. Provide an opportunity for promoting equity and social justice. Establish a mechanism to provide flexibility to the states and the community to promote local initiatives. Develop a framework for promoting inter-sectoral convergence for promotive and preventive health care. The Objectives of the Mission Reduction in child and maternal mortality

Universal access to public services for food and nutrition, sanitation and hygiene and universal access to public health care services with emphasis on services addressing women’s and children’s health and universal immunization Prevention and control of communicable and non-communicable diseases, including locally endemic diseases. Access to integrated comprehensive primary health care. Population stabilization, gender and demographic balance. Revitalize local health traditions & mainstream AYUSH. Promotion of healthy life styles.

The core strategies of the Mission Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services. Promote access to improved healthcare at household level through the female health activist (ASHA). Health Plan for each village through Village Health Committee of the Panchayat. Strengthening sub-centre through better human resource development, clear quality standards, better community support and an untied fund to enable local planning and action and more Multi Purpose Workers (MPWs). Strengthening existing (PHCs) through better staffing and human resource development policy, clear quality standards, better community support and an untied fund to enable the local management committee to achieve these standards. Provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard. (IPHS defining personnel, equipment and management standards, its decentralized administration by a hospital management committee and the provision of adequate funds and powers to enable these committees to reach desired levels) Preparation and implementation of an inter sector District Health Plan prepared by the District Health Mission, including drinking water, sanitation, hygiene and nutrition. Integrating vertical Health and Family Welfare programmes at National, State, District and Block levels. Technical support to National, State and District Health Mission, for public health Management

Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision. Formulation of transparent policies for deployment and career development of human resource for health. Developing capacities for preventive health care at all levels for promoting healthy life style, reduction in consumption of tobacco and alcohol, etc. Promoting non-profit sector particularly in underserved areas. The supplementary strategies of the mission Regulation for Private sector including the informal Rural Medical Practitioners (RMP) to ensure availability of quality service to citizens at reasonable cost. Promotion of public private partnerships for achieving public health goals. Mainstreaming AYUSH – revitalizing local health traditions. Reorienting medical education to support rural health issues including regulation of medical care and medical ethics. Effective and visible risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care. OR

The purpose of NRHM among other things was to strengthen the primary health centres (PHCs) and sub-centers and creates a network of rural hospitals. However it was felt that several developments since the launch of the NRHM in April 2005 point to increased privatization of health care services. For instance in several states the NRHM under the garb of better health management opened up space to outsourcing and privatization of PHCs and subcentres.

The NRHM is criticized for adopting a system of Indian Public Health Standards which was seen as having severe limitations. While it defined the minimum manpower requirement and the equipment and infrastructure needed to attain a set of well defined health outcomes the attempts to achieve these were not comprehensive in scope and were biased largely towards reproductive and child health. The IPHS was adopted for CHCs, PHCs and district hospitals as well. However the emphasis was still on purchasing equipment and attaining standards of infrastructure development rather than raising the level of overall service provision.

The policy in some states of allowing public participation in the monitoring and administration of health care services also backfired. The Rogi Kalyan samities that were started with the intent of greater public participation in the health care system degenerated into a system of cost recovery with the introduction of user fee for many services in government hospitals. Donor agencies pushed for the user -fee system and this resulted in a reduction of state investment in

the maintenance of health care facilities. The public participation has been trivialized: it translated into better access for the privileged and the politically powerful.

Urban health statistics revealed that in many states the key indicators such as urban infant mortality rate had remained stagnant or their trend had even reversed. The specific vulnerability of urban slum dwellers the lack of basic amenities and health services for them was an area yet to be addressed. The NRHM was formally empowered to cover urban slums but in reality the coverage was negligible. Whatever urban component was there in health care ,it was in the RCH plans in a limited manner.There was no equivalent plan to set up PHCs,CHCs or sub centres in urban areas.

ASHA plan conceived as an important component of NRHM was a let down due to de-emphasizing of the workers' curative and symptomatic roles and the piece rate system of payment .While the strategy of deploying ASHAs was plausible what had not been anticipated was the inability of the existing departmental structures to implement such a large scale mobilization and the absence of support structures. The implementation of the ASHA plan was poor. The NRHM was a compulsion to show the pro-poor face of the new government. It has been found during a study conducted by Jan Swasthya Abhiyan that most of the ASHAs had yet to start work; the Anganwadi worker or the Auxiliary Nurse Midwife allocated them work. Under the NRHM the ASHA was required to be accountable to the community and not subservient to the ANM or AWW.Dalit health workers were discriminated against. In MP nearly 50% of the PHCs surveyed were being managed by non medical staff, in Bihar 30%, in Rajasthan 25% and in Jharkhand 12%.The main problems plaguing PHCs related to improper drug supply and shortage of staff.

In many of the states the PHCs and even some of the CHCs had been contracted out to NGOs under the managed care approach. This system which is in vogue in Bihar, Karnataka and Arunchal Pradesh entailed the offering of a specified package of services. There is no notion of decentralization and community management. In Gujarat under the Chiranjeevi Programme private clinics are reimbursed at fixed rates for institutional deliveries and emergency obstetric care services. The government has also contracted out peripheral health facilities and has a proposal to contract out district hospitals to corporates.Some of the private health insurance schemes supported by state governments had failed. However in some states such as Tamil Nadu and West Bengal the partnership is working well. The core of the public health system stayed within the public domain and only some of the ancillary services were contracted out.

According to Jan Kalyan Abhiyan a vast network of government run health subcentres and PHCs supported by CHCs and district hospitals is required along with a large community -health-worker force, the expansion of nursing staff and the upgrading of their skills. The notion of primary health care continues to be limited in that it is applied to RCH and a few disease control programmes.There is still reluctance to move towards the goal of comprehensive primary health care. The health policy is silent on is the need to set up a rational drug policy. All policies including NRHM had glossed over this aspect despite the fact that nearly 2/3 of all health costs go into drugs. There is no regulation of the prices of essential drugs whose list had been brought down to 30 in 2002 from 347 in 1977.

There has been lot of importance given to two vaccination initiatives-pulse polio and universal Hepatitis B vaccination. More than Rs 1000 crore is spent annually on the pulse polio programme while the budget for other vaccines in the National Immunization Programme in 2005-06 was only Rs 327 crore.

The objectives of any health policy have to be seen in the light of the Alma Ata declaration where health was not just a desired goal but one of the main harbingers of equity in society.

The government's intent in bringing changes to the health care system may be good but their implementation seems to be directed by donor directed priorities.

……………………………………………………………..

1.Advantages and disadvantages of succession planning:

Many years ago I worked for a large privately held company whose number

two executive was the presumed heir apparent for many years. Then, the

aging founder and CEO had a change of heart despite very successful

performance by that person and named his daughter to be the successor to

run the firm. The company was then split into two large independent

corporations with the number two person as CEO of a new entity that was no

longer owned by the original firm.

Since then, I’ve learned other important lessons about the advantages and

disadvantages of succession planning, which I am going to share with you

here throughout the rest of this post, but first…

Quick Summary

Key Advantages

The advantages of succession planning include the opportunity to:

Conduct a SWOT analysis of the business to determine its leadership needs

now and in the coming years

Develop a strategic Leadership Human Resource Plan that includes

comprehensive position descriptions, needs analysis and plans to bridge the

gaps

Build relationships with and carefully study the performance and behavior of

successors over a long period of time

Provide a sense of direction, stability and expectations for all key

stakeholders: employees, customers, shareholders and vendors

Retain a critically important employee who might otherwise leave if not

formally recognized as the successor

Key Disadvantages

It’s difficult to think that there might be disadvantages to succession

planning but here are some things to consider:

Appointing the wrong person can lead to a variety of problems that result in

poorer company performance and turnover

Pulling the trigger too quickly to appoint someone only to have a better

candidate appear later on

Engaging in succession planning when the business is immature may lead to

erroneous conclusions about leadership needs

A poorly conducted succession planning process will lead to poor decisions,

disharmony and ultimately poor company performance as well

2.challenges of hospital administration

FIVE CHALLENGES FOR HEALTHCARE LEADERS

Sustaining the organization's viability and mission in the face of

growing resource needs and reimbursement constraints

Most healthcare organizations are faced with an aging population,

growing numbers of uninsured and underinsured persons, the need for

costly technology, and other pressures that require greater resources.

At the same time, both governmental and private payers are

constraining reimbursement, and most organizations' income from

investments has been affected adversely by events over the past three

years. Twenty-five of the 29 responding CEOs believed these factors

represent a problem for healthcare executives, governance, and clinical

leaders who are responsible for maintaining their organizations' viability

and mission and for responding to their communities' needs. In

February, PriceWaterhouseCoopers (2003) published a report, entitled

"Cost of Caring: Key Drivers of Growth in Spending on Hospital Care,"

that informs us of the impact of these factors on hospitals. To a

considerable degree, however, the same factors affect all providers of

healthcare services and, at least indirectly, all health-related firms.

2. Meeting the multifaceted workforce crisis that exists throughout the

country

Twenty-two of the 29 responding CEOs identified workforce issues as a

principal challenge. Their deep concerns mirror the position taken by

many healthcare organizations, including the American Hospital

Association, that the healthcare industry is in the midst of a real

workforce crisis. This crisis is not simply about the short supply of

workers, although we are experiencing significant shortages of nursing

personnel, certain physician specialists, and other professional

caregivers. Other dimensions of the workforce crisis include:

* changes in the skill mix to meet new service requirements,

* high levels of dissatisfaction expressed by many nurses and other

employees about their work situation, and

* the tremendous need for care continuity in a period where

recruitment is difficult and turnover is high.

All of these elements affect the cost and quality of care. A study

prepared by the VHA (Voluntary Hospitals of America [2003]), entitled

"The Business Case for Workforce Stability," found that the average

annual turnover rate in hospitals is nearly 21 percent. The study also

documents the adverse effects of high turnover rates on cost per

discharge, severity-adjusted length of stay, return on assets, and other

quality and cost variables. This is a report worth reading. It paints a

sobering picture. The CEOs know that our problems have no easy

solutions and that we have to address their root causes, not just their

symptoms.

3. Ensuring patient safety and good clinical outcomes; reducing

variability in quality and costs; and demonstrating positive impact on

the health status of individuals, families, and communities

Over the past decade or so, there had been little evidence to indicate

that managed care programs have had a positive impact on improving

access to and quality of healthcare services or containing healthcare

costs. The Institute of Medicine (IOM) reports--Crossing the Quality

Chasm and To Err Is Human--and other studies have described serious

problems and defects in the U.S. healthcare system. As does the IOM,

the CEOs I spoke to agreed that we need to provide care that is safe,

effective, patient centered, timely, efficient, and equitable. But they

understand clearly that we are a long way from fulfilling these six aims.

Pioneering work at the University of Michigan, Dartmouth College, and

elsewhere has revealed the startling variability in levels of healthcare

utilization, quality, and cost from community to community. In the early

1980s, John Griffith of the University of Michigan acquainted me and

colleagues at the Sisters of Mercy Health Corporation with data on the

large variation in use rates among Michigan communities where the

Sisters of Mercy operated healthcare facilities. I recall our early efforts,

which were far less than adequate, to understand the underlying

reasons for the variations and to do something about them. A new study

by Elliot Fisher and colleagues (2003) at Dartmouth, entitled "The

Implications of Regional Variations in Medicare Spending-Part I: The

Content, Quality, and Accessibility of Care" (as quoted in the Wall Street

Journal [2003]) speaks graphically of this variation:

The federal Medicare Program spends about 60% more for health care

for beneficiaries in White Plains, N.Y. and Detroit than it does in

Rochester, N.Y. and Grand Rapids, Michigan. Yet the quality of care

delivered to patients living in 'high-spending' communities is no better

and in some cases worse than what people in low-spending

communities get ... a large fraction of medical care is devoted to services

that neither improve health nor quality of care.

Both healthcare leaders and the public at large are feeling a growing

discomfort with the performance, the impact, and the cost of our

nation's healthcare system. Closing the gaps and achieving measurable

improvements are great mandates for executive, clinical, and

governance leaders. It is a challenge for us in the academic community

as well.

4. Redesigning systems and processes, building new operating models,

and overcoming both technical and cultural obstacles along the way

Various reports, including those by the IOM, have illustrated the

importance of assessing and redesigning systems and processes to bring

about improvements in patient safety, quality outcomes, and costs.

Crossing the Quality Chasm strongly recommends "the systematic

identification of priority areas for improvement" (IOM 2001).

Subsequent IOM reports--Fostering Rapid Advances in Healthcare:

Learning from System Demonstrations, which was developed by a

committee chaired by Gall Warden of the Henry Ford Health System,

and Priority Areas for National Action: Transforming Healthcare Quality--

also provide useful roadmaps for moving toward improvement goals.

Great work is being done in many communities. Here are a few

examples:

* At Texas Health Resources, a multiunit system based in Arlington,

Texas, headed by Douglas Hawthorne, a strategic initiative called "The

Patient and Family Journey" is transforming processes and services

systemwide, from the point of initial contact through the care processes

to discharge and follow-up care.

* At Sentara Healthcare in Tidewater, Virginia, with David Bernd's

leadership, intensive care specialists remotely monitor ICU patients

through electronic means. This remote ICU supplements and enhances

traditional rounds and onsite monitoring. Sentara has reported that

patient mortality rates have dropped between 25 percent and 35

percent since this system was installed. In addition, Sentara has

achieved a 150 percent payback on its investment (Trustee 2003).

* With the leadership of Sister Mary Jean Ryan, SSM Health Care (based

in St. Louis, Missouri) received the Malcolm Baldrige National Quality

Award in 2003, making the system the first healthcare organization to

be so honored. SSM's strategies involved a fundamental redesign of its

systems, processes, and operating models and necessitated sustained

commitment to overcoming the cultural resistance and technical

barriers that arose during the transformation.

The CEOs spoke candidly about the vast amount of work that lies ahead.

Many feel, and I concur, that redesigning systems and processes is

necessary but not sufficient, that what is needed are entirely new

operating models.

5. Maintaining access to capital to enable needed investments in

facilities, technology, and equipment

Even with concerted efforts to improve the appropriateness of

utilization and to enhance the efficiency of existing facilities, healthcare

organizations clearly need large amounts of capital to meet the growing

demand for services, to acquire needed technology, and to redesign

existing processes. Firms like KaufmanHall and The Advisory Board and

several CEOs with whom I work believe healthcare organizations need to

generate an EBITDA (earnings before interest, taxes, depreciation, and

amortization) of at least 14 percent to maintain long-term viability.

Many organizations are not coming close to this standard. As Gary

Mecklenburg of Northwestern Memorial Healthcare stated to me:

"Healthcare will face a capital crisis in the near future and be unable to

respond to the growth in demands.... [A] lot of institutions have no

access to the debt markets and have not funded depreciation. With

limited margins, how will we replace those old Hill-Burton hospitals or

acquire contemporary technology?" Raising capital is an enormous

challenge, particularly for small institutions that are not part of strong

systems. With a broader, more diversified base, these systems are

somewhat more likely to have access to capital, at least for the near

term.

To prepare qualify and efficient administrators to manage hospitals.

To train the candidates in various methods of administration of

hospitals.

To develop better systems for effective delivery of healthcare in

hospitals.

To train the candidates in developing better leadership skills.

To train the candidates in understanding the concepts of

organizational behaviour and human resource management.

To provide the necessary skills and knowledge for practical

orientation and implementation of strategies with relation to modern

hospitals.

3.Role of private sector in health care

Private- and Public-Sector Involvement in Health Care

DELIVERY

Public Private

FINANCI

NG

Publ

ic

Insurance and service

delivery are handled by

a single public agency.

Norway, Sweden,

Denmark, Finland

The public pays for services

through taxes or social

security and the services are

provided by private agencies

(commercial or non-profit).

Canada, Japan, Germany,

France, United Kingdom

The cost is charged

directly to users

(through insurance or

Health care is funded by

private insurance or paid for

directly by the patient and is

Priv

ate

out-of-pocket

payments) but services

are provided in public

facilities.

To our knowledge, no

good examples of this

system exist.

provided in private facilities.

United States

Throughout the developing world, most health systems are characterized by

mixed public and private financing and delivery of care. In many countries,

private providers--including a plethora of different types of formal and

informal, for profit and not for profit organizations and individuals—are

more numerous than their government counterparts. Health expenditure data

show that, although the public-private mix varies significantly by country

(and information to accurately quantify this mix is scarce), more than half of

total health spending is private out-of pocket in at least 19 countries in Asia

and 15 countries in Africa, including many of the world’s most populous

nations (China, India, Pakistan, Bangladesh, Nigeria). Private providers, and

the health markets that they operate in, have the potential to both harm and

improve the health of the poor. In order to ensure that health markets and

private providers contribute to national health and financial protection goals,

governments must play an important stewardship role of their whole health

systems, including the part that they don’t directly operate, by better

regulating, managing, and incentivizing the “non-state” part of the health

sector. Meanwhile, innovative private health delivery and financing models

that show promise for improving health and financial protection can be

better nurtured.

In January 2008, the Rockefeller Foundation asked the Results for

Development Institute (R4D) to lead an effort to better understand the role

of the private sector in health systems in developing countries. In partnership

with the International Health Policy Program of the Thai Ministry of Public

Health and other health policy research organizations, R4D has worked to

identify opportunities to strengthen public/private health systems through the

collection, analysis, and dissemination of information and evidence on non-

state health care providers and funders, and on public stewardship

mechanisms designed to better harness these private actors. This effort,

drawing on the work of a wide range of academic, think tank, and consulting

partners, included the following activities:

Analysis of Demographic and Health Survey data on where people

seek care for various health issues.

Cataloguing and analysis of private sector health delivery and

financing models that some have characterized as “innovative.”

A global scan and survey of countries about their regulatory models.

A web-based survey and in-depth interviews of attitudes toward the

private health sector.

Analysis of how purchasing and contracting models can support

health systems goals.

New thinking on stewardship and how to make health markets work

better for the poor.

Macroeconomic analysis of national public and private health

spending

An analysis of the potential of the private sector to enhance health

product supply chains.

private sector including:

health ministers

representatives from governmentntelligence Unit

academia

regulators

associations

hospital administration

pharmaceutical

medical equipment

insurance

doctors and patient groups.

“private” may refer to involvement by businesses, charitable organizations

or individuals.

STRUCTURE OF PRIVATE HEALTH SECTOR

Insight into the healthcare provisioning showed that the private health sector

accounts for over 70 percent of all primary medical care and over 40 percent

of all hospital care (NSS 1987, Duggal & Amin1987, Thankappan et al

1987, NCAER 1992, George et al 1992). As per the National Health Policy

1983, the healthcare expenditure in India is 6 % of GDP of which 1.3% is

contributed by the public sector and 4.7 % is contributed by private sector.

The private sector healthcare provisioning has a pyramidal structure. The

base is formed by individual practitioners; the large middle piece consists of

small hospitals and nursing homes and the apex includes large Super

Specialty Research Centres, Public Ltd., Corporate and Trust hospitals.

Majority of the individual practitioners are usually general practitioners

(GP). They are concentrated in rural areas.

The bulk of medical care in rural India is provided through the private

practitioners who are untrained, non-graduates practicing allopathy and

providing outpatient care. The nursing homes consist of 2 to 50 bed units,

which are owned individually or in joint partnership. They generally operate

as family businesses. These centers provide outpatient as well as in patient

care. The Trust Hospitals, Corporate Hospitals, Public Ltd. and

Superspecialty Research Institutes constitute the tertiary care providers. The

private sector hospitals have 300 to 500 bed and have well trained nursing

and paraclinical support staff. These hospitals generate revenue to self

sustain and expand further. Majority of these hospitals are under private

sector and located in urban areas.

CHARACTERISTICS AND UTILIZATION PATTERNS

Based on NSS survey (1986-87) and NCAER survey (1993), a study was

conducted on the characteristic and utilization patterns of health care

facilities in rural and urban sector (Purohit and Siddiqui, 1994). It was

observed:

Majority of the outpatient services are provided by private doctors (both in

rural and urban areas) but the inpatient (IPD) care is mostly provided by the

public hospitals. The private sector possesses less than half the number

(30%) of beds than that available with the public sector (70%).

The household expenditure on curative care is 5.28% of income in rural

areas while in urban area the average is 4.29% of the income. The household

expenditure is more in rural area probably due to the traveling expenses

incurred during treatment. Interestingly, the per capita annual expenditure on

health is less in rural than in urban area.

In rural areas, people utilizing private care either belong to the affluent or to

the economically weaker class and majority are wage earners. Their

education levels are low – usually secondary school education.

In urban areas, people utilizing private health care usually belong to the

affluent class running their own businesses, salaried or wage earners. The

education standard is also higher among them - the average qualification

being graduate.

Distance Traveled for Inpatient Services

Healthcare Facility RURAL URBAN

Public 18.6

Kms.

5.7

Kms.

Private 18.7

Kms.

6.2

Kms.

For outpatient treatment or consultations, the distance travelled by rural

population is about 5.9 kms at an average while in urban area it is 2.2 kms.

A large number of private clinics are concentrated in urban areas hence

outpatient medical treatment is easily available which possibly explains the

less distance traveled by urban population. The inpatient treatment facilities

available in rural areas are almost at the same distance in public (18.6 kms.)

and private (18.7 kms.) healthcare units. In urban areas, the average distance

travelled for inpatient services is 5.7 kms. for public sector centres and 6.2

kms for private healthcare centers which is almost the same. This skewed

availability is because of majority of inpatient facilities like hospitals and

nursing homes are located in urban areas so the distance travelled is less

within urban areas. In states like AP, Bihar , Maharashtra due to better

accessibility among rural areas the average distance travelled by indoor

patient is reduced to 12 - 13 kms against the national average of 18.6 kms.

Similarly, the urban inpatient facilities are easily accessible in states of AP,

Bihar , Haryana, Kerala and Rajasthan so distance traveled is less than the

national average of 5.9 kms.

Inpatients typically face trade off: Public sector hospitals are inexpensive

while private sector hospitals provide skilled and reputed clinicians.

The care given and the availability of trained staff at the private primary care

units are not satisfactory. It was observed that the practitioners involved in

primary care were unaware of the treatment regimens, used expensive and

poor quality drugs, overprescribed diagnostic tests and used untrained and

semi trained (ANM) staff for patient care (Private Health Sector and Related

Issues, 1997). The pharmacists at these units were instrumental in

recommending drugs to patients.

In a study conducted by Priya Nanda and Dr. Rama Baru in Delhi , it was

found that majority of the nursing homes were operating as business centers.

Often, a husband-wife team of doctors runs these nursing homes. The quality

of nursing was undersupplied as untrained nurses had been recruited at lesser

salary. The major revenue earners were outpatient consultations,

investigations, obstetric cases and surgeries. Generally the patients were

satisfied with the care given to them in the private sector, as time allotted

during examination was more than that given by a public sector doctor.

In another study conducted by Dr. Rama Baru on corporate hospitals it was

found that majority of hospitals were owned by business groups and

operated as Public Ltd. / Pvt. Ltd. / Trust Hospitals . These superspecialty or

multi specialty hospitals were run as profit earning institutes. These hospitals

are catering to the middle and upper middle socio economic segment of the

society. The consultants partially share the operating costs of these institutes.

The cost of care is high by Indian standards but still cheap compared to

western medical care (for same procedures and treatments).

The expenses per illness episode for outpatients are higher in urban areas

irrespective of public or private sector. The public sector is of course

cheaper than private sector as consultations are usually free.

Similarly, the inpatient care cost is high in urban private than rural private

healthcare. Interestingly, the expenses per illness episode are high in

inpatient rural public sector than urban public because of the transportation

charges borne for transference of non-ambulatory patients to inpatient units

concentrated in urban areas.

States like Andhra Pradesh, Bihar , Karnataka and Gujarat have high rural

private inpatient healthcare costs because of poor public healthcare

infrastructure and patients need to be transferred to private inpatient units.

States like Delhi, West Bengal, Madhya Pradesh and Uttar Pradesh have

high urban private IPD healthcare cost. Majority of these affluent states are

inhabited by population, which can afford and prefers the treatment in

private sector.

RESULTS We could evaluate 458 subjects out of the targeted 600

(response rate 76.7%), 226 men and 232 women. The mean age in men was

43.2+14.6 years and women was 44.7+15.3 years. Prevalence of risk factors

in the study group is shown in Table 1. There is a high prevalence of family

history of CHD and diabetes in the study subjects. In both men and women

respectively there is a high prevalence of obesity (BMI >30 kg/m2, men

20.8%, women 32.3%), truncal obesity (77.4%, 80.2%), hypertension

(51.3%, 51.7%), diabetes (17.7%, 14.2%), lipid abnormalities, and the

metabolic syndrome (36.2%, 47.8%).

Family history of CHD was present in 45 men (19.9%) and 50 (21.6%)

women and 95 (20.7%) subjects overall. Subjects with family history of

CHD had significantly greater BMI, systolic BP, and triglycerides levels

(unpaired t-test, p < 0.05) (Table 2). Among men subjects with family

history of CHD had greater prevalence of obesity BMI > 30 kg/m2, central

obesity (waist size > 102 cm), and hypertriglyceridemia and in women the

prevalence of obesity BMI > 25 kg/m2 and central obesity was significantly

greater (chi-square test, p < 0.05). In the overall study group prevalence of

obesity BMI > 25 kg/m2, central obesity, diabetes, hypertriglyceridemia and

metabolic syndrome was significantly greater in subjects with family history

of CHD. Expenses per Illness Episode (in Rs.)

Healthcare Facility RURAL URBAN

OPD Public 49 63

Private 130 152

IPD Public 535 452

Private 1877 2318

The future for private healthcare sector looks promising. Overcrowding of

prime public facilities (secondary care hospitals) and inadequacy of ordinary

public facilities (PHC and Rural Hospitals ) in terms of medical supplies and

staff would catalyze the growth of private sector to fulfill the unmet need

(Duggal, 1994). The rising cost of medical care would necessitate health

insurance which would encourage the private sector participation.

CHALLENGES AND RECOMMENDATIONS FOR PRIVATE

SECTOR

Despite the tremendous growth of private healthcare sector, the initial fears

of policy makers remain unassuaged. The polarization among the affordable

and non –affordable population (socio-economic inequality) and the quality

of care are the issues which have surfaced up. These challenges need to be

carefully observed and analyzed. The recommendations would be based on a

holistic view to avoid any socio-economic biases.

Healthcare is always perceived to be on philanthropic lines but with the

participation of private sector, this ideology needs to be undone. The

professionals feel that they are doing a service to the mankind and they are

not accountable for it (Jesani A. and Nandraj S. 1994). They tend to forget

that for such services they are charging a fee and not providing it free!

Hence, a set of regulations needs to be adopted to avoid exploitation of

majority of population. It would be preferred if the professionals formulate

regulations to operate private nursing home and hospitals. Otherwise, the

government will have to participate in laying down guidelines, directives or

regulations to ensure quality care. The Nursing Home Act of Mumbai and

Delhi need to be revised (Nanda and Baru, 1994) and used as a backdrop for

this. Strict enforcement of these regulations is desired. Non-compliance

should result in harsh legal and capital punishments. Statutory bodies like

MCI need to be involved and defaulters must be barred from clinical

practice. Effective legislature and executive would minimize any non-

conformity. Above all, political will would result in the desired achievement.

The private healthcare units are concentrated in urban areas or centers of

affluence. These curative facilities are not uniformly located and not

accessible to all. A detailed areawise ‘need based’ planning of public and

private medical services should be undertaken to establish uniform health

care system (curative aspect) and accordingly identify pockets of private

health sector participation (“health map”). Thus, private healthcare units

would be evenly spaced unlike the present skewed conglomeration within

urban centers. Secondary and tertiary private healthcare units being

established in the rural areas should be encouraged and the government may

provide higher subsidy or infrastructure assistance for such units.

There is lack of continuous medical education programmes for these

healthcare providers. A continuous education programme for physicians

should be introduced to improve quality care.

The drug industry is totally dominated by private sector and lacks proper

legislation. Legislation to control sale of drugs and education and training

programmes for pharmacists should be made mandatory. As per the National

Drug Policy, 1994 a National Drug Authority needs to be set up. It will

assist in defining quality standards, assess that pharmaceutical products meet

India ’s medical need, monitor drug promotion and prescribing practices

among professionals (Medicines, Medical Care and Drug Policy, 1997).

The privatization of health insurance has ushered in a new concept. The

Government has already established IRDA (Insurance Regulatory

Development Authority) to regularize this sector. Minimum requirements to

operate insurance companies and TPAs (Third Party Administrators) have

also been proposed to generate confidence among the investors or public.

It has been feared that the voluntary organizations and multinationals foreign

aid agencies start dictating the health requirements and policies as per their

interests and research activities in lieu of providing financial aid. This would

result in digressing from the actual healthcare issues and need of the local

population (Health Policy, 1997. Report of the Independent Commission on

Health in India. ). Indian government needs to prioritize health needs based

on the morbidity and mortality pattern rather than by the policies of the

aiding agencies.

To curtail the high costs of allopathy, indigenous system like Ayurveda,

Unani or Siddha system of medicine need to be encouraged and promoted.

The private, corporate hospitals and nursing homes need to associate with

preventive care also. It should be mandatory for all private healthcare units

to adopt a section of the underprivileged population before starting their

treatment centers. This can be inducted as a part of the regulations for

private healthcare units.

The untrained and non-qualified practioners and quacks should be banned.

People with better / higher education e.g. school teachers may be involved in

providing emergency treatment as reinforcement agencies among healthcare

delivery units. The teachers are closely associated with the community and

are respected. Their availability is always guaranteed to the community.

At the time of inception of a private hospital, the government heavily

subsidizes land and waives off duty on equipment in lieu a certain

percentage of underprivileged population is provided free healthcare

services. This policy is not adhered by majority of the private sector

hospitals. Government should be harsher and strictly enforce this rule. As

mentioned above, apart from Medical Council of India other governmental

agencies need to be involved for compliance.

The usage of untrained staff – especially nurses, technicians etc. should be

checked. Such units should be banned, their operating incharges should be

tried in criminal courts and the public should be informed from time to time

about such delisted organizations.

The medical colleges which are run by private sector, receive government

subsidies. Such colleges should also associate with public healthcare

activities and programmes.

New legislature might increase the bottlenecks but they need to be framed to

assist in smooth and efficient disposal of work. These legislatures should

bring in accountability and quality to the existing healthcare system rather

than delays in implementation.

A central committee or an organization should be formed for monitoring

technology adoption by private sector. This would check the rising cost of

healthcare with newer technology.

The net effect of these recommendations is not to idealize the private sector

but to regularize it (since it caters to 70% of primary healthcare). The public

healthcare requires an upgradation to perform better and function

harmoniously with the private sector. The policy makers need to note that

future decisions will not be based on public or private sector alone but a mix

of public – private healthcare system.

OR

Role of Private Sector in Healthcare

India is encouraging investment in healthcare sector; over the years,

the private sector in India has gained a significant presence in all the

sub-segments of medical education and training, medical technology

and diagnostics, pharmaceutical manufacture and sale,

hospital construction and ancillary services, as also the

provisioning of medical care. Over 75% of the human resources

and advanced medical technology, 68% of estimated 15,097

hospitals and 37% of 623,819 total beds in the country are in the

private sector35.

The composition of private sector in India is diverse with large

number of sole practitioners or small nursing homes having bed

capacities of less than 20. There are also several corporate entities,

including pharmaceutical firms, and non-resident Indians (NRIs), who

have invested in the Indian healthcare sector and are providing world-

class care at a fraction of the cost compared to many developed

countries. In addition, there are also traditional healthcare providers,

such as Ayurveda and Yoga, who have set up facilities.

It is reported that there are 1369 hospitals with a bed capacity of over

53000 in India catering to the needs of traditional Indian healthcare;

about 726,000 registered practitioners are working

under the traditional healthcare system36. Indian hotels are also

entering the wellness services market offering Spas and Ayurvedic

massages, tying up with professional organizations in a range of

wellness fields.

Categories of Public and Private

Category Levels

Public Nation

Province or state

Region

Local

Private Corporate/for-profit

Small

business/entrepreneurial

Charity/non-profit

(paid employees or

volunteers)

Family/personal

4.Write about the Prospects & Challenges of Telemedicine

Telemedicine has been defined as the use of telecommunication to

provide diagnostic and therapeutic medical information and to provide

healthcare services between patient and doctor without either of them

having to travel across geographic, time, social, and cultural barriers.

In other words, telemedicine is the delivery of healthcare services,

where distance is a critical factor, by all healthcare professionals

using information and communication technologies

for the exchange of valid information for diagnosis, treatment, and

prevention of disease and injuries, research and evaluation, and for

the continuing education of healthcare providers, all in the interests of

advancing the health of individuals and their communities.

The ongoing advancement of the sensors, low-power integrated

circuits, and wired or wireless

high data-rate broadband communication services under the umbrella

of the telecommunication technology recently flickered renewed

research trends and prospects for the efficient and cost-effective

deployment of state-of-the-art technologies in telemedicine.

It is therefore worthwhile to evaluate the technologies involved in

telemedicine applications

and establish a relationship between telemedicine system analysis

and design to efficiently deliver services in a wider geographic area

depending on the bandwidth and user requirements.

This chapter therefore describes the trends and prospects of

research in telemedicine in this emerging world of broadband

convergence with a view to review and establish system design

issues in this area. First we will review the definitions of telemedicine

with some background information on the development of

telemedicine. Subsequent sections of this chapter

explore the different applications and design issues of telemedicine in

different settings of technologies.

As a part of telemedicine system development using current wireless

technologies, the system architecture of a mobile telemedicine

application is detailed thereafter. Later on, we narrate the other

research issues in telemedicine and finally summarize the

possibilities and future directions in a technical perspective.

Background

The term “telemedicine” derives from the Greek “tele” meaning “at a

distance” and the present word “medicine,” which itself derives from

the Latin “mederi” meaning “healing” (Feliciani, 2003, p. 114). A 1999

definition adopted for a Congressional briefing on telemedicine in the

USA produces a statement as follows:

Telemedicine utilizes information and telecommunication

technology to transfer medical information

for diagnosis, therapy and education.

The World Health Organization (WHO) describes the definition of

telemedicine as follows:

The practice of medical care using interactive

audiovisual and data communications including

medical care delivery, diagnosis, consultation and

treatment, as well as education and the transfer of

medical data.

In addition to patient records, medical professionals can obtain vital

signs and other reference data through telemedicine applications.

Depending on the need and availability of communications

infrastructure, telemedicine uses a variety of transmission modes

including integrated services digital network (ISDN), local area

network (LAN), asynchronous transfer mode (ATM), digital subscriber

line, satellite, microwave, digital wireless, and the Internet.

With all these ranges of technology deployment, telemedicine works

have paved the right impetus for a cost-effective telemedicine

network.

Telemedicine can be divided into two modes of operations: real-time

mode (synchronous), in which patient data are available at the

remote terminal immediately after acquisition, and store-and-forward

mode (asynchronous), which involves accessing the data at a later

time (Craig, 1999, p. 5). In the store-and-forward mode, a digital

image is taken, stored, and then forwarded to another location to a

medical specialist for consultation and avoids the simultaneous

communication between both parties in real time. Teleradiology,

where radiographic images are needed to be transferred or in

dermatology, where visually skin lesions are examined, are very good

examples of this kind of mode. Store-and-forward also includes the

asynchronous

transmission of clinical data, such as blood glucose levels and

electrocardiogram (ECG)

measurements, from one site (e.g., patient’s home) to another site

(e.g., home, health agency, hospital, or clinic).

OR

Telemedicine is defined as delivering medicine at a distance and most

commonly applies to videoconferencing. 2 Telemedicine can be used to

transmit X-ray images and scan images, view pathology slides fro ma

remote site and conduct face-toface consultations in real time.

C o n f e rences can occur between patients and doctors, as in telepsychiatry;

renal specialists can monitor patients in remote dialysis centres. Conferences

can also occur between doctors, for example remote doctors and

multidisciplinary cancer specialists in a teleoncology meeting. Remote

practices may benefit

most from enhanced patient care and educational opportunities that

telemedicine allows as meetings can be

held without spending time travelling between remote sites. GPs, specialists

and allied health workers will have to assess the usefulness of telemedicine

in their working environment.3 An overview of l a rge randomised trials

evaluating telemedicine against face-to-face care showed little evidence of

clinical benefit.4 For each application, therefore, the pros and cons should be

identified as telemedicine is evaluated for efficacy and cost effectiveness.

Experiences in countries like Cambodia, Kosova and Uzbekistan has shown

that low bandwidth can reach very remote areas. And in fact it has been said

telemedicine may have more impact in developing countries than in

developed countries. Obviously cost will be the major determining factor.

However, I think the long term benefits far outweigh the costs.

Once set up and running there are many challenges that will have to faced.

From my own experience in PNG, technical and system support must be

regular and continuous. Lack of these kind of support may lead to virus or

worm infection. A regular and reliable Internet connection is also very vital

and it must be affordable. In the PNG context, Telikom PNG may become a

partner in telemedicine in PNG so as to subsidise the cost of

telecommunication in telehealth.

A major challenge of telemedicine in developing countries will also be how

local telemedicine service providers will carry own after the “out side help”

has moved on. There are many examples in PNG where after the donor

funding agencies move on after the planned funding period (eg five years) of

project, in most instances, the locals are not able to maintain and continue

whatever that was established with donor funding. Systems have to be set up

for the telemedicine services to be self sufficient. This will also allow

softwares and hardwares used to be updated regularly.

Another thing that need consideration is that once telemedicine is set up in a

developing country, care must be taken so that the locals do not become too

dependent on the “outside” help. Telemedicine must be not be used to

replace existing health care systems in developing countries but rather must

complement them.

Questions of legal implications in case of a law suit have also been raised.

For example, if a specialist in USA makes the diagnosis of a case in Enga

province, PNG, and it turns out that the diagnosis was wrong. And knowing

Engans, they decide to take the doctor to court for professional negligence,

the question now is, under which jurisdiction will the doctor be tried? Papua

New Guinea or USA?

Having said all these, telemedicine has a lot more potential and its a new

field of medicine that is evolving with information communication

technology that seem to change daily. I think if we bear the challenges in

mind, telemedince may in fact help solve some our problems of specialists

shortage and quality health care delivery to remote areas.

INTRODUCTION

Telemedicine is a function of information and communication

technologies (ICT) that facilitates exchange of medical data to assist the

health care industry in providing services to the society more competently.

Its applications range from diagnosis, treatment, and prevention of disease,

to continuing education of medical professionals, research and evaluation.

Telemedicine is not a process aimed to replace traditional practices of

medicine. It simply acts as a partner of the industry to reduce inadequacies

in time and resources. ICT should not be viewed only as a competitive

advantage of health care organizations, but rather a fundamental commodity

intrinsic to the delivery of global health care (Iyer & Dey, 2005; Nash &

Gremmillion, 2004).

Pedigo (1997) illustrates the essence of telemedicine with the follow

example: In April 1995, a student at Peking University sent an e-mail

requesting medical assistance for a fellow student, Zhu Ling. Zhu Ling was

experiencing rapid hair loss and paralysis. An extensive online network of

physicians, toxicologists and other experts collaborated with Ling’s

physician in Beijing to respond to the SOS email. With the assistance and

suggestions from over 2,000 responses, the Beijing physician was able to

treat Ling in the best possible way and prevent death. The Zhu Ling case

was the first recorded use of the Internet to seek diagnosis and patient care

from a distance.

Telemedicine has the potential to help bridge the time and distance gaps

that can mean life or death for some patients. It can provide live video

conferencing between local, rural doctors and clinics to the necessary

specialists at a major hospital or research center. These conferences can

provide quick and accurate diagnosis and save both the patient and the

doctor time and money.

This article presents a background on telemedicine including

components, applications and benefits of telemedicine, challenges and

trends in telemedicine, and conclusion with some direction for future

research in telemedicine.

BACKGROUND

Telemedicine removes geographic barriers and is anticipated to save

money by treating patients on-site rather than in an expensive hospital

setting, improve patient care by giving health care providers access to

teaching medicine resources, and target services to populations that have

been hard to reach (remote rural areas), expensive to serve (prisons, mental

institutions), and historically neglected (urban poor). The most important

benefit of telemedicine is its ability to access patient data from any remote

location (Demiris, 2004). It is impossible to have specialists in all areas

available at all times to any given hospital or emergency care service. There

are people worldwide that live in rural and remote areas who are not able to

receive the type of care they need due to their distance from the nearest

facility that specializes in their illness. Moreover, in most developing

countries, there is a severe scarcity of medical specialists. Lack of capital,

facilities, and systems are some of the common problems faced by

developing countries. Telemedicine coupled with telecommunications can

provide a solution to some of the above problems.

The U.S. Department of Defense has been using tele-medicine

technologies to support their operations in Saudi Arabia, Kuwait,

Somalia, Haiti, Cuba, Panama, Croatia, and Macedonia (Garshnek, Logan,

& Hassell, 1997). The telemedicine project in the Persian Gulf in 1993 had

computerized tomography (CT) scanners installed in transportable modular

military hospital units and deployed in the Saudi desert just south of the Iraqi

and Kuwaiti borders. During Operation Restore Hope, physicians in Somalia

were able to communication and share medical data with specialists in

Washington DC.

Telemedicine has always played an important role in astro medicine as

well. From the 1960s, astronauts have been monitored by groups of medical

specialists through telemetry during the space operations. Currently, NASA

is making efforts to hold conferences in the micro-gravity environment

between astronauts on the orbiting space-crafts and the medical specialists

on earth (Garshnek et al., 1997). These one-way video and two-way audio

conferences would make a phenomenal difference in the safety and security

of the astronauts on board.

Treatment of inmates in the prison (Cooper, 1997) is another application

of telemedicine. It helps to maintain a secure prison system by minimizing

movement of the prisoners in case of a medical problem. The state of Iowa

has implemented a telemedicine project via which medical staff of the prison

can consult with doctors at the University of Iowa through a two-way video

conference. This system transmits captured images letting physicians located

at a remote place view a patient’s ears, throat, or skin. It also enables sharing

of x-rays and other information to help with diagnosis and follow-up care.

Telemedicine and telehealth also eliminates travel cost as well as travel

delay (Jossi, 2005). Moreover, immediate real-time access to patient data

gets rid of time lag and accelerates early detection of diseases that can

improve overall performance of the health care industry (Jossi, 2005).

Medical information shared over a network can support research

collaboration by allowing researchers to exchange findings over the

networks at no additional cost. Informational networks online also provide a

means to establish official and unofficial educational programs over a wide

area across the globe.

Components of Telemedicine

The success of telemedicine depends on how effectively the capabilities of

technology have been exploited to benefit the health care industry. Health

care industry requirements should be analyzed carefully before considering

technology as a solution. Telemedicine systems may be developed using two

key dimensions: internal and external integrations (Raghupathi & Tany,

2002). Internal integration refers to technologies that are applied to integrate

systems with one another within an organization. External integration refers

to systems and technologies interfacing with outside organizations and

agency computer systems.

The fundamental telemedicine integration should be planned to allow a

scope for future expansion if necessary. Scalability should be used as a

valuable measuring rod for every telemedicine project. The basic

components of a telemedicine project infrastructure are discussed in the

following sections.

Telecommunication

The first step is to ensure a network connecting all remote facilities in

order to communicate with each as desired. This could vary from a basic

telephone service to broadband Internet. Considering complex operations

requiring huge amounts of data being interchanged across the globe in

seconds between systems, telemedicine networks often require a high

bandwidth.Asynchronous transfer mode (ATM) coupled with resilient

synchronous optical network (SONET) has been one of the most popular

configurations from the early 2000s. It offers high-quality and low-delay

conditions. These systems are supported by fiber optic cables that allow data

to be transferred up to 40 gigabytes per second.

Mobile communication systems are also critical to tele-medicine

industry. This includes cordless, cellular, satellite, paging, and private

mobile radio systems (Ackerman, et al., 2002). Wireless technology is the

next big step for telemedicine. Wireless end users within a physician’s

office, hospital building, or even medical campus can be connected with a

wireless local area network (WLAN).

Interoperable Systems

Interoperability adds value to the system by ensuring flexibility and

cost-effectiveness (Ackerman et al., 2002). The system design should

allow stations developed by independent vendors to interact with each other.

Medical devices and other peripherals connected to one vendor’s station

should be able to interact with that of another station created by another

vendor. Systems should be further designed to allow creation of individual

stations in a plug-and-play fashion from components developed by multiple

vendors. Middleware is a possible solution to ensure interoperability with

systems.

Table 1. Telemedicine interactions and technical requirements

Applications Interaction Processes Data

Transferred

Min.

Bandwidt

h Reqd.

Telepsychiatry

Remote Surgery

* Interactive

Exams

Real time, one-way or

two-way interactive

motion video

Voice,

sound,

motion

video,

images, text

Moderate

to High

Dermatology

Cardiology

Otolaryngology

* Orthopedics

Still images or video clips

with real-time telephone

voice interaction, ‘store

and forward’ with data

acquired and sent for later

review

Voice,

sound, still

video

images, text

Low to

Moderate

Distance One-way or two-way Voice, Full

Education

* Training

real-time or delayed video sound,

motion

video,

images, text

Spectrum:

Low to

High

Health Info.

Networks

* Medical

Records

Transfer of electronic

text, image, or other data

Text, images,

documents,

related data

Low to

High

Computing Processes

Store-and-Forward: It is usually used for sending digital data between

hosts in a telemedicine network. Images taken on digital cameras or still

videos are sent as simple e-mail attachments. Depending on the data range,

computing power and speed requirements may vary from two desktops

connected to the Internet to a whole grid-enabled network.

Real-Time Video Linking: Typically higher bandwidth communication

channels (ISDN lines) are required to enable real-time processing

(Biomedical Informatics Ltd., 2003). It is the basis for “face-to-face”

consultation between patients and specialists located at two different parts of

the world. Specialized video conferencing equipments at both locations are

used to facilitate “real-time” consultation.

Computing power and speed are determined based on the combination of

processes involved in the particular telemedicine application. Table 1

illustrates the differences in the technical requirements of telemedicine in

respect to its application.

Telemedicine Equipment

There are a huge range of devices that are used in telemedicine for

acquisition, presentation, storage and delivery of medical data (Mirza

2004). In this article, a few typical equipments are discussed as follows:

Electric Phone Stethoscope is used to pass high quality auscultation

sounds over low bit rate with switches at receiving units picking

diaphragm frequency sounds. An e-steth produces phonocardiogram

by digitalizing heart and lung sounds using a sound card. The relevant

data is then attached to an email for transmission. Physicians opening

the email attachments receive the pertinent diaphragm frequency with

the phonocardiogram and sound playing in the background

automatically.

Telemedicine Video Imaging System assists diagnosis of patient

data. Special cameras with specific features to power zoom, auto

focus, frame capture, and electronic image polarization together are

used for video imaging.

Vital Signs Devices is typically used for homebound patients. It

helps in the constant monitoring of heart rate, respiratory rate, blood

pressure, and temperature of patients located in remote areas. Patient

data can be transmitted to the hospital through this machine while the

patient remains at their home or any other remote location.

APPLICATIONS OF TELEMEDICINE

Telemedicine enables health care providers to deliver efficient and cost

effective quality care to persons at some distance from the provider.

Organizations such as the European Space Agency (ESA) are providing

funding for projects to support the provision of health care services in rural

and remote areas (see Figure 1).

The most common applications of telemedicine are telecardiology,

teledentistry, teledermatology, telepathology, telepsychiatry, and

telesurgery.

Telecardiology

Telecardiology, along with ECG interpretation service, aids physicians by

providing them with instant access to cardiac assessment. Besides direct

telephone access to cardiologists, general practitioners are prepared with

hand-held, automatic standard 12-lead electrocardiogram ECG transmitters.

These 12- ECG transmitters allow for online cardiac consultations and ECG

interpretation. A full medical report including ECG signals are sent out by

the general practitioners to the cardiologists. In turn, the respective

cardiologists respond to the report with their consultation to the general

practitioners.

Teledentistry

Teledentistry benefits patients in remote locations by allowing them to get

specialized dental consultation over a network. Their dental information is

electronically sent and reviewed by dental specialists. Teledentistry

encompasses real time and offline dental care which includes diagnosis,

treatment planning, consulting and follow-up.

Figure 1. Visiting patients in their homes through telemedicine

Teledermatology

Teledermatology is the process of providing patients situated at remote

locations with dermatology consultations using information technology

mechanisms. Telemedicine is exceptionally valuable to teledermatology

since it is visual in nature, and health practitioners other than dermatologists

are poor at diagnosing skin diseases. Studies have shown that 20% of

general practitioners are not able to diagnose twenty of the most common

dermatological problems.

Telepathology

Telepathology is the transmission of digitalized histological or

macroscopic images between remote locations. It is used for diagnostic,

prognostic, quality control, research, and educational purposes. An example

of a typical telepathological structure would consist of a CCD or digital

camera connected to a microscope with a computer having a good graphics

card and software to control the images over a network. Telepathology is an

important contribution to the health care industry as it allows for faster

diagnosis and consultations by pathologists located at remote places.

Telepsychiatry

Telepsychiatry provides specialized psychiatry care or support from

remote settings. Patients, physicians, and specialists communicate with

each other by phone, fax, e-mail, the Internet, still imaging, and live

interactive two-way audio-video conferences. Video conferencing is

primarily used for clinical consultative sessions. Telepsychiatry services

include assessments, diagnosis, treatment, psychological testing, medico

legal assessment, case conferencing and management, education,

supervision, support, administration, and research. However, patient’s

privacy and confidentiality of communication are vital concerns in

telepsychiatry. Telepsy-chiatry sessions are making sincere efforts to

maintain the same standards as those followed by face-to-face consultations

to protect patient information.

Telesurgery

Telesurgery is the most interesting application of telemedi-cine.

Surgeons perform micro-surgery by manipulating the hands of a robot

(Angood, 2001). Over 2,000 brain surgeries performed by telesurgery have

been successful. Currently, the main problem is that the robotic tools do not

let surgeons feel patients’ tissues. Researchers at the Biorobotics Laboratory

at Harvard are conducting further research to enhance this issue. Sensors

enabled to send three-dimensional information to tiny pins on the surgeon’s

fingertips are being designed to let the doctors feel changes in texture or the

strength of his or her grip. This technology is being developed to be used as

a medium to detect lung tumors or to insert needles into delicate tissues.

Telecardiology, teledentistry, teledermatology, telepa-thology,

telepsychiatry, and telesurgery are only a few of the extensive list of

applications of telemedicine. However, there are several challenges of

telemedicine that it needs to overcome before being utilized to its full

potential.

TELEMEDICINE CHALLENGES

There are many issues involved with telemedicine that must be addressed

before it can be utilized or applied to its full potential. Some of these issues

include: licensure of those that provide the service over state/country lines,

insurance payment issues, privacy and security, cost and accessibility, and

industry-wide standards, especially relating to safety and liability (Kantor,

1997). Organizations such as the Sandia National Laboratories

(www.sandia.gov) are developing secure online telemedicine techniques.

Figure 2 shows Sandia’s Linda Gallagher checking her blood oxygenation

and pressure with sensors connected to a state-of-the-art unit from TelAssist

Corp.

In general the challenges of telemedicine can be broadly categorized into the

two following sections.

Figure 2. Use of online techniques at Sandia National Lab for checking

blood oxygenation and pressure

Telecommunications Challenges

In rural and underdeveloped areas, where telemedicine is most needed,

telecommunication technology is not up-to-date. Standard telephone lines do

not provide the bandwidth necessary for many telemedicine projects.

In addition, setting up telecommunication channels is an expensive mission.

Proponents of telemedicine are still not sure whether they can afford such a

huge investment solely because cost of telemedicine projects is not yet

accurately justified (Huston & Huston, 2000). Even though a large number

of prison-based teleconsultations cases have been able to show cost savings,

this data could not be used for reimbursement purposes considering its

exclusive security and transportation expenses.

Socioeconomic Challenges

Legal issues regarding physician licensing, liability, and patient

confidentiality exist. As physicians are licensed by states, there is a legal

problem when a physician consults across state lines. It is necessary for

states to engage in interstate provisions of service in order to fully benefit

from telemedicine. Currently, interstate agreements vary greatly. Several

states maintain that physicians must be licensed in both the sending and

receiving states. Other states have entered reciprocity agreements with

neighbors.

Liability is an obstacle in providing telemedicine. There is a debate

related to which physician would be liable for a poor patient outcome: the

primary care or the consulting physician. In the case of a poor outcome, it is

not clear if the patient should file suit in the residing state or in the state the

practitioner is located.

Medicaid covers telemedicine consultation in only 10 states. Medicare

will reimburse for telemedicine services provided in rural counties that are

designated as health professional shortage areas. This Medicare provision,

authored by North Dakota Senator Kent Conrad, was part of the Balanced

Budget Act of 1997 (Moreno 1998). Most commercial payers do not cover

routine telemedicine consultation. Physician reluctance and patient

apprehension are also obstacles. Some rural physicians fear the loss of

patients to urban facilities.

The public and physicians worry about the impersonality of telemedicine as

well. Differences in resources available, language, and literacy together with

cultural differences in acceptability of telemedicine are other serious

obstacles telemedicine needs to overcome.

TELEMEDICINE TRENDS

The full scope of telemedicine is currently being defined, but its future

will be driven primarily by the new economic imperatives which are

dramatically changing health care delivery. Telemedicine will not only allow

physicians and other health care workers to take better care of patients, but

will provide patients with tools to allow them to take a much more active

and effective role in taking care of themselves. There have been several

measures taken to solve the issues discussed. In the United States, the

Telecommunications Act of 1996 established supplements to the cost of

providing the necessary structure to support the technology in some rural

areas. In addition, telecommunication companies are working on projects to

connect the government with education, health care and business (Brown,

2002). There are scientific advancements such as ” intelligent clothing,”

which monitors the condition of a patient’s health then relays that

information to medical specialist. Nevertheless, these measures are still at

their development stages. The full potential of telemedicine can only be

understood when all or most of the barriers of telemedicine are eliminated.

CONCLUSION

Developing a reliable delivery system has been slow, which contributed to

the cautious pace of telemedicine in the early 90s. Reliability is an issue for

some aspects partly due to a lack of industry standards. Although the

technology appears as simple and as familiar as turning on a TV set, in fact

multiple technical elements are involved, and users must be trained to

operate the equipment. Telemedicine projects require broad-based planning,

installation, and operational support. Legal and jurisdiction issues are also a

concern for some types of telemedicine. If the diagnosis is incorrect, who is

liable: the consulting doctors or the one that is present with the patient?

Which state or country is responsible? Who gets paid by the insurance

company and how much? These are questions that are still being considered

for the future of telemedicine.

KEY TERMS

ICT (Information and Communication Technologies): Includes

computers, software, peripherals, and connections that are intended to fulfill

information processing and communications functions.

Internet: A computer network consisting of a worldwide network of

computer networks that use the network protocols to facilitate data

transmission and exchange.

ISDN (Integrated Services Digital Network): A system of digital phone

connections that allows voice and data to be transmitted simultaneously

across the world using end-to-end digital connectivity.

SONET (Synchronous Optical NETwork): The standard for synchronous

data transmission on optical media.

Telehealth: The use of ICTs to deliver health and health care services and

information over large and small distances.

Telemedicine: Derived from the Greek ‘tele’ meaning “at a distance” and

the present word “medicine” which itself derives from the Latin “mederi”

meaning”healing”.

Teleradiology: A means of transmitting radiographic patient images and

consultative text from one location to another with the use of ICTs.

Telesurgery: The use of medical technology such as robotics, sensory

devices and imaging video that allows a surgeon to operate long distance.

This technology provides doctors the full sensory experience of hands-on

surgery.

5.Mention the Health Committees appointed by Government

I mentioned that there are now eight different UN committees of

governmentappointed

independent experts, serviced by the UN Office of the High Commissioner

for Human Rights, reviewing states‟ policies and practices across a wide

range of

issues. Two deserve special mention because they are key to women‟s and

children‟s

health.

The Child Rights Committee reviews implementation of the Convention on

the Rights

of the Child that all countries in the world have signed up to (all countries

bar two).

And the Women‟s Rights Committee reviews implementation of the

Convention on

the Elimination of all form of Discrimination against Women that 186

countries have

agreed to be bound by. Because of their subject matter - and because they

are almost

universally ratified – we should use, and build upon, these international

commitments

in our work. Frankly, it would look very strange if we didn‟t.

Of course, international independent accountability arrangements are not

confined to

the UN Office of the High Commissioner for Human Rights.

For decades, ILO committees of independent experts have reviewed

whether or not

countries are complying with their obligations under a wide-range of labour-

related

international instruments and recommendations. The ILO understands

recommendations to be agreed guidelines for national action.

UNESCO also has procedures to review whether or not countries are

conforming to a

number of international instruments and recommendations falling within its

mandate.

Because one international instrument (relating to the terms and conditions of

teaching

staff) is relevant to both their mandates, the ILO and UNESCO have

established a

joint committee of twelve independent experts – six appointed by the ILO

and six by

UNESCO – to review countries‟ conduct on this issue.

UNESCO also has a joint expert group with the UN Committee on

Economic, Social

and Cultural Rights. In other words, here you have a UN specialised agency

joining

with a UN human rights treaty-body to consider the right to education.

Established in 1993, the World Bank Inspection Panel consists of three

independent

experts who determine whether or not the Bank is complying with its own

policies

and procedures, which are intended to ensure that Bank-financed operations

provide

social and environmental benefits and avoid harm to people and the

environment.

UNFPA has recently established an independent External Advisory Panel to

help the

Executive Director and senior management ensure that they are meeting

UNFPA‟s

goals and targets. I have the honour to serve on this Panel – we call

ourselves “critical

friends” of UNFPA.

Of course, WHO also has independent panels of experts to assist with its

work, such

as the independent Technical Steering Committee that, for some years, has

reviewed

and advised the Department of Child and Adolescent Health and

Development.

Recently, in light of the H1N1 pandemic, WHO established the expert

Review

Committee anticipated by the International Health Regulations (2005).

While the

5

WHO Framework Convention on Tobacco Control does not establish an

independent

review body, it is instructive for present purposes because it sets up a

process

whereby governments report, every few years, on implementation of their

commitments under the Convention.

There are numerous other diverse examples and I am not holding up any of

them as

models to be slavishly followed. Nonetheless, they confirm that independent

expert

reviews are commonplace within the United Nations.

While some of these independent arrangements are designed to ensure that

international agencies are effective and do as they said they would, others

are

designed to check whether or not governments are keeping their

international

commitments.

Q.6 Write about the Classification of hospitals

CLASSIFICATION OF HOSPITALS AND OTHER HEALTH FACILITIES

Government or Private

Government – operated and maintained partially or wholly by the

national, provincial, city or municipal government, or other political

unit; or by any department, division, board or agency thereof.

1.2. Private – privately owned, established and operated with funds

through donation, principal, investment, or other means, by any

individual, corporation, association, or organization.

General or Special

2.1. General – provides services for all types of deformity, disease,

illness or injury.

2.2. Special – primarily engaged in the provision of specific clinical

care and management. A primary care hospital, secondary care

hospital, tertiary care hospital, or infirmary, may provide special

clinical service(s).

Service Capability

3.1. Primary Care Hospital –

3.1.1. Non-departmentalized hospital that provides clinical care and

management on the prevalent diseases in the locality

3.1.2. Clinical services include general medicine, pediatrics,

obstetrics and gynecology, surgery and anesthesia

3.1.3. Provides appropriate administrative and ancillary services

(clinical laboratory, radiology, pharmacy)

3.1.4. Provides nursing care for patients who require intermediate,

moderate and partial category of supervised care for 24 hours or

longer

3.2. Secondary Care Hospital –

3.2.1. Departmentalized hospital that provides clinical care and

management on the prevalent diseases in the locality, as well as

particular forms of treatment, surgical procedure and intensive care

3.2.2. Clinical services provided in the Primary Care Hospital, as well

as specialty clinical care

3.2.3. Provides appropriate administrative and ancillary services

(clinical laboratory, radiology, pharmacy)

3.2.4. Nursing care provided in the Primary Care Hospital, as well as

total and intensive skilled care

3.3. Tertiary Care Hospital –

3.3.1. Teaching and training hospital that provides clinical care and

management on the prevalent diseases in the locality, as well as

specialized and sub-specialized forms of treatment, surgical

procedure and intensive care

3.3.2. Clinical services provided in the Secondary Care Hospital, as

well as sub-specialty clinical care

3.3.3. Provides appropriate administrative and ancillary services

(clinical laboratory, radiology, pharmacy)

3.3.4. Nursing care provided in the Secondary Care Hospital, as well

as continuous and highly specialized critical care

3.4. Infirmary – a health facility that provides emergency treatment

and care to the sick and injured, as well as clinical care and

management to mothers and newborn babies.

3.5. Birthing Home – a health facility that provides maternity service

on pre-natal and post-natal care, normal spontaneous delivery, and

care of newborn babies.

3.6. Acute-Chronic Psychiatric Care Facility – a health facility that

provides medical service, nursing care, pharmacological treatment

and psychosocial intervention for mentally ill patients.

3.7. Custodial Psychiatric Care Facility – a health facility that provides

long-term care, including basic human services such as food and

shelter, to chronic mentally ill patients.

OR

Hospitals are classified as general hospitals, convalescent hospitals,

hospitals for chronic patients, active treatment teaching psychiatric hospitals,

active treatment hospitals for alcoholism and drug addiction and regional

rehabilitation hospitals, and are graded as,

Group A hospitals, being general hospitals providing facilities for giving

instruction to medical students of any university, as evidenced by a

written agreement between the hospital and the university with which it

is affiliated, and hospitals approved in writing by the Royal College of

Physicians and Surgeons for providing post-graduate education leading to

certification or a fellowship in one or more of the specialties recognized

by the Royal College of Physicians and Surgeons;

Group B hospitals, being general hospitals having not fewer than 100

beds;

Group C hospitals, being general hospitals having fewer than 100 beds;

Group D hospitals, being hospitals that treat patients suffering from

cancer, that undertake research with respect to the causes and treatment

of cancer and that provide facilities for the instruction of medical

students;

Group E hospitals, being general rehabilitation hospitals;

Group F hospitals, being hospitals for chronic patients having not fewer

than 200 beds but not including Group R hospitals;

Group G hospitals, being hospitals for chronic patients having fewer than

200 beds but not including Group R hospitals;

Group H hospitals, being psychiatric hospitals providing facilities for

giving instruction to medical students of any university;

Group I hospitals, being hospitals for the treatment of patients suffering

from alcoholism and drug addiction;

Group J hospitals, being hospitals designated by the Minister to provide

special rehabilitation services for disabled persons in a region of Ontario

specified by the Minister for each hospital;

Group K hospitals, being separate organized facilities approved as such

by the Minister, to provide local diagnostic and treatment services in a

community or district to handicapped or disabled individuals requiring

restorative and adjustive services in an integrated and co-ordinated

program;

Group L hospitals, being hospitals for the treatment of patients suffering

from alcoholism and drug addiction and providing facilities for giving

instruction to medical students of any university as evidenced by a

written agreement between the hospital and the university with which it

is affiliated;

Group M hospitals, being hospitals that may charge and accept payment

from other hospitals for the performance of computerized axial

tomography scans;

Group N hospitals, being hospitals that may acquire and operate

magnetic resonance imaging equipment and may charge and accept

payment from other hospitals for the performance of magnetic resonance

imaging;

Group O hospitals, being hospitals used as transplantation centres;

Group P hospitals, being hospitals that may acquire and operate extra

corporeal shock wave lithotripsy equipment;

Group Q hospitals, being hospitals that may provide in vitro fertilization

services;

Group R hospitals, being facilities for chronic patients that are called

continuing care centres;

Group S hospitals, being hospitals that provide biosynthetic human

growth hormones;

Group T hospitals, being hospitals that may act as distributing centres for

drugs for cystic fibrosis treatment and that provide drug-related therapy

for cystic fibrosis treatment;

Group U hospitals, being hospitals that may act as distributing centres for

drugs for thalassemia treatment and that provide drug-related therapy for

thalassemia treatment; and

Group V hospitals, being hospitals that operate ambulatory care centres.

R.R.O. 1990, Reg. 964, s. 1 (1); O. Reg. 172/95, s. 1; O. Reg. 611/98,

s. 1; O. Reg. 321/01, s. 1.

Q.7 Mention the Objectives, of NATIONAL HEALTH POLICY

2002

OBJECTIVES

The main objective of this policy is to achieve an acceptable

standard of good health amongst the general population of

the country. The approach would be to increase access to the

decentralized public health system by establishing new

infrastructure in deficient areas, and by upgrading the

infrastructure in the existing institutions. Overriding importance

would be given to ensuring a more equitable access to health

services across the social and geographical expanse of the

country. Emphasis will be given to increasing the aggregate

public health investment through a substantially increased

contribution by the Central Government. It is expected that this

initiative will strengthen the capacity of the public health

administration at the State level to render effective service

delivery. The contribution of the private sector in providing

health services would be much enhanced, particularly for the

population group which can afford to pay for services. Primacy

will be given to preventive and first-line curative initiatives at

the primary health level through increased sectoral share of

allocation. Emphasis will be laid on rational use of drugs within

the allopathic system. Increased access to tried and tested

systems of traditional medicine will be ensured. Within these

broad objectives, NHP-2002 will endeavour to achieve the

time-bound goals mentioned in Box-IV.

The 11 objective domains

Participation and influence in society

2. Economic and social prerequisites

3. Conditions during childhood and adolescence

4. Health in working life

5. Environments and products

6. Health-promoting health services

7. Protection against communicable diseases

8. Sexuality and reproductive health

9. Physical activity

10. Eating habits and food

11. Tobacco, alcohol, illicit drugs, doping and gambling

Q.8 Explain the Marketing of Hospital services

Hospital marketing is a specialized field that deals with connecting

patients, physicians, and hospitals in mutual relationships.

HOSPITAL MARKETING MIX

PRODUCT

A product is a set of attributes assembled in an identifiable

form. The product is the central component of any

marketing mix. The product component of the marketing

mix deals with a variety of issues relating to development,

presentation and management of the product which is to be

offered to the market place. It covers issues such as service

package, core services and peripherals, managing service

offering and developing service offering.

Hospitals today offer the following services:

1. Emergency services – Emergency services and care at

most of the hospitals is unique and advanced. The hospitals

have state-of-the-art ambulances. The CCU's on Wheels

under supervision by medical and para-medical staff. There

is hi-tech telecommunication available to a patient in an

emergency at any given time.

2. Ambulance services – Hi-tech ambulances linked by

state-of-the-art telecommunications are fully equipped with

doctors that are available to render medical attention and

assistance in case of emergencies at the patient's doorstep.

3. Diagnostic services – Modern Hospitals are multi-

speiality and multi-disciplinary, that can handle any kind of

ailment, they offer a wide range of facilities for instance,

Oncology, Orthopedics, Neurology, Plastic surgery and so

on.

4. Pharmacy services – Most of the hospitals also have a

pharmacy which is open 24 hours. It caters to the needs

not only of the inpatients and outpatients, but also patients

from other hospitals who require emergency drugs.

5. Causality services – Causality service includes a 24

hrs. causality department, which attends to the accident or

emergency cases.

Apart from the above mentioned services, hospital also

offers "Health Diagnosis Programme" which is a complete,

comprehensive, periodic health check up offered for busy

executives, professionals, business persons and so on. The

health diagnosis programme comprises of the following:

1. Master health check up

2. Executive Health check up

3. Diabetics health check ups etc.,

Generally, the service offering in a hospital comprises of the

following levels:

1. Core level – it comprises of the basic treatment facilities

and services offered by the hospital like diagnostic services,

emergency services, casuality services etc.

2. Expected level – it comprises of cleanliness and hygiene

levels maintained in the hospital.

3. Augmented level – it comprises of dress code for staff, air

conditioning of the hospital, use of state of art technology,

services of renowned consultants.

Or

NOW YOU MUST PROFILE THE MARKET SEGMENT BY CUSTOMERS

Market needs should be interpreted very broadly, in terms far broader than

only product characteristics. Customers and prospects may differ also in

their needs for information, re-assurance, technical support, service,

distribution, and a host of other benefits that are part of their purchase.

1. MARKET SIZE FOR EACH PRODUCT

It is difficult to see how marketing can be properly planned unless the

relationship of the company's product sales to the total market sales is

known.

2. COMPETITIVE STRUCTURE FOR EACH PRODUCT

The competitive structure also effects the opportunity to force a change in

market structure, this information is vital.

3. MARKET TRENDS FOR EACH PRODUCT

This is the most important of all information, which is needed to assess the

opportunities for increased profits. There are three critical areas to review:

(A) MARKET TREND:

1.IS THE MARKET GROWING RAPIDLY?

This should provide the change for good profits

on growing sales.

2.IS THE MARKET STATIC?

This is often highly competitive, with

corresponding low profit margins.

3.IS THE MARKET DECLINING?

This, again, is often highly competitive, with

correspondingly low profit margins, is not only

due to competition but also due to higher

overheads on a smaller volume.

(B) PRODUCT SERVICE VOLUME TREND:

1. IS THE SERVICE VOLUME AT THE DEVELOPMENT STAGE? Accelerate the

sales, exploit this stage and increase the profit level.

2.IS THE SALES VOLUME AT THE GROWTH STAGE?

Stretch this stage of the product cycle through

proper promotions.

3.IS THE SALES VOLUME AT THE MATURITY LEVEL?

Stretch this stage by innovation of the product

or extending into a new market.

4.IS THIS SERVICE VOLUME AT THE DECLINING LEVEL? This stage needs

complete rethinking - product, market, channel and sales operation.

(C) PRODUCT UNIT PROFIT TREND

Unit contribution trend has different structure. It normally peaks-out

before the end of the "growth" stage of the product life cycle and then

drops rapidly. This "change point" in the curve is the most important point

of the life cycle to identify.

Q.9 What are the Legal Issues for Hospital Administrators

Definition

Hospital administration is a phrase used to describe those professionals who

choose to be a part of upper management in organized hospitals.

Hospital administrators spend a significant amount of time addressing legal

issues including contracts, partnerships, joint ventures, joint operating

agreements, group purchasing, and management contracts.

There are multiple skills needed for effective hospital administration.

Knowledge of basic leadership skills and organizational management is

required along with an understanding of organizational culture, i.e., the

unwritten rules that determine how an organization operates as a separate

system. The hospital administrator provides leadership and strategic

directions within the organization to insure continuity and targeted growth

over time. People-skills is a phrase used to describe someone who interacts

positively with others at all levels. Administrators use people-skills along

with an effective communication style to deal with issues in human

resources, negotiation, and conflict resolution. Ability to interact positively

with the Board of Directors/Trustees, the varied specialty physician groups,

allied health care providers, paid staff in general, and the public is essential.

Intermixed with the above skills, an administrator uses marketing expertise

to ensure that the organization is meeting its market share in providing

care. Administrators often interact with patients and families to determine

if the organization is meeting patient/family expectations. Also, the

administrator must be concerned with maintaining a positive image for the

organization and must be able to maintain effective public relations within

the community.

10.Role of natural justice in hospital

Natural justice or procedural fairness is a legal philosophy used in some

jurisdictions in the determination of just, or fair, processes in legal

proceedings. The concept is very closely related to the principle of natural

law (Latin: lex naturalis) which has been applied as a philosophical and

practical principle in the law in several common law jurisdictions,

particularly in the UK, Canada and Australia.[1][2]

In common law legal systems the term natural justice refers to two specific

legal principles.

Natural justice includes the notion of procedural fairness and may

incorporate the following guidelines:

A Right to Advanced Warning. Contractual obligations depriving

individuals of their Rights cannot be imposed retrospectively.

A person accused of a crime, or at risk of some form of loss, should be given

adequate notice about the proceedings (including any charges).

A person making a decision should declare any personal interest they may

have in the proceedings.

A person who makes a decision should be unbiased and act in good faith. He

or she therefore cannot be one of the parties in the case, or have an interest

in the outcome. This is expressed in the Latin maxim, nemo iudex in causa

sua: "no man is permitted to be judge in his own cause".

Proceedings should be conducted so they are fair to all the parties -

expressed in the Latin maxim audi alteram partem: "let the other side be

heard".

Each party to a proceeding is entitled to ask questions and contradict the

evidence of the opposing party.

A decision-maker should take into account relevant considerations and

extenuating circumstances, and ignore irrelevant considerations.

Justice should be seen to be done. If the community is satisfied that justice

has been done, they will continue to place their faith in the courts.[4]

11.Environmental protection act 1986

THE ENVIRONMENT (PROTECTION) ACT, 1986

The main objective of this Act is to provide the protection and improvement

of environment (which includes water, air, land, human being, other living

creatures, plants, micro-organism and properties) and for matters connected

therewith. There is a constitutional provision also for the environment

protection. Article 48A, specify that the State shall endeavour to protect and

improve the environment and to safeguard the forests and wildlife of the

country and every citizen shall protect the environment (51 A). The

Environment (Protection) Act is applicable to whole of India including

Jammu & Kashmir.

Environment: It includes water, air, and land and the inter-relationship

which exists among and between water, air and land and human beings,

other living creatures, plants, micro-organism and property.

Environmental Pollution: It means any solid, liquid or gaseous substances

present in such concentration as may be or tend to be injurious to

environment and human being are known as pollutant and presence of any

pollutant in the environment in such proportion and concentration that has

bearing on health and environment is termed as "Environmental Pollution".

Handling: In relation to any substance, it means the manufacturing,

processing, treatment, packaging, storage, transportation, use, collection,

destruction, conversion, offering for sale, etc.

Occupier: It means a person who has control over the affairs of the factory

or the premises, and includes, in relation to any substance, the person in

possession of the substance.

The Act provide power to make rules to regulate environmental pollution, to

notify standards and maximum limits of pollutants of air, water, and soil for

various areas and purposes, prohibition and restriction on the handling of

hazardous substances and location of industries (Sections 3-6).

The Central Government is empowered to constitute authority or authorities

for the purpose of exercising of performing such of the powers and functions

(Sec 3), appoint a person for inspection (Sec 4), for analysis or samples and

for selection or notification of environmental laboratories. Such person or

agency has power to inspect or can enter in the premises or can take samples

for analysis (Secs 10, 11).

According to the section 5, the Central Government may issue directions in

writing to any person or officers or any authority to comply. There could be

closure, prohibition of the supply of electricity or operation or process; or

stoppage or regulation of the supply of electricity or water or any other

service.

Section 6 empower the government to make rules to achieve the object of

the Act.

Persons carrying on industry, operation etc. not to allow emission or

discharge of environmental pollutants in excess of the standards (Sec 7).

Persons handling hazardous substances must comply with procedural

safeguards (Sec 8) and occupiers must furnish the information to authority.

Penalty

Whoever Person or Owner/Occupier of companies, factories or whichever

source found to be the cause of pollution may be liable for punishment for a

term which may extend to five years or with fine which may extend to one

lakh rupees or both (Sec 15, 16, 17). If not comply fine of Rs. 5000 per day

extra and if not comply for more than one year then imprisonment may

extend up to 7 years. Section 17 specify that Head of the department/ in-

charge of small unit may be liable for punishment if the owner /occupier

produce enough evidence of innocence. The CPCB or state boards have

power to close or cancel or deny the authorisation to run the

factory/institution/hospital whichever is causing pollution. No suit,

prosecution or other legal proceedings shall lie against govt. officer who has

exercise power in good faith in pursuance of this Act (Sec 18).

OR

THE ENVIRONMENT (PROTECTION) ACT, 1986

No. 29 OF 1986

[23rd May, 1986.]

An Act to provide for the protection and improvement of environment and

for matters connected there with:

WHEREAS the decisions were taken at the United NationsConference on

the Human Environment held at Stockholm in June, 1972, in which India

participated, to take appropriate steps for the protection and improvement of

human environment;

AND WHEREAS it is considered necessary further to implement the

decisions aforesaid in so far as they relate to the protection and improvement

of environment and the prevention of hazards to human beings, other living

creatures, plants and property;

BE it enacted by Parliament in the Thirty-seventh Year of the Republic of

India as follows:-

CHAPTER I

PRELIMINARY

1.SHORT TITLE, EXTEND AND COMMENCEMENT

This Act may be called the Environment (Protection) Act, 1986.

It extends to the whole of India.

It shall come into force on such date as the Central Government may, by

notification in the Official Gazette, appoint and different dates may be

appointed for different provisions of this Act and for different areas.1

2.DEFINITIONS

In this Act, unless the context otherwise requires,--

"environment" includes water, air and land and the inter- relationship

which exists among and between water, air and land, and human beings,

other living creatures, plants, micro-organism and property;

"environmental pollutant" means any solid, liquid or gaseous substance

present in such concentration as may be, or tend to be, injurious to

environment;

"environmental pollution" means the presence in the environment of any

environmental pollutant;

"handling", in relation to any substance, means the manufacture,

processing, treatment, package, storage, transportation, use, collection,

destruction, conversion, offering for sale, transfer or the like of such

substance;

"hazardous substance" means any substance or preparation which, by

reason of its chemical or physico-chemical properties or handling, is

liable to cause harm to human beings, other living creatures, plant, micro-

organism, property or the environment;

"occupier", in relation to any factory or premises, means a person who

has, control over the affairs of the factory or the premises and includes in

relation to any substance, the person in possession of the substance;

"prescribed" means prescribed by rules made under this Act.

CHAPTER II

GENERAL POWERS OF THE CENTRAL GOVERNMENT

POWER OF CENTRAL GOVERNMENT TO TAKE

MEASURES TO PROTECT AND IMPROVE ENVIRONMENT

Subject to the provisions of this Act, the Central Government, shall have the

power to take all such measures as it deems necessary or expedient for the

purpose of protecting and improving the quality of the environment and

preventing controlling and abating environmental pollution.

In particular, and without prejudice to the generality of the provisions of

sub-section (1), such measures may include measures with respect to all or

any of the following matters, namely:--

co-ordination of actions by the State Governments, officers and other

authorities--

under this Act, or the rules made thereunder, or

under any other law for the time being in force which is relatable to the

objects of this Act;

(ii) planning and execution of a nation-wide programme for the prevention,

control and abatement of environmental pollution;

(iii) laying down standards for the quality of environment in its various

aspects;

(iv) laying down standards for emission or discharge of environmental

pollutants from various sources whatsoever:

Provided that different standards for emission or discharge may be laid down

under this clause from different sources having regard to the quality or

composition of the emission or discharge of environmental pollutants from

such sources;

restriction of areas in which any industries, operations or processes or

class of industries, operations or processes shall not be carried out or

shall be carried out subject to certain safeguards;

(vi) laying down procedures and safeguards for the prevention of accidents

which may cause environmental pollution and remedial measures for such

accidents;

(vii) laying down procedures and safeguards for the handling of hazardous

substances;

(viii) examination of such manufacturing processes, materials and

substances as are likely to cause environmental pollution;

(ix) carrying out and sponsoring investigations and research relating to

problems of environmental pollution;

inspection of any premises, plant, equipment, machinery, manufacturing

or other processes, materials or substances and giving, by order, of such

directions to such authorities, officers or persons as it may consider

necessary to take steps for the prevention, control and abatement of

environmental pollution;

(xi) establishment or recognition of environmental laboratories and institutes

to carry out the functions entrusted to such environmental laboratories and

institutes under this Act;

(xii) collection and dissemination of information in respect of matters

relating to environmental pollution;

(xiii) preparation of manuals, codes or guides relating to the prevention,

control and abatement of environmental pollution;

(xiv) such other matters as the Central Government deems necessary or

expedient for the purpose of securing the effective implementation of the

provisions of this Act.

The Central Government may, if it considers it necessary or expedient so to

do for the purpose of this Act, by order, published in the Official Gazette,

constitute an authority or authorities by such name or names as may be

specified in the order for the purpose of exercising and performing such of

the powers and functions (including the power to issue directions under

section 5) of the Central Government under this Act and for taking measures

with respect to such of the matters referred to in sub-section (2) as may be

mentioned in the order and subject to the supervision and control of the

Central Government and the provisions of such order, such authority or

authorities may exercise and powers or perform the functions or take the

measures so mentioned in the order as if such authority or authorities had

been empowered by this Act to exercise those powers or perform those

functions or take such measures.

4. APPOINTMENT OF OFFICERS AND THEIR POWERS AND

FUNCTIONS

Without prejudice to the provisions of sub-section (3) of section 3, the

Central Government may appoint officers with such designation as it thinks

fit for the purposes of this Act and may entrust to them such of the powers

and functions under this Act as it may deem fit.

The officers appointed under sub-section (1) shall be subject to the general

control and direction of the Central Government or, if so directed by that

Government, also of the authority or authorities, if any, constituted under

sub- section (3) of section 3 or of any other authority or officer.

5. POWER TO GIVE DIRECTIONS

Notwithstanding anything contained in any other law but subject to the

provisions of this Act, the Central Government may, in the exercise of its

powers and performance of its functions under this Act, issue directions in

writing to any person, officer or any authority and such person, officer or

authority shall be bound to comply with such directions.3

Explanation--For the avoidance of doubts, it is hereby declared that the

power to issue directions under this section includes the power to direct--

the closure, prohibition or regulation of any industry, operation or

process; or

stoppage or regulation of the supply of electricity or water or any other

service.

6. RULES TO REGULATE ENVIRONMENTAL POLLUTION

The Central Government may, by notification in the Official Gazette, make

rules in respect of all or any of the matters referred to in section 3.

In particular, and without prejudice to the generality of the foregoing power,

such rules may provide for all or any of the following matters, namely:--

the standards of quality of air, water or soil for various areas and

purposes;4

the maximum allowable limits of concentration of various environmental

pollutants (including noise) for different areas;

the procedures and safeguards for the handling of hazardous substances;5

the prohibition and restrictions on the handling of hazardous substances

in different areas;6

the prohibition and restriction on the location of industries and the

carrying on process and operations in different areas;7

the procedures and safeguards for the prevention of accidents which may

cause environmental pollution and for providing for remedial measures

for such accidents.8

CHAPTER III

PREVENTION, CONTROL, AND ABATEMENT OF

ENVIRONMENTAL POLLUTION

7. PERSONS CARRYING ON INDUSTRY OPERATION, ETC., NOT

TO ALLOW EMISSION OR DISCHARGE OF ENVIRONMENTAL

POLLUTANTS IN EXCESS OF THE STANDARDS

No person carrying on any industry, operation or process shall discharge or

emit or permit to be discharged or emitted any environmental pollutants in

excess of such standards as may be prescribed.9

8. PERSONS HANDLING HAZARDOUS SUBSTANCES TO

COMPLY WITH PROCEDURAL SAFEGUARDS

No person shall handle or cause to be handled any hazardous substance

except in accordance with such procedure and after complying with such

safeguards as may be prescribed.10

9. FURNISHING OF INFORMATION TO AUTHORITIES AND

AGENCIES IN CERTAIN CASES

Where the discharge of any environmental pollutant in excess of the

prescribed standards occurs or is apprehended to occur due to any accident

or other unforeseen act or event, the person responsible for such discharge

and the person in charge of the place at which such discharge occurs or is

apprehended to occur shall be bound to prevent or mitigate the

environmental pollution caused as a result of such discharge and shall also

forthwith--

intimate the fact of such occurrence or apprehension of such occurrence;

and

be bound, if called upon, to render all assistance,

to such authorities or agencies as may be prescribed.11

On receipt of information with respect to the fact or apprehension on any

occurrence of the nature referred to in sub-section (1), whether through

intimation under that sub-section or otherwise, the authorities or agencies

referred to in sub-section (1) shall, as early as practicable, cause such

remedial measures to be taken as necessary to prevent or mitigate the

environmental pollution.

The expenses, if any, incurred by any authority or agency with respect to the

remedial measures referred to in sub-section (2), together with interest (at

such reasonable rate as the Government may, by order, fix) from the date

when a demand for the expenses is made until it is paid, may be recovered

by such authority or agency from the person concerned as arrears of land

revenue or of public demand.

10. POWERS OF ENTRY AND INSPECTION

Subject to the provisions of this section, any person empowered by the

Central Government in this behalf12 shall have a right to enter, at all

reasonable times with such assistance as he considers necessary, any place--

for the purpose of performing any of the functions of the Central

Government entrusted to him;

for the purpose of determining whether and if so in what manner, any

such functions are to be performed or whether any provisions of this Act

or the rules made thereunder orany notice, order, direction or

authorisation served, made, given or granted under this Act is being or

has been complied with;

for the purpose of examining and testing any equipment, industrial plant,

record, register, document or any other material object or for conducting

a search of any building in which he has reason to believe that an offence

under this Act or the rules made thereunder has been or is being or is

about to be committed and for seizing any such equipment, industrial

plant, record, register, document or other material object if he has reason

to believe that it may furnish evidence of the commission of an offence

punishable under this Act or the rules made thereunder or that such

seizure is necessary to prevent or mitigate environmental pollution.

Every person carrying on any industry, operation or process of handling any

hazardous substance shall be bound to render all assistance to the person

empowered by the Central Government under sub-section (1) for carrying

out the functions under that sub-section and if he fails to do so without any

reasonable cause or excuse, he shall be guilty of an offence under this Act.

If any person wilfully delays or obstructs any persons empowered by the

Central Government under sub-section (1) in the performance of his

functions, he shall be guilty of an offence under this Act.

The provisions of the Code of Criminal Procedure, 1973, or, in relation to

the State of Jammu and Kashmir, or an area in which that Code is not in

force, the provisions of any corresponding law in force in that State or area

shall, so far as may be, apply to any search or seizures under this section as

they apply to any search or seizure made under the authority of a warrant

issued under section 94 of the said Code or as the case may be, under the

corresponding provision of the said law.

11. POWER TO TAKE SAMPLE AND PROCEDURE TO BE

FOLLOWED IN CONNECTION THEREWITH

The Central Government or any officer empowered by it in this behalf,13

shall have power to take, for the purpose of analysis, samples of air, water,

soil or other substance from any factory, premises or other place in such

manner as may be prescribed.14

The result of any analysis of a sample taken under sub-section (1) shall not

be admissible in evidence in any legal proceeding unless the provisions of

sub-sections (3) and (4) are complied with.

Subject to the provisions of sub-section (4), the person taking the sample

under sub-section (1) shall--

serve on the occupier or his agent or person in charge of the place, a

notice, then and there, in such form as may be prescribed, of his intention

to have it so analysed;

in the presence of the occupier of his agent or person, collect a sample for

analysis;

cause the sample to be placed in a container or containers which shall be

marked and sealed and shall also be signed both by the person taking the

sample and the occupier or his agent or person;

send without delay, the container or the containers to the laboratory

established or recognised by the Central Government under section 12.

When a sample is taken for analysis under sub-section (1) and the person

taking the sample serves on the occupier or his agent or person, a notice

under clause (a) of sub-section (3), then,--

in a case where the occupier, his agent or person wilfully absents himself,

the person taking the sample shall collect the sample for analysis to be

placed in a container or containers which shall be marked and sealed and

shall also be signed by the person taking the sample, and

in a case where the occupier or his agent or person present at the time of

taking the sample refuses to sign the marked and sealed container or

containers of the sample as required under clause (c) of sub-section (3),

the marked and sealed container or containers shall be signed by the

person taking the samples, and the container or containers shall be sent

without delay by the person taking the sample for analysis to the

laboratory established or recognised under section 12 and such person

shall inform the Government Analyst appointed or recognised under

section 12 in writing, about the wilfull absence of the occupier or his

agent or person, or, as the case may be, his refusal to sign the container or

containers.

12.ENVIRONMENTAL LABORATORIES

The Central Government15 may, by notification in the Official Gazette,--

establish one or more environmental laboratories;

recognise one or more laboratories or institutes as environmental

laboratories to carry out the functions entrusted to an environmental

laboratory under this Act.16

The Central Government may, by notification in the Official Gazette, make

rules specifying--

the functions of the environmental laboratory;17

the procedure for the submission to the said laboratory of samples of air,

water, soil or other substance for analysis or tests, the form of the

laboratory report thereon and the fees payable for such report;18

such other matters as may be necessary or expedient to enable that

laboratory to carry out its functions.

13. GOVERNMENT ANALYSTS

The Central Government may by notification in the Official Gazette, appoint

or recognise such persons as it thinks fit and having the prescribed

qualifications19 to be Government Analysts for the purpose of analysis of

samples of air, water, soil or other substance sent for analysis to any

environmental laboratory established or recognised under sub-section (1) of

section 12.

14. REPORTS OF GOVERNMENT ANALYSTS

Any document purporting to be a report signed by a Government analyst

may be used as evidence of the facts stated therein in any proceeding under

this Act.

15. PENALTY FOR CONTRAVENTION OF THE PROVISIONS OF

THE ACT AND THE RULES, ORDERS AND DIRECTIONS

Whoever fails to comply with or contravenes any of the provisions of this

Act, or the rules made or orders or directions issued thereunder, shall, in

respect of each such failure or contravention, be punishable with

imprisonment for a term which may extend to five years with fine which

may extend to one lakh rupees, or with both, and in case the failure or

contravention continues, with additional fine which may extend to five

thousand rupees for every day during which such failure or contravention

continues after the conviction for the first such failure or contravention.

If the failure or contravention referred to in sub-section (1) continues beyond

a period of one year after the date of conviction, the offender shall be

punishable with imprisonment for a term which may extend to seven years.

16. OFFENCES BY COMPANIES

Where any offence under this Act has been committed by a company, every

person who, at the time the offence was committed, was directly in charge

of, and was responsible to, the company for the conduct of the business of

the company, as well as the company, shall be deemed to be guilty of the

offence and shall be liable to be proceeded against and punished

accordingly:

Provided that nothing contained in this sub-section shall render any such

person liable to any punishment provided in this Act, if he proves that the

offence was committed without his knowledge or that he exercised all due

diligence to prevent the commission of such offence.

Notwithstanding anything contained in sub-section (1), where an offence

under this Act has been committed by a company and it is proved that the

offence has been committed with the consent or connivance of, or is

attributable to any neglect on the part of, any director, manager, secretary or

other officer of the company, such director, manager, secretary or other

officer shall also deemed to be guilty of that offence and shall be liable to be

proceeded against and punished accordingly.

Explanation--For the purpose of this section,--

"company" means any body corporate and includes a firm or other

association of individuals;

"director", in relation to a firm, means a partner in the firm.

17. OFFENCES BY GOVERNMENT DEPARTMENTS

Where an offence under this Act has been committed by any Department of

Government, the Head of the Department shall be deemed to be guilty of the

offence and shall be liable to be proceeded against and punished

accordingly.

Provided that nothing contained in this section shall render such Head of the

Department liable to any punishment if he proves that the offence was

committed without his knowledge or that he exercise all due diligence to

prevent the commission of such offence.

Notwithstanding anything contained in sub-section (1), where an offence

under this Act has been committed by a Department of Government and it is

proved that the offence has been committed with the consent or connivance

of, or is attributable to any neglect on the part of, any officer, other than the

Head of the Department, such officer shall also be deemed to be guilty of

that offence and shall be liable to be proceeded against and punished

accordingly.

CHAPTER IV

MISCELLANEOUS

18. PROTECTION OF ACTION TAKEN IN GOOD FAITH

No suit, prosecution or other legal proceeding shall lie against the

Government or any officer or other employee of the Government or any

authority constituted under this Act or any member, officer or other

employee of such authority in respect of anything which is done or intended

to be done in good faith in pursuance of this Act or the rules made or orders

or directions issued thereunder.

19. COGNIZANCE OF OFFENCES

No court shall take cognizance of any offence under this Act except on a

complaint made by--

the Central Government or any authority or officer authorised in this

behalf by that Government,20 or

any person who has given notice of not less than sixty days, in the

manner prescribed, of the alleged offence and of his intention to make a

complaint, to the Central Government or the authority or officer

authorised as aforesaid.

20. INFORMATION, REPORTS OR RETURNS

The Central Government may, in relation to its function under this Act, from

time to time, require any person, officer, State Government or other

authority to furnish to it or any prescribed authority or officer any reports,

returns, statistics, accounts and other information and such person, officer,

State Government or other authority shall be bound to do so.

21. MEMBERS, OFFICERS AND EMPLOYEES OF THE

AUTHORITY CONSTITUTED UNDER SECTION 3 TO BE PUBLIC

SERVANTS

All the members of the authority, constituted, if any, under section 3 and all

officers and other employees of such authority when acting or purporting to

act in pursuance of any provisions of this Act or the rules made or orders or

directions issued thereunder shall be deemed to be public servants within the

meaning of section 21 of the Indian Penal Code (45 of 1860).

22. BAR OF JURISDICTION

No civil court shall have jurisdiction to entertain any suit or proceeding in

respect of anything done, action taken or order or direction issued by the

Central Government or any other authority or officer in pursuance of any

power conferred by or in relation to its or his functions under this Act.

23. POWERS TO DELEGATE

Without prejudice to the provisions of sub-section (3) of section 3, the

Central Government may, by notification in the Official Gazette, delegate,

subject to such conditions and limitations as may be specified in the

notifications, such of its powers and functions under this Act [except the

powers to constitute an authority under sub-section (3) of section 3 and to

make rules under section 25] as it may deem necessary or expedient, to any

officer, State Government or other authority.

24. EFFECT OF OTHER LAWS

Subject to the provisions of sub-section (2), the provisions of this Act and

the rules or orders made therein shall have effect notwithstanding anything

inconsistent therewith contained in any enactment other than this Act.

Where any act or omission constitutes an offence punishable under this Act

and also under any other Act then the offender found guilty of such offence

shall be liable to be punished under the other Act and not under this Act.

25. POWER TO MAKE RULES

The Central Government may, by notification in the Official Gazette, make

rules for carrying out the purposes of this Act.

In particular, and without prejudice to the generality of the foregoing power,

such rules may provide for all or any of the following matters, namely--

the standards in excess of which environmental pollutants shall not be

discharged or emitted under section 7;21

the procedure in accordance with and the safeguards in compliance with

which hazardous substances shall be handled or caused to be handled

under section 8;22

the authorities or agencies to which intimation of the fact of occurrence

or apprehension of occurrence of the discharge of any environmental

pollutant in excess of the prescribed standards shall be given and to

whom all assistance shall be bound to be rendered under sub-section (1)

of section 9;23

the manner in which samples of air, water, soil or other substance for the

purpose of analysis shall be taken under sub-section (1) of section 11;24

the form in which notice of intention to have a sample analysed shall be

served under clause (a) of sub section (3) of section 11;25

the functions of the environmental laboratories,26 the procedure for the

submission to such laboratories of samples of air, water, soil and other

substances for analysis or test;27 the form of laboratory report; the fees

payable for such report and other matters to enable such laboratories to

carry out their functions under sub-section (2) of section 12;

the qualifications of Government Analyst appointed or recognised for the

purpose of analysis of samples of air, water, soil or other substances

under section 13;28

the manner in which notice of the offence and of the intention to make a

complaint to the Central Government shall be given under clause (b) of

section 19;29

the authority of officer to whom any reports, returns, statistics, accounts

and other information shall be furnished under section 20;

any other matter which is required to be, or may be, prescribed.

26. RULES MADE UNDER THIS ACT TO BE LAID BEFORE

PARLIAMENT

Every rule made under this Act shall be laid, as soon as may be after it is

made, before each Hose of Parliament, while it is in session, for a total

period of thirty days which may be comprised in one session or in two or

more successive sessions, and if, before the expiry of the session

immediately following the session or the successive sessions aforesaid, both

Houses agree in making any modification in the rule or both Houses agree

that the rule should not be made, the rule shall thereafter have effect only in

such modified form or be of no effect, as the case may be; so, however, that

any such modification or annulment shall be without prejudice to the validity

of anything previously done under that rule.

1 It came into force in the whole of India on 19th November, 1986 vide

Notification No. G.S.R. 1198(E) dated 12-11-86 published in the Gazette of

India No. 525 dated 12-11-86.

2 The Central Government has delegated the powers vested m it under

section 5 of the -Act to the State Governments of Andhra Pradesh, Assam,

Bihar, Gujarat, Haryana, Himachal Pradesh, Karnatalca, Kerala, Madhya

Predesh, Mizoram, Orissa, Rajasthan, Sikkim and Tamil Nadu subject to the

condition that the Central Government may revoke such delegation of

Powers in respect of all or any one or more of the State Governments or may

itself invoke the provisions of section 5 of the Act, if in the opinion of the

Central Government such a course of action is necessary in public interest,

(Notification No, S.O. 152 (E) dated 10-2-88 published in Gazette No. 54 of

the same date). These Powers have been delegated to the following State

Governments also on the same terms:

Meghalaya, Punjab and Uttar Pradesh vide Notification No. S.0.389 (E)

dated 14-4-88 published in the Gazette No. 205 dated 144-88;

Maharashtra vide Notification No. S.O. 488(E) dated 17-5-88 published in

the Gazette No. 255 dated 17-5-88;

Goa and Jammu & Kashmir vide Notification No. S.O. 881 (E~ dated 22-9-

88; published in the Gazette No. 749 dated 22.9.88.

West Bengal Manipur vide Notificadon N. S.O. 408 (E) dated 6-6-89;

published in the Gazette No. 319 dated 6-6-89;

Tripura vide Notification No. S.O. 479 (E) dated 25-7-91 published in thc

Gazene No. 414 dated 25-7-91.

3 For issuing directions see r.4 of Itnviromnent (Protection) Rules, 1986.

4 See r. 3 of Environment (Protection) Rules, 1986 and Schedules thereto.

i. Schedule I lists the standards for emission or discharge of environmental

pollutants from the industries, processes or operations and their maximum

allowable limits of concentration;

ii. Schedule II lists general standards for discharge of effluents and their

maximum limits of concentration allowable;

iii. Schedule III lists ambient air quality standards in respect of noise and its

maximum allowable limits; and

iv. Schedule IV lists standards for emission of smoke, vapour etc. from

motor vehicles and maximum allowable limits of their emission.

5 See r. 13 of Environment (Protection) Rules, 1986, and

i. Hazardous Wastes (Management and Handling) Rules, 1989;

ii. Manufacture, Storage and Import of Hazardous Chemicals Rules, 1989;

and

iii. Rules for the Manufacture, Use, Import, Export and Storage of

Hazardous Micro organisms, Genetically-engineered organisms or Cells.

6 Rule 13 SUPRA.

7 See r. 5 of Environment (Protection) Rules, 1986.

8 See r. 12 of Environment (Protection) Rules and Schedule 11, and relevant

provisions of Hazardous Wastes (Management and Handling) Rules,

Manufacture, Storage and Import of Hazardous Chemicals Rules and Rules

for the Manufacture, Use, Import Export and Storage of hazardous Micro-

organisms, Genetically Engineered Organisms or Cells.

9 See r. 3 of Environment (Protection) Rules, 1486 and Schedule I.

10 See r. 13 of Environment (Protection) Rules, 1986 and

i. Hazardous Wastes (Management and Handling) Rules, 1989;

ii. Manufacture, Storage and h7lporl of Hazardous Chemicals Rules, 1989;

and

iii. Rules for the Manufacture, Use Import, Export and Storage of Hazardous

Micro organisms, Genetically Engineered organisms or Cells.

11 For authorities or agencies see r. 12 of Environment (Protection) Rules,

1986 and Schedule

12 The Central Govt. has empowered 60 persons listed in the Table (p. 251)

vide S.O. 83 (E) published in the Gazette of India No. 66 dated 16-2-87 and

S.O. 63 (E) published in the Gazette of India No. 42 dated 18-1-88.

13 In excercise of powers conferred under sub-section (i) of section 11 the

Central Government has empowered 60 officers listed in the Table (p. 254)

vide S.O. 84. (E) published in the Gazette No. 66 dated 16-2-87 and S.O.

62(E) published in the Gazette No. 42 dated 18-l-88.

14 For procedure for taking samples see r. 6 of Environment (Protection)

Rules, 1986, also.

15 The Central Government has delegated its powers under clause (b) of sub-

section (i) of section 12 and section 13 of the Act to the Central Pollution

Control Board vide Notification No. S.O. 145 (E) dated 21-2-91 published in

the Gazette No. 128 dated 27-2-91.

16 The list of laboratories/institutes recognised as environmental laboratories:

and the persons recognised as Govt. Analysts is given in the table (p. 223).

17 See r. 9 of Environment (Protection) Rules, 1986.

18 See r. 8 of Environment (Protection) Rules, 1986.

19 For qualifications of Govt. Analyst see r. 10 of Environment (Protection)

Rules, 1986.

20 In exercise of powers conferred under clause (a) of section l9, the Central-

Government has authorised the officers and authorities listed in the Table (p.

238) vide S.O. 394 (E) published in the Gazette No. 185 dated 164-87, S.O.

237(E) published in the Gazette No. 171 dated 29-3-89 and S.O. 656(E)

dated 21-8-89 published in the Gazette No. 519 dated 21-8-89.

21 See footnote 2 on Page 213.

22 See footnote 3 on Page 213.

23 See footnote I on Page 214.

24 See r.6 of Environment (Protection) Rules, 1986.

25 See r. 7 of Environment (Protection) Rules, 1986.

26 See r. 9 of Environment (Protection) Rules, 1986.

27 For the procedure for submission of samples to laboratories and the form

of laboratory report see r. 8 of Environment (Protection) Rules, 1986.

28 See r. 10 of Environment (Protection) Rules, 1986.

29 See r. 11 of Environment (protection) Rules, 1986.

13.The Hazardous Wastes (Management and Handling) Rules, 1989 (as

amended, May, 2003)

1. Short title and commencement

(1) These rules may be called the Hazardous Wastes (Management and

Handling) Rules, 1989, as amended in January 6, 2000 and May 21, 2003.

(2) They shall come into force on the date of their publication in the Official

Gazette.

2. Application

These rules shall apply to the handling of hazardous wastes as specified in

Schedules and shall not apply to-

(a) waste water and exhaust gases as covered under the provisions of the Water

(Prevention and Control of Pollution) Act. 1974 (6 of 1974) and the Air

(Prevention and Control of Pollution) Act, 1981 (14 of 1981) and rules made

thereunder;

(b) wastes arising out of the operation from ships beyond five kilometers as

covered under the provisions of the Merchant Shipping Act, 1958 (44 of 1958)

and the rules made thereunder.

(c) radio-active wastes as covered under the provisions of the Atomic Energy

Act, 1962 (33 of 1962) and rules made thereunder.

(d) bio-medical wastes covered under the Bio-Medical Wastes (Management

and Handling) Rules, 1998 made under the Act;

(e) wastes covered under the Municipal Solid Wastes (Management and

Handling) Rules, 2000 made under the Act; and

(f) the lead acid batteries covered under the Batteries (Management and

Handling) Rules, 2001, made under the Act.

3. Definitions

In these rules, unless the context otherwise requires:-

(1) "Act" means the Environment (Protection) Act, 1986 (29 of 1986);

(2) "applicant" means a person or an organisation that applies, in Form 1, for

granting of authorisation to perform specific activities connected with handling

of hazardous wastes;

(3) "auction" means bulk sale of wastes by invitation of tenders or auction,

contract or negotiation by individual(s), companies or Government

departments;

(4) "auctioneer" means a person or an organisation that auctions wastes;

(5) "authorisation" means permission for colection, transport, treatment,

reception, storage and disposal of hazardous wastes, granted by the competent

authority in Form-2;

(6) "authorised person" means a person or an organisation authorised by the

competent authority;

(7) "Central Pollution Control Board" means the Central Board constituted

under sub-section (1) of section 3 of Water (Prevention and Control of

Pollution) Act, 1974 (6 of 1974);

(8) "dispoal" means deposit, treatment, recycling and recovery of any

hazardous wastes;

(9) "export" means with its grammatical variations and cognate expressions,

means taking out of India to a place outside India;

(10) "exporter" means any person under the jurisdiction of the exporting

country who exports hazardous wastes and the exporting country itself, who

exports hazardous wastse to India;

(11) "environmentally sound management of hazardous wastes" means

taking all steps required to ensure that the hazardous wastes are managed in a

manner which will protect health and the environment against the adverse

effects which may result from such wastes;

(12) "facility" means any location wherein the processes incidental to the

waste generation, collection, reception, treatment, storage and disposal are

carried out;

(13) "form" means a Form appended to these rules;

(14) "hazardous waste" means any waste which by reason of any of its

physical, chemical, reactive, toxic, flammable, explosive or corrosive

characteristics causes danger or is likely to cause danger to health or

environment, whether alone or when in contact with other wastes or substances,

and shall include-

wastes listed in cloumn (3) of Schedule-1;

(b) wastes having constituents listed in Schedule-2 of their concentration is

equal to or more than the limit indicated in the said Schedule; and

(c) wastes listed in Lists 'A' and 'B' of Schedule-3 (Part-A) applicable only in

case(s) of import or export of hazardous wastes in accordance with rules 12,

13 and 14 if they possess any of the hazardous characteristics listed in Part-B

of Schedule-3.

Explanation: For the purposes of this clause-

(i) all wastes mentioned in column (3) of Schedule-1 are hazardous wastes

irrespective of concentration limits given in Schedule-2 except as otherwise

indicated and Schedule-2 shall be applicable only for wastes or waste

constituents not covered under column (3) of Schedule-1;

(ii) Schedule-3 shall be applicable only in case(s) of import or export;

(15) "hazardous waste site" means a place for collection, reception, treatment,

storage and disposal of hazardous wastes which has been duly approved by the

competent authority;

(16) "illegal traffic" means any transboundary movement of hazardous wastes

as specified in rule 15;

(17) "import" with its grammatical variations and cognate expressions, means

bringing into India from a place outside India;

(18) "importer" means an occupier or any person who imports hazardous

wastes;

(19) "manifest" means transporting document(s) prepared and signed by the

occupier in accordance with rule 7;

(20) "non-ferrous metal wastes" means wastes listed in Schedule 4;

(21) "operator of facility" means a person who owns or operates a facility for

collection, reception, treatment, storage or disposal of hazardous wastes;

(22) "recycler" means an occupier who procures and processes wastes for

recovery;

(23) "recycling of waste oil" means reclamation by way of treatment to

separate solids and water from waste oils using methods such as heating,

filtering, gravity, settling, centrifuging, dehydration, viscosity and specific

gravity adjustment;

(24) "registered re-refiner or recyler" means a re-refiner or recycler

registered for reprocessing wastes with the Minister of Environment and forests

or the Central Pollution Control Board as the case may be fore reprocessing

wastes;

(25) "re-refining of used oil" means applying a process to the material

composed of used oil so as to produce high quality base stock for further

manufacture of lubricants or for other petroleum products by blending or any

other process;

(26) "schedule" means a Schedule appended to these rules;

(27) "State Government" means a State Government and in relation to a

Union territory, the Administrator thereof appoined under article 239 of the

Constitution;

(28) "State Pollution Control Board or Committee" means the Board or

Committee constituted under sub-section (1) of section 4 of the Water

(Prevention and Control of Pollution) Act, 1974 (6 of 1974).

(29) "storage" means storing hazardous wastes for temporary period, at the

end of which the hazardous wastes is treated and disposed off;

(30) "transboundary movement" means any movement of hazardous waste or

other wastes from an area under the national jurisdiction of one country to or

through an area under the national jurisdiction of another country or to or

through an area not under the national jurisdiction of any country, provided at

least two countries are involved in the movement;

(31) "transport" means off-site movement of hazardous waste by air, rail, road

or water;

(32) "transporter" means a person engaged in the off-site transporation of

hazardous waste by air, rail, road or water;

(33) "treatment" means a method, technique or process, designed to change

the physical, chemical or biological characteristics or composition of any

hazardous waste so as to render such wastes harmless;

(34) "used oil" means any oil-

derived from crude oil or mixtures containing synthetic oil including used

engine oil, gear oil, hydraulic oil, turbine oil, compressor oil, industrial gear

oil, heat transfer oil, transformer oil, spent oil and their tank bottom sluidges;

and

(ii) suitable for re-refining if it meets the specifications laid daown in

Schedule 5, but does not include waste oil;

(35) "waste oil" means any oil-

which includes spills of crude oil, emulsions, tank bottom sludge and slop

oil generated from petroleum refineries, installations or ships; and

(ii) is unsuitable for re-refining but can be used as fuel in furnaces if it meets

the specifications laid down in Schedule 6;

(36) words and expressions used in these rules and not defined but defined in

the Act shall have the meanings respectively assigned to them in the Act.'

4. Responsibility of the occupier and operator of facility for handling of the

wastes.

(1) The occupier and the operator of a facility shall be responsible for proper

collection, reception, treatment, storage and disposal of hazardous wastes listed

in Schedule 1, 2 and 3.

(2) The occupier or any other person acting on his behalf who intends to get his

hazardous waste treated by the operator of a facility under sub-rule(1), shall

give, to the operator of a facility, such information as may be specified by the

State Pollution Control Board.

(3) It shall be the responsibility of the occupeir and the operator of a facility, to

take all steps to ensure that the wastes listed in schedules-1, 2 and 3 are

properly handled, and disposed of without any adverse effects to the

environment.

4A. Duties of the occupier and operatory of a facility

It shall be the duty of the occupier and the operator of a facility to take adequate

stpes while handling hazardous waste to-

Contain contaminants and prevent accidents and limit their consequences on

human and the environment; and

(ii) provide persons working on the site with information, training and

equipment necessary to ensure their safety.

5. Grant of authorisation for handling hazardous wastes

Hazardous wastes shall be collected, treated, stored and disposed of only in

such facilites as may be authorised for this purpose

(2) Every occupeir handling, or a recycler recycling, hazardous wastes shall

make an application in Form 1 to the Member Secretary, State Pollution Control

Board or Committee, as the case may be or any officer designated by the State

Pollution Control Board or Committee for the grant of authorization for any of

the said activities:

Provided that an occupier or a recycler not having a hazardous wastes treatment

and disposal facility of his own and is operating in an area under the jurisdiction

assigned by the State Pollution Control Board or Committee, as the case may

be, for a Common Treatment, Storage and Disposal Facility (TSDF) shall

become a member of this facility and send his waste to this facility to ensure

proper treatment and disposal of hazardous wastes generated failing which the

authorization granted to the said occupier or recycler in accordance with sub-

rule may be cancelled after giving a reasonable opportunity to such occupier or

recycler as the case may be, of being heard or shall not to be granted by the

State Pollution Control Board or Committee, as the case may be.;

(3) Any person who intends to be an operator of a facility for the collection,

reception, treatment, transport, storage and disposal of hazardous wastes, shall

make an application in Form 1 to the Member Secretary, State Pollution Control

Board or Committee for the grant of authorization for all or any of the above

activities specified in this rule.

(4) The Member Secretary, State Pollution Control Board or any officer

designated by the Board or Committee shall not issue an authorisation unless he

is satisfied that the operator of a facility or an occupier, as the case may be,

possesses appropriate facilities, technical capabilities and equipment to handle

hazardous wastes safely.

(4A) The authorisation application complete in all respect shall be processed by

the State Pollution Control Boards within ninety days of the receipt of such

application.

(5) The authorisation to operate a facility shall be issued in Form 2 and shall be

subject to conditions laid down therein.

(6)(i) An authorisation granted under this rule shall, unless suspended or

cancelled, be in force during the period of its validity as specified by the State

Pollution Control Board or Committee from the date of issue or from the date of

renewal, as the case may be.

(ii) An application for the nrenewal of an authorisation shall be made in Form 1

before its expiry.

(iii) the authoirsation shall continue to be in force until it is renewed or revoked.

(7) The Member Secretary, State Pollution Control Board or any officer

designated by the Board or Committee, may, after giving reasonable

opportunity of being heard to the applicant refuse to grant any, authorisation.

(8) The Member Secretary, State Pollution Control Board or any officer

designated by the Board shall renew the authorisation granted under sub-rule

(6), after examining each case on merit, subject to the following-

on submission of annual returns by the occupier or operator of facility in

Form 4;

(ii) on steps taken, by the applicant whereever feasible, for reduction and

prevention in the waste generated or recycling or reuse;

(iii) on fulfillment of conditions prescribed in the authorisation regarding

management in an environmentally sound manner of wastes.

(9) Ever State Pollution control Board or Committee shall maintain a register

containing particulars of the condiditons imposed under these rules for any

disposal of hazardous wastes, on any land or premises and it shall be open for

inspection during office hours to any person interested or affected or a person

authorized by him in this behalf. The entries in the register shall be conclusive

proof of grant of authorisation for management and handling of hazardous

wastes on such land or premises and the conditions subject to which it was

granted.

6. Power to suspend or cancel an authorisation

(1) The State Pollution Control Board or Committee may cancel an

authorisation issued under these rules or suspend it for such period as it thinks

fit, if in its opinion, the authorised person has failed to comply with any of the

conditions of the authorisation or with any provisions of the act or these rules,

after giving the authorised person an opportunity to show cause and after

recording reasons therefor.

(2) Upon suspension or/cancellation of the authorisation and during the

pendency of an appeal under rule 12, the State Pollution Control Board or

Committee may give directions to the persons whose authorisation has been

suspended or cancelled for the safe storgae of the hazardous wastes, and such

person shall comply with such directions.

7. Packaging, labelling and transport of hazardous wastes

The occupier or operator of a facility shall ensure that the hazardous wastes are

packages, based on the composition in a manner suitable for handling, storage

and transport and the labelling and packaging shall be easily visible and be able

to withstand physical conditions and climatic factors.

(2) Packaging, labelling and transport of hazardous wastes shall be in

accordance with the provisions of the rules made by the Central Government

under the Motor Vehicles Act, 1988 and other guidelines issued from time to

time.

(3) All hazardous waste containers shall be provided with a general label as

given in Form 8.

(4) The occupier shall prepare six copies of the manifest in Form 9 comprising

of colour code indicated below (all six copies to be signed by the transporter):

Copy number

with colour

code

Prupose

Copy 1 (White) to be forwarded by the occupier to the State Pollution

Control Board or Committee

Copy 2 (Yellow) to be retained by the occupier after taking signature on it

from the transporter and rest of the four copies to be

carried by the transpoter

Copy 3 (Pink) to be retained by the operator of the facility after signature

Copy 4 (Orange) to be returned to the transporter by the operator of facility

after accepting waste

Copy 5 (Green) to be returned by the operator of the facility to State

Pollution Control Board/Committee after treatment and

disposal of wastes.

Copy 6 (Blue) to be returned by the operator of the facility to the

occupier after treatment and disposal of wastes

(5) The occupier shall forward copy number 1 (white) to the State Pollution

Control Board or Committee and in case the hazardous waste is likely to be

transported through any transit State, the occupier shall prepare an additional

copy each for such State and forward the same to the concerned State Pollution

Control Board or Committee before the hands over the hazardous waste to the

transporter. No transporter shall accept hazardous wastes from an occupier for

transport unless it is accompanied by copy number 2 to 5 of the manifest. The

transporter shall return copy number 2 (yellow) of the manifest signed with date

to the occupier as token of receipt of the other four copies of the manifest and

retain the remaining four copies to the carried and handed over to respective

agencies as specified in sub-rule (4).

(6) In case of transport of hazardous wastes to a facility for treatment, storage

and disposal existing in a State other than the State where hazardous wastes are

generated, the occupier shall obtain 'No Objection Certificate' from the State

Pollution Control Board or Committee of the concerned State or Union

Territory Administration where the facility is existing.

(7) the occupier shall provide the transporter with relevant information in Form

10, regarding the hazardous nature of the wastes and measures to be taken in

case of an emergency.

8. Disposal Sites

(1) The occupier or operator of a facility or any association of occupiers, shall

be jointly and severally responsible for identifying sites for establishing the

facility for treatment, storage and disposal of hazardous wastes.

(2) The State Government, operator of a facility or any association of occupiers

shall jointly and severally be responsible for and identify sites for common

facility for treatment, storage and disposal of hazardous wastes in the State.

(3) The operator of a facility, occupier or any association of occupiers shall

undertake an environmental impact assessment (EIA) of the selected site(s) and

shall submit the EIA report to the State Pollution Control Board or Committee.

(4) The State Pollution Control Board or Committee shall on being satisfied

with the EIA report, cause a public notice for conducting a public hearing as per

the procedure contained in the Environmental Impact Assessment Notification,

1994 published vide S.O. 60(E) dated 27th January, 1994 as amended from time

to time.

(5) The State Pollution Control Board or Committee shall forward to the State

Government or Union territory Administrator, as the case may be, the project

report including EIA report and details of public hearing alonwith its

recommendations within a period of 30 days from the last date of public

hearing.

(6) The State Government shall complete the assessment within a period of

thirty days from the date of receipt of the documents mentioned in sub-rule (5)

and convey the decision of its approval of site(s) or otherwise within 30 days

thereafter to the concerned operator of the facility, occupier or any association

of occupiers.

(7)After approval of the site or sites, the State Government shall acquire the site

or inform the occupiers to acquire the site(s) for settling up the facility for

treatment, storage and disposal of hazardous wastes. The State Government

shall simultaneously notify such site(s). The State Government shall also

compile and publish periodically an inventory of such hazardous wastes

disposal sites and facilities;

(8) Setting up of an on-site facility for treatment, storage and disposal of

hazardous wastes for captive use shall be govenred by the authorisation

procedure laid down in rule 5.

8A. Design and setting up of disposal facility

(1) The occupier any association or operator of a facility, as the case may be

shall design and set up disposal facility as per the guidelines issued by the

Central Government or the State Government as the case may be.

(2) The occupier, any association or operator, shall before setting up a disposal

facility get the design and the layout of the facility approved by the State

Pollution Control Board.

(3) The State Pollution control Board shall monitor the setting up and operation

of a facility regularly.

8B. Operation and closure of landfill site

(1) The occupier or the operator as the case may be, shall be responsible for

safe and environmentally sound operation of the facility as per design approved

under Rule 8A by the State Pollution Control Board.

(2) The occupier or the operator shall ensure that the closure of the landfill is as

per the desgn approved under Rule 8A by the State Pollution Control Board.

9. Records and returns

(1) The occupier generating hazardous waste and operator of a facility for

collection, reception, treatment, transport, storage and disposal of hazardous

waste shall maintain records of such operations in Form 3.

(2) The occupier and operator of a facility shall send annual returns to the State

Pollution Control Board or Committee in Form 4.

(3) The State Pollution Control Board or Committee shall prepare an inventory

of hazardous wastes, as early as possible as per Form 4, within its jurisdiction

and compile other related information like treatment and disposal of hazardous

wastes based on the returns filed by respective occupier and operator of facility

as per sub-rule(2).

10. Accident reporting and follow-up

Where an accident occurs at the facility or on a hazardous waste site or during

transporation of hazardous waste, the occupier or operator of a facility shall

report immediately to the State Pollution control Board or Committee about the

accident in Form 5.

11. Import and Export of Hazardous Wastes for dumping and disposal

(1) Import of hazardous wastes from any country to India and export of

hazardous wastes from India to any country for dumping or disposal shall not

be permitted.

(2) The exporting country or the exporter or the exporter as the case may be of

hazardous wastes shall communicate in Form 6 to the Central Government (the

Ministry of Environment & Forests) of the proposed trans-boundary movement

of hazardous wastes.

(3) The Central Government shall, after examining the communication received

under sub-rule (2) and on being satisfied that the import of such hazardous

wastes is to be used for processing or reuse as raw material grant permission for

the import of such wastes subject to such conditions as the Central Government

may specify in this behalf and if, however the Central Government is not

satisfied with the communication received under sub-rule (2), may refuse

permission to import such hazardous wastes.

(4) Any importer importing hazardous waste shall provide necessary

information as to the type of hazardous wastes he is to import, in Form 6, to the

concerned State Pollution Control Board or Committee/the Central Pollution

Control Board in the case of Union Territories.

(5) The State Pollution Control Board or Committee shall examine the

information received under the sub-rule (4) and issue instruction to the

importers as its considers necessary.

(6) The Central Government or the State Pollution Control Board or

Committee, as the case may be, shall inform the concerned Port Authority to

take appropriate steps regarding the safe handling of the hazardous wastes at the

time of off-loading the same.

(7) Any person importing hazardous wastes shall maintain the records of the

hazardous wastes imprted as specified in Form 7 and the records so maintained

shall be open for inspection by the State Pollution Control Board or

Committee/the Ministry of Environment and Forests/the Central Polltion

Control Board in the case of Union Territories or an officer appointed by them

in this behalf.

12. Import and Export of Hazardous Wastes for recycling and reuse

(1) No person shall import or export hazardous wastes or substances containing

or contaminated with such hazardous wastes as specified in Schedule 8, even

for recycling.

(2) The Ministry of Environment and forests shall be the Nodal Ministry to deal

with the trans-boundary movement of hazardous wastes and to grant permission

of transit of hazardous wastes through any part of India.

(3) Import and export of hazardous wastes shall be permitted only as raw

materials for recycling or reuse. (Schedule 3, 4).

(4) The authorities mentioned in column 2 of Schedule 7 shall be responsible

for regulation of export and import of hazardous wastes.

(5) Any occupier importing or exporting hazardous wastes shall provide

detailed information in Form 7A to the Customs authorities.

(6) Any occupier importing or exporting hazardous wastes shall comply with

the articles of the Basel Convention to which the Central Government is a

signatory.

(7) In case of any dispute as the grant of permission to import or export of

hazardous wastes, the matter shall be referred to the Central Government for a

decision.

13. Import of Hazardous Waste

Every occupier seeking to import hazardous wastes shall apply to the State

Pollution Control Board or Committee at least 120 days in advance of the

intended date of commencement of the shipment in Form 6;

(2) The State Pollution Control Board shall examine the application received

from the occupier within thirty days and forward the application with

recommendation and requisite stipulations for safe transport, storage and

processing, to the Ministry of Environment and Forests;

(3) The Ministry of Environment and Forests, Government of India will

examine the application received from the State Pollution Control Board and

after satisfying itself will grant permission for imports subject to the following:

environmentally friendly/appropriate technology used for re-processing;

(b) the capability of the importer to handle and reprocess hazardous wastes

in an environmentally sound manner;

(c) presence of adequate facility for treatment and disposal of wastes

generated; and

(d) approvals, no objection certificates and authorisation from all concerned

authorities.

(4) The Ministry of Environment & Forests, Government of India, shall forward

a copy of the permission granted, to the Central Pollution Control Board, the

State Pollution Control Board and the concerned Port and Customs authorities

for ensuring compliance of the conditions of imports and to take appropriate

steps for safe handling of the waste at the time of off-loading;

(5) An application for licence to the directorate General of Foreign Trade for

import shall be accompanied with the permission granted by the Ministry of

Environment & Forests, Government of India under sub-rule (3) to the importer

and an authenticated copy of Form 7 of the Exporter under sub-rule (3) of rule

14;

(6) The Port and Custom authorities shall ensure that the shipping document is

accompanied with an authenticated copy of Form 7 and the test report from an

accredited laboratory of analysis of the hazardous waste shipped;

(7) The occupier having valid permission to import shall inform the State and

Central Pollution Control Board and the Port authorities of the arrival of the

consignment of hazardous wastes ten days in advance;

(8) The occupier importing hazardous waste shall maintain the records of

hazardas wastes imports as specified in Form 6A and the record so maintained

shall be available for inspection;

(9) An occupier importing hazardous wastes listed under an Open General

Licence of the Directoral General of Foreign Trade shall register himself with

the Ministry of Environment and Forests or any other authority or agency such

as the Central Pollution Control Board designed by it in accordance with the

procedure laid down under rule 19.

14. Export of Hazardous Waste

(1) The exporting country or the exporter as the case may be of hazardous waste

shall apply ninety days in advance in Form 7 to the Ministry of Environment

and Forests, Government of India, seeking permission for the proposed export

and transboundary movement;

(2) The Ministry of Environment and Forests, Government of India, on receipt

of such Form 7 from an exporter or an exporting country shall examine the case

on merit and grant or refuse permission for export to India;

(3) The Ministry of Environment and Forests, shall communicate the grant of

permission by authentication on Form 7 to the exporter and the exporting

country and endorse a copy of the same to the Central Pollution Control Board

and the State Pollution Control Board.

(4) The exporter shall ensure that no consignment is shipped prior to the

requisite authentication being received. The exporter shall also ensure that the

shipping document is accompanied with Form 7A, an authenticated copy of

Form 7 and an authenticated copy of the test report from an accredited

laboratory of analysis of the hazardous waste.

(5) The occupier, exporting hazardous waste to any other country shall seek

permission from the competent authority of that country prior to any shipment.

(6) Every occupier exporting hazardous waste shall inform the Central

Government of the permission sought for exporting, permission granted for

export and details of the export in Form 7.

15. Illegal Traffic

The movement of hazardous wastes from or to the country shall be considered

illegal:

if it is without prior permission of the Central Government; or

(ii) if the permission has been obtained through falsification, mis-

representation or fraud; or

(iii) it does not conform to the shipping details provided in the document;

In case of illegal movement, the hazardous wastes in question;

shall be shipped back within thirty days either to the exporter or to the

exporting country;

or

(ii) shall be disposed of within thirty days from the date of off-loading

subject to inability to comply with sub-rule 2(i) above in accordance with

the procedures laid down by the State Pollution Control Board or Committee

in constitution with Central Pollution Control Board.

(3) In case of illegal transboundary movement of hazardous wastes, the

occupier exporting hazardous waste from the country or the exporter exporting

hazardous waste to the country and importer importing hazardous waste into the

country shall ensure that the waste in question is safely stored and shipped or

disposed off in an environmentally sound manner within thirty days from the

date of off-loading.

(4) The exporter shall bear the costs incurred for the disposal of such wastes.

16. Liability of the occupier, transporter and operatory of a facility

(1) The occupier, transporter and operator of a facility shall be liable for

damages caused to the environment resulting due to improper handling and

disposal of hazardous waste listed in Schedule 1, 2 and 3;

(2) The occupier and operator of a facility shall also be liable to reinstate or

restore damaged or destroyed elements of the environment at his cost, failing

which the occupier or the operator of a facility, as the case may be, sahll be

liable to pay the entire cost of remediation or restoration and pay in advance an

amount equal to the cost estimated by the State Pollution Control Board or

Committee. Thereafter the Board or Committee shall plan an cause to be

executed the programme for remediation or restoration. The advance paid to

State Pollution Control Board or Committee towards the cost of remediation or

restoration shall be adjusted once the actual cost of remediation or restoration is

finally determined and the remaining amount, if any, shall be recovered from

the occupier or the operator of the facility.

(3) The occupier and operator of a facility shall be liable to pay a fine as levied

by the State Pollution Control Board with the approval of the Central Pollution

Control Board for any violation of the provisions under these rules.

17. Transitional provisions - Where -

(a) On the date of coming into operation of these rules, an occupier handling

hazardous wastes who is required to comply with the provisions of these rules,

it will be sufficient compliance if the occupier and the authorities do so within

three months after the date of coming into force of these rules;

(b) State Pollution Control Board and Pollution Control Committee are required

to oversee the compliance.

18. Appeal

(1) An appeal shall lie, against any order of grant or refusal of an authorisation

by the Member Secretary, State Pollution Control Board or any officer

designated by the Board or the Secretary, Department of Environment of the

State Government by whatever name called.

(2) Ever appeal shall be in writing and shall be accompanied by a copy of the

order appealed against and shall be presented within thirty days of the receipt of

the order passed.

(3) Ever appeal filed under this rule shall be disposed of within a period of sixty

days from the date of such filing.

19. Procedure for registration and renewal of registration of recyclers and

refiners.

Every person desirous of recycoling or re-refining non-ferrous metal wastes as

specified in Schedule 4 or used oil or waste oil shall register himself with the

Central Pollution Control Board

Provided that no ownder or occupier of an industrial unit having captive

recycling or non-ferrous metals or recycling or waste oil or re-refining oil or

used oil facility shall be required to register under these rules.

Provided further that no person who has registered with the Ministry of

Environment & Forests before the commencement of the Hazardous Wastes

(Management and Handling) Amendment rules, 2003, shall, unless such

registration is cancelled or ceases to operate under sub-rule (3) of rule 21, be

required to register under this sub-rule as given in the certificate of registraion.

(2) Every application for registration under this rule shall be made in Form 11

along with a copy of each of the following doucments to the Central Pollution

Control Board for the grant of such registration or renewal:-

letter of consent granted under the Water (Prevention and Control of

Pollution) Act, 1974 and the Air (Prevention and Control of Pollution) Act,

1981;

(b) authorisation granted under rule 5 of these rules;

(c) certificate of registration with Distrcit Industries Centre;

(d) proof of installed capacity of plant and machinery issued by either State

Pollution Control Board or Committee or the District Industries Centre; and

(e) report from the State Pollution Control Board or Committee regarding

proof of compliance of effluent and emission standards and treatment and

disposal of hazardous wastes as stipulated by that Board or Commiittee.

(3) If the Central Pollution Control Board is satisfied that the recyclers or re-

refiners possess requisite facilities, technical capabilities, and equipment to

recycle or re-refine the wastes and dispose of the hazardous wastes generated, it

shall grant a certificate of registration to such recycler or re-refiner, as the case

may be.

(4) The Central Pollution Control Board shall dispose of the application for

registration within 120 days of receipt of such application with complete

details.

(5) The certificate of registration granted under sub-rule(3) shall be valid for a

period of two years from the date of its issue unless suspended or cancelled

earlier.

(6) Every application for renewal of registration ofa a certificate of registration

granted under sub-rule(3) shall me made in Form 11 along with the documents

mentioned in such-rule(2) atleast two monts before the expiry of the period of

validity of such certificate. The Central Pollution Control Board shall renew the

registration of the recycler or re-refiner granted under sub-rule(3) after examing

each case on merit.

(7) The Central Pollution Control Board may, after giving reasonable

opportunity to the applicant of being heard, by order, refuse to grant certificate

of registration of renewal.

(8) The Central Pollution Control Board may cancel or suspend a registration or

renewal granted under these rules, if in its opinion the registered recycler has

failed to comply with any of the conditions of registration, or with any

provisions of the act or rules made thereunder after giving him an opportunity

of being heared and after recording the reasons therefor;

(9) An appeal against any order of suspension or cancellation or refusal of

registration or renewal passed by Central Pollution Control Board shall lie with

the Secretary, Ministry of Environment and Forests (hereafter referred to as the

appellate authority).

(10) The memorandum of appeal under sub-rule (9) shall be in writing and shall

be accompanied with a copy of the order appealed against and shall be

presented within 30 days of passing of the order;

Provided that the appellate authority may allow a memorandum of appeal to be

filed after the expiry of the said period of thirty days, but in no case later than

45 days if the appellate authority is satisfied that there exists sufficient cause for

not preferring the appeal in time.

(11) On receipt of a memorandum of appeal under sub-rule (9) the appellate

authority shall within ninty days from the date of receipt of such memorandum

of appeal and after giving the appellant an opportunity of being heard pass such

order as he may deem fit.

(12) In case of units registered with the Ministry of Environment and Forests or

the Central Pollution Control Board for items placed under "free category" in

Notification nos. 22(RE-99), 1997-2002 dated 30th July, 1999; 26 (RE-99)

1997-2002 dated 10th September, 1999; 38(RE-2000) 1997-2002 dated 16th

October, 2000 and 6(RE-2001) dated 31st March, 2001 issued by the Directorate

General of Foreign Trades and oterh similar notifications issued based on the

advice of Ministry of Environment and Forests, prior import permission from

that Ministry shall not be required.

(13) Recyclers and re-refiners registered with the Government of India in the

Ministry of Environment and Forests or the Central Pollution Control Board

shall maintain a record of wastes purchased, processed and sold and shall file an

annual return in Form 12 to the respective State Pollution Control Board or

Committee, as the case may be, latest by 31st January of every year.

20. Responsibility of waste generator

(1) No owner or occupier generating non-ferrous metal waste specified in

Schedule 4 or generating used oil or waste oil of ten tons or more per annum

shall sell or acution such non-ferrous metal wastes, used oil or waste oil except

to registered re-refiner or recycler, as the case may be, who undertakes to re-

refine or recycle the waste within the period of validity of his certificate of

registration.

(2) Any waste oil which does not meet the specifications laid down in Schedule

6 shall not be auctioned or sold but shall be disposed of in hazardous wastes

incineratory installed with air pollution control devices and meeting emission

standards.

(3) The persons generating wase or auctioneers shall ensure that at the time of

auction or sale, he period of validity of the certifciate of registration of the

registered re-refiner or recycler is sufficient to reprocess the quantity of wastes

being sold or acutioned to him.

(4) The waste generators and auctioneers shall ensure that the wastes are not

allowed to be stored for more than ninety days and shall maintain a record of

auctions and sale of such wastes and make there records available to the State

Pollution Control Board or Committee for inspections.

(5) The waste generators and auctioneers shall file annual returns of auctions

and sale in Form 13 latest by 31st day of January of every year to the respective

State Pollution Control Board or Committee.

21. Technoloy and standards for re-refining or recyling

Re-refiners and recyclers shall use only environmetally sound technologies

while recycling and re-refining non-ferrous metal wastes or used oil or waste

oil. In case of used oil, re-refiners using acid clay process or modified acid clay

process shall switch over within six months from the date of commencement of

the Hazardous Waste (Management and Handling) Amendements Rules, 2003

to other environmentally sound technologies as under:

Vaccum distillation with clay tretament;

(b) Vaccum distillation with hydrotreating;

(c) Thin film evaporation process; or

(d) Any other technology approved by the Ministry of Environment and

Forests.

(2) The re-refiners and recyclers registered with the Ministry of Environment

and Forests or the Central Pollution Control Board in accordance with the

procedure laid down in rule 19 shall file a compliance report of having adpoted

one of the technologies mentioned in sub-rule (1) within six months from the

date of commencement of the Hazardous Wastes (Management and Handling)

Amendment Rules, 2003.

(3) Notwithstanding anything contained in a certificate of registration granted to

a recycler or re-refiner, such registration with the Ministry of Environment and

Forests shall cease to be valid if he fails to comply with sub-rule (1).

(4) The State Pollution Control Board or Committee shall inspect the re-refining

and recycling units withing three months of the expiry of the six months period

referred to in sub-rule(1) and submit a compliance report to the Central

Pollution Control Board which shall compile such information and furnish the

same to the Ministry of Environment and Forests on a regular basis.

(5) The Ministry of Environment and Forests shall notify time-to-time

specifications and standards to be followed by recyclers and re-refiners.

14. THE ROLE OF THE PUBLIC SECTOR IN HEALTH CARE

THE ROLE OF THE PUBLIC SECTOR IN HEALTH CARE

Public-sector involvement in health care dates back to 1883 when compulsory sickness

insurance was introduced in Germany for some categories of workers. This established

the first model of mandatory health-care insurance in the Western world. Almost all

industrialized countries now have health-care systems in which there is a high level of

public-sector involvement. Nonetheless, there is little consensus between economists

about the precise role that the public sector should play in financing and delivering health

care. Some of the arguments for public-sector involvement in health care include social

justice, restriction of monopolies, redistribution and public goods.(3) These arguments

may overlap.

The social justice argument applies to situations in which the provision of health services

to one person is advantageous for other members of society. For example, the treatment

of an infectious disease provides a broad societal benefit. From a social standpoint,

public-sector delivery of these types of health services may be preferred to private-sector

delivery because when the price of a service is determined privately, it may not

incorporate the positive external social benefits of delivering it. As a result, the price

may be higher when it is determined privately. If the price exceeds what people can

afford, or are willing, to pay, they will forego the treatment. This may have undesirable

social consequences. For example, an infectious disease may spread to a broad segment

of society.

The second argument is that government involvement in health care prevents health-care

providers from exercising a monopoly. In a health-care monopoly, the medical

profession is able to control access to training or impose restrictions on medical

substitutes. This can restrict the availability of services.

The redistribution argument asserts that public-sector involvement permits the

redistribution of funds from people who are in good health to people who are in poor

health. Individuals are not equally afflicted with health problems. People with unhealthy

lifestyles or dangerous jobs, for example, have a higher risk of developing health

problems. In a private insurance system, these people would pay a higher premium, but

in a public insurance system, the risks are pooled and everyone pays the same premium,

regardless of the risk for filing a claim. In the public model, insurance must be

mandatory, otherwise those at low risk would almost certainly opt out. In the private

model, insurance is voluntary and insurers may choose who they wish to insure. In some

cases, people in poor health may have difficulty finding an insurer who is willing to cover

them. Figure 1 depicts the health-care funding, risk pooling, and insurance coverage

patterns in selected countries.

The public goods argument in favour of public-sector involvement in health care suggests

that health care is a public good in the sense that it “cannot be managed by market

mechanisms because it is impossible to exclude people who have not paid from

consuming it.”(4) Clean air and military defence are two other examples of public goods.

There is a consensus that governments have a legitimate economic role and responsibility

to fund and deliver public goods.

15. What are the Legal Issues for Hospital Administrators

Biomedical Waste Management : An

Infrastructural

Survey of Hospitals

Biomedical waste consists of solids, liquids, sharps, and laboratory waste that are

potentially infectious or dangerous and are considered biowaste. It must be properly

managed to protect the general public, specifically healthcare and sanitation workers who

are regularly exposed to biomedical waste as an occupational hazard.

Biomedical waste differs from other types of hazardous waste, such as industrial waste,

in that it comes from biological sources or is used in the diagnosis, prevention, or

treatment of diseases. Common producers of biomedical waste include hospitals, health

clinics, nursing homes, medical research laboratories, offices of physicians, dentists, and

veterinarians, home health care, and funeral homes.

Components The following is a list of materials that are generally considered biomedical waste:

Solids Catheters and tubes[1]

Disposable gowns, masks,[1] and scrubs

Disposable tools, such as some scalpels and surgical staplers

Medical gloves[1][2]

Surgical sutures and staples

Wound dressings[1]

Liquids Blood[1][2]

Body fluids and tissues[1][2]

Cell, organ,[1] and tissue[1] cultures

Sharps Blades, such as razor or scalpel blades[1][2]

Lancets[1][3]

Materials made of glass, such as cuvettes and slides[1][2]

Metal stylets

Needles[1][2]

Plastic pipettes and tips[1][2]

Syringes[2]

Laboratory waste Animal carcasses[1][2]

Hazardous chemicals with biological components[2]

Media[2]

Medicinal plants

Radioactive material with biological components[2]

Supernatants[2]

Syringes

Biomedical Waste Management Sorting of medical wastes in hospital.At the site where it is generated, biomedical waste

is placed in specially-labelled bags and containers for removal by biomedical waste

transporters. Other forms of waste should not be mixed with biomedical waste as

different rules apply to the treatment of different types of waste.

Household biomedical waste usually consists of needles and syringes from drugs

administered at home (such as insulin), soiled wound dressings, disposable gloves, and

bedsheets or other cloths that have come into contact with bodily fluids.[3] Disposing of

these materials with regular household garbage puts waste collectors at risk for injury and

infection especially from sharps as they can easily puncture a standard household garbage

bag. Many communities have programs in place for the disposal of household biomedical

waste. Some waste treatment facilities also have mail-in disposal programs. Biomedical

waste treatment facilities are licensed by the local governing body which maintains laws

regarding the operation of these facilities. The laws ensure that the general public is

protected from contamination of air, soil,groundwater, or municipal water supply. One

company, BioMedical Technology Solutions, Inc., offers a green alternative to haul-away

services for disposal of biomedical waste. The Company's desktop unit, the Demolizer®

II, is the only patented, portable, and self-contained system able to process both sharps

and typical red bag biomedical waste onsite. Upon processing the biomedical waste in the

unit, all regulatory paperwork is printed from the system and the waste is able to be

disposed of as common trash.

Protection from Biomedical Waste Wash your hands with soap and warm water after handling biomedical waste. Also, wash

all areas of your body with soap and water that you think may have come into contact

with biomedical waste, even if you are not sure your body actually touched the

biomedical waste.

Keep all sores and cuts covered.

Immediately replace wet bandages with clean, dry bandages.

Wear disposable latex gloves when handling biomedical waste. Discard the gloves

immediately after use.

Wear an apron or another type of cover to protect your clothes from contact with the

waste. If your clothes become soiled, put on fresh clothes, and take a shower, if possible.

Launder or throw away clothes soiled with biomedical waste.

Promptly clean and disinfect soiled, hard-surfaced floors by using a germicidal or bleach

solution and mopping up with paper towels.

Clean soiled carpets. First blot up as much of the spill as possible with paper towels and

put the soiled paper towels in a plastic lined, leak-proof container. Then try one of the

following:

Steam clean the carpet with an extraction method.

Scrub the carpet with germicidal rug shampoo and a brush. Soak the brush used for

scrubbing in a disinfectant solution and rinse the brush. Let the carpet dry, and then

vacuum it.

Never handle syringes, needles, or lancets with your hands. Use a towel, shovel, and/or

broom and a dustpan to pick up these sharp objects. Dispose of them in a plastic soda pop

bottle with a cap. Tape down the bottle cap. Then throw the bottle in the trash.

16. Describe about role Hospital Administrators in legal matters

Role of hospital administrators in legal matters

Though all hospital administrators are not qualified legal persons

yet they are supposed to possess sufficient knowledge of the Indian

Laws

to be able to take decisions on legal matters.

For example, if he wants to terminate a contract with the contractor

who is building a particular portion of the hospital building he needs

to have knowledge of the Nigerian Contract Act.

Similarly, if he wants to terminate services of an employee, he should

know the provisions of the Industrial Employment Standing Orders

Act, the Industrial Disputes Act and the principles of natural justice.

No doubt he is briefed by the law officer of his hospital before he

takes decision on any legal matter, but he is still required to have

some knowledge of the laws.

Secondly, all hospitals cannot afford to engage full time law officers

or retain part time legal advisors. It is the hospital administrator who

keeps the reign of legal kingdom in his hand in small and medium

size hospitals and decides all matters rightly or wrongly on the basis

of his knowledge and common sense.

Thirdly, the hospitals are no longer immune to legal suits due to

reinduction of the Industrial Disputes Act, 1947 and application of the

Consumer Protection Act, 1986. These acts have made employees

as well as patients morconscious about their rights and privileges and

they expect better working conditions and services from the hospital

administrator. Thuss the hospital administrator has crucial role to play

in legal matters these days.

CEO’s vision to improve hospital services

What does a hospital employee want from his job? Money, security

and career development can be high on the list for most of them, but

Mike Rudd, Logistics Director at Bulmers, says that what really

motivates employees is sharing the CEO’s vision. Though it sounds

odd, with the new world of independent and short stay of personnel, it

is true.

The CEO should communicate his vision about the hospitals as well

as involve the employees at every step. They should be invited to

give their views and discuss how they would work towards the vision.

It would beeasy to say that such as activity is nothing more than a

paper exercise, but it can be very productive and useful because

each individual’s job contributes towards achieving the vision. The

process should entail remaining firmly focused on the CEO’s vision in

conversations and meetings. Thus, one can defuse difficult situations

very quickly by understanding where the personnel are, why they are

there and where they need to go next so that everyone in the hospital

begins to work in a better way and the vision of the CEO becomes

the vision of each and every employee of the hospital.

The focus should be on people first and always on caring rather than

managing. The following approach works in good as well as bad

times:

Share the vision with high and low personnel leaving no place

for suspicion.

Share even confidential information, personal hopes and fears

to create a common vision and promote trust.

Seize every opportunity such as open doors, management by

walking around, networks etc. to make a point, emphasize values,

disseminate information, share your experience, express interest

and show your care and concern.

Recognize performance and contribution of your personnel.

Use incentive programmes whose main objective is not

compensation but recognition.

17. Describe the Health Committees recommendations

Recommendation 1: Promote population-based approaches

The Health Equities Committee recommends an on-going, substantial investment

in public health activities that will prevent disease and promote the health of

Oregonians. Culturally-specific approaches to disease prevention and health

promotion must be part of this investment.

Recommendation 2: Strengthen the relationship between health-focused

Community-Based Organizations and the health care delivery system.

The Health Equities Committee recommends designing a contracting mechanism

that will empower primary care clinics who primarily serve vulnerable

populations to build financial agreements with health-focused community-based

organizations that provide culturally-specific health promotion and disease

management services.

Recognizing that not every organization providing an integrated health home is

focused on serving vulnerable populations, an alternative to renewable contracts

should exist that will enable a provider to purchase community-based and/or

culturally-specific services.

The Health Equities Committee recommends that high-value community-based

health promotion, disease prevention, and chronic disease management services

be eligible for direct reimbursement. Accountable Health Plans must reimburse a

broader range of health professionals including, but not limited to, Community

Health Workers, and a broader range of services including, but not limited to,

peer-led disease management support groups in culturally-specific programs to

maximize the health and function of individuals, families, and communities.

Recommendation 3: Develop programs to incentivize healthy personal decision-

making HEALTH EQUITIES COMMITTEE FINAL REPORT 9

The Health Equities Committee recommends that the state create a Wellness

Account for individuals participating in the Oregon Health Fund program who

receive a subsidy.

The state would deposit money in the Wellness Account based on completion of

wellness activities. Monies accrued in the account could be used towards program

cost-sharing expenses such as premiums and co-pays, or towards non-covered

wellness activities, such as gym memberships or yoga classes. Financial incentives

would encourage individuals to engage in activities that promote health, such as

participating in a smoking-cessation program, getting recommended tests and

procedures, and chronic disease management activities.

The Wellness Account is modeled after Enhanced Benefit Accounts (EBAs) that are

currently being implemented in several state Medicaid programs.

18. What are the Functions of hospital

FUNCTIONS OF THE HOSPITAL

Hospital administration functions can be classified into three broad categories:

Medical - which involves the treatment and management of patients through

the staff of physicians.

2. Patient Support - which relates directly to patient care and includes nursing,

dietary diagnostic, therapy, pharmacy and laboratory services.

3. Administrative - which concerns the execution of policies and directions of the

hospital governing discharge of support services in the area of finance,

personnel,materials and property, housekeeping, laundry, security, transport,

engineering and board and the maintenance.

MAJOR FUNCTIONS OF THE ADMINISTRATIVE SERVICE

Provide service related to accounting, billing, budget, cashiering,

housekeeping,laundry, personnel, property and supply, security, transport,

engineering, and maintenance; and

Render support services to hospital care providers, clients, other

government, and private agencies, and professional groups.

19. Write about Hospital Ethics

Medical ethics is a system of moral principles that apply values and judgments to the

practice of medicine. As a scholarly discipline, medical ethics encompasses its practical

application in clinical settings as well as work on its history, philosophy, theology, and

sociology.

20. Mention briefly about Nursing Service administration

Specific objectives

Understand the principles and functions of management

Understand the elements and process of management

Appreciate the management of nursing services in the hospital and

community.

Apply the concepts, theories and techniques of organizational behaviour

and human relations.

Develop skills in planning and organizing in service education

Understand the management of nursing educational institutions.

Describe the ethical and legal responsibilities of a professional nurse

Understand the various opportunities for professional advancement

20. Write about the History of Indian Hospitals

A hospital, in the modern sense, is an institution for health care providing patient

treatment by specialized staff and equipment, and often, but not always providing for

longer-term patient stays. Its historical meaning, until relatively recent times, was "a

place of hospitality", for example the Chelsea Royal Hospital, established in 1681 to

house veteran soldiers.

Today, hospitals are usually funded by the public sector, by health organizations (for

profit or nonprofit), health insurance companies or charities, including by direct

charitable donations. Historically, however, hospitals were often founded and funded by

religious orders or charitable individuals and leaders. Conversely, modern-day hospitals

are largely staffed by professional physicians, surgeons, and nurses, whereas in history,

this work was usually performed by the founding religious orders or by volunteers.

Today, there are various Catholic religious orders, such as the Alexians and the Bon

Secours Sisters which still focus on hospital ministry.

There are over 17,000 hospitals in the world.[1]

Types Some patients go to a hospital just for diagnosis, treatment, or therapy and then leave

('outpatients') without staying overnight; while others are 'admitted' and stay overnight or

for several days or weeks or months ('inpatients'). Hospitals usually are distinguished

from other types of medical facilities by their ability to admit and care for inpatients

whilst the others often are described as clinics.

General The best-known type of hospital is the general hospital, which is set up to deal with many

kinds of disease and injury, and normally has an emergency department to deal with

immediate and urgent threats to health. Larger cities may have several hospitals of

varying sizes and facilities. Some hospitals, especially in the United States, have their

own ambulance service.

District A district hospital typically is the major health care facility in its region, with large

numbers of beds for intensive care and long-term care; and specialized facilities for

surgery, plastic surgery, childbirth, bioassay laboratories, and so forth.

Specialized

teaching hospital in Canada

Types of specialized hospitals include trauma centers, rehabilitation hospitals, children's

hospitals, seniors' (geriatric) hospitals, and hospitals for dealing with specific medical

needs such as psychiatric problems (see psychiatric hospital), certain disease categories

such as cardiac, oncology, or orthopedic problems, and so forth.

A hospital may be a single building or a number of buildings on a campus. Many

hospitals with pre-twentieth-century origins began as one building and evolved into

campuses. Some hospitals are affiliated with universities for medical research and the

training of medical personnel such as physicians and nurses, often called teaching

hospitals. Worldwide, most hospitals are run on a nonprofit basis by governments or

charities. Within the United States, most hospitals are nonprofit.[citation needed]

Teaching A teaching hospital combines assistance to patients with teaching to medical students and

nurses and often is linked to a medical school, nursing school or university.

Clinics Main article: Clinic

A medical facility smaller than a hospital is generally called a clinic, and often is run by a

government agency for health services or a private partnership of physicians (in nations

where private practice is allowed). Clinics generally provide only outpatient services.

History

he earliest surviving encyclopedia of medicine in Sanskrit is the Carakasamhita

(Compendium of Caraka). This text, which describes the building of a hospital is dated

by Dominik Wujastyk of the University College London from the period between 100

BCE and CE150.[8] According to Dr.Wujastyk, the description by Fa Xian is one of the

earliest accounts of a civic hospital system anywhere in the world and, coupled with

Caraka’s description of how a clinic should be equipped, suggests that India may have

been the first part of the world to have evolved an organized cosmopolitan system of

institutionally-based medical provision.[8]

King Ashoka is said to have founded at least eighteen hospitals ca. 230 B.C., with

physicians and nursing staff, the expense being borne by the royal treasury.[9] Stanley

Finger (2001) in his book, Origins of Neuroscience: A History of Explorations Into Brain

Function, cites an Ashokan edict translated as: "Everywhere King Piyadasi (Asoka)

erected two kinds of hospitals, hospitals for people and hospitals for animals. Where

there were no healing herbs for people and animals, he ordered that they be bought and

planted."[10] However Dominik Wujastyk disputes this, arguing that the edict indicates

that Ashoka built rest houses (for travellers) instead of hospitals, and that this was

misinterpreted due to the reference to medical herbs.

According to the Mahavamsa, the ancient chronicle of Sinhalese royalty, written in the

sixth century A.D., King Pandukabhaya of Sri Lanka (reigned 437 BC to 367 BC) had

lying-in-homes and hospitals (Sivikasotthi-Sala) built in various parts of the country. This

is the earliest documentary evidence we have of institutions specifically dedicated to the

care of the sick anywhere in the world.[11][12] Mihintale Hospital is the oldest in the

world.[13] Ruins of ancient hospitals in Sri Lanka are still in existence in Mihintale,

Anuradhapura, and Medirigiriya.[14]

The first teaching hospital where students were authorized to practice methodically on

patients under the supervision of physicians as part of their education, was the Academy

of Gundishapur in the Persian Empire. One expert has argued that "to a very large extent,

the credit for the whole hospital system must be given to Persia".[

Quality and Accreditation

Laverty Pathology is committed to providing the highest quality service to doctors and

their patients. The management systems we have in place uphold the quality standards

within our organisation and form the platform on which our commitment to continuous

improvement is built.

This is assured through quality management principles of medical accreditation bodies as

the basis of continuous performance improvement.

Management Systems An extensive internal Quality Control Program throughout all areas of testing.

Participation in the continuous external Quality Assurance Programs of the Royal

College of Pathologists (RCPA).

Accreditation and compliance with Quality Managements Standards including Australian

Standard (AS) 4633:2004 (ISO 15189) – Medical Laboratories – Particular requirements

for quality and competence.

Accreditation to Australian/New Zealand Standard (AS/NZS) 4308: 2001.

Accreditation for specific areas of laboratory testing by the Therapeutic Goods

Administration (TGA).

Our demonstrated technical competence is assured through accreditation by the National

Association of Testing Authorities (NATA).

Specialist Diagnostic Services Pty Ltd is committed to ongoing customer satisfaction and

continuous quality improvement which form the basis of our organisational values.

Bio-Medical Waste: Management Issues

A major issue related to current Bio-Medical waste management in many hospitals is that

the implementation of Bio-Waste regulation is unsatisfactory as some hospitals are

disposing of waste in a haphazard, improper and indiscriminate manner.

Lack of segregation practices, results in mixing of hospital wastes with general waste

making the whole waste stream hazardous. Inappropriate segregation ultimately results in

an incorrect method of waste disposal.

A bag not securely tied results in scattering of Bio-Medical waste. Bio-Medical waste

scattered in and around hospitals invites flies, insects, rodents, cats and dogs that are

responsible for spread of communicable diseases like plague and rabies.

Most importantly there is no mechanism to ensure that all waste collected and segregated,

reaches its final destination without any pilferage. Additional hazard includes recycling

of

disposables without even being washed. [5].

Usage of same wheel barrow for transportation of all categories of waste is also a cause

of

infection spreading. Most of the times there is no monitoring of trolley routes, resulting in

trolley movement around patient care units posing a serious health hazard.

There is no mechanism for ensuring waste treatment within prescribed time limits. Note

that, Bio-Medical waste if not handled properly and within the stipulated time period

could

strike in the form of fatal infections.

In some hospitals there is no proper training of the employees in hazardous materials

management and waste minimization aspects. This indicates the lack of even basic

awareness among hospital personnel regarding safe disposal of Bio-Medical waste.

7 approaches to marketing hospital services Product/Service:

The hospital or healthcare industry produces services as against product. The healthcare

service is intangible, it is inseparable, it is variable and it is perishable. It is because of

the nature of healthcare service that its marketing differs from a conventional

product. The hospital should bring out the service variety, design features, warranties

and returns of their service. These attribute will aid the consumer in understanding the

whole package of treatment.

Place: Under the place element, the hospital should bring out the channel, coverage,

location and the transportation means for reaching the hospital. It will be anti marketing

for a hospital that is in Lagos for instance to be hard to reach. The place element also

bears implications for the structure of the hospital. A building that will provide a

healthcare service should reflect this from its plan, building and its interior.

Price: The price element may include the least price, discount, allowances, payment

period and credit terms. All these must be determined by the hospitals so that the buyer

of their service can know what decision to make. Where there are charges to be paid,

these should be made known for people to know. This will reduce rumour mongering

about illegal collection of fees. This is very important because of the negative publicity

such issues may cause.

Promotion: The promotion element is one of the items that make people to attribute

marketing to advertising. Every hospital is involved in one promotion or the other. The

hospital sign board is a promotional item. The doctor’s complimentary card is a

promotional material. The hospital letter head and house colour are all promotional

materials. It should be noted that the nature of hospital service determines the type of

promotion that will best suit them. The promotion mix includes sales promotion,

advertising, sales force, public relations and direct marketing. The promotion of hospital

service brings goodwill for that hospital.

People: Hospital services are provided by highly skilled people. That is why the

selection, training and motivation of these highly skilled professionals can make a huge

difference in patient satisfaction. Healthcare professionals who work in the hospital

should exhibit competence, caring attitude, responsiveness, initiative, problem solving

ability and goodwill. They should be competent enough because hospital service is life

related. Non competence as an excuse will not be tolerated. A caring attitude towards

the patients and responsiveness to the problems of their patients and their relatives are the

attributes of a good health professional.

Physical Evidence: Physical evidence of a hospital includes things like cleanliness,

physical structures of the hospital, equipment, and the admission process. They also

include such things as symbols, cars, ambulances, the reception room and the state of the

wards. Hospitals can try to demonstrate their service quality through physical evidence

and presentations. For instance, making the admission procedures less stressful and time

wasting can go a long way in positioning the hospital well. The way the beds are dressed

can go a long way in creating a good image for the hospital. There is the need for

hospitals to demonstrate their service quality through this physical evidence since

hospital services cannot be felt or touched.

Process: Hospitals processes could be made easier and less stressful. The admission

procedure, the discharge process, the drug collection procedures can be made to have a

human face. Hospitals can also choose among different process to deliver their

services. It is suggested that hospitals can integrate these marketing ingredients of

product, place, price, promotion, people, physical evidence and process in their

operations.

Ogukwe Chukwu Anyim is a council member of the Institute of Health Service

Administrators of Nigeria (IHSAN) and a member of the Nigerian Institute of Public

Relations. He is also a Registered Dental Technologist and a member of the Dental

Technologist Registration Board of Nigeria (DTRBN). Presently, he consults for Now

Strategies Ltd – a healthcare marketing outfit based in Lagos

Human Resource Planning We can't negate the fact that sophisticated bio-medical equipment and availability of

world class supporting infrastructural facilities substantially influence the quality of

health care services but ultimately, it is quality of human resources that significantly

govern the development processes. Since we talk about quality in totality, it is pertinent

that all the required inputs are of world class and the human resources prove to be a super

performer. It is in this context that we need to assign due weightage to the development

of a right perception of quality people because a majority of us feel that professional

excellence is the only thing that we need in the development of human resources.

We find several cases where the hospital personnel are efficient but lack human values

which stands as a barrier while developing ethical values. Professional excellence draws

our attention on perfection which is not possible unless the hospitals get human resources

having a fair synchronisation of professional excellence and personal commitments.

Patients and visitors are more impressed and concerned with the attentiveness, empathy

and responsiveness of the health care personnel than with the architecture of the hospital

building, sophisticated machines or ward facilities like television, refrigerator, telephone,

newspaper, music etc.

Today it is increasingly recognized that survival and success depends largely on the

quality of human assets.

Manpower planning is the prime function of the hospital personnel manager, manpower

planning starts with the analysis of the future needs of the hospital and its objectives. It

determines organization structure, decides what jobs have to be filled and what their

requirements are.

Human resource management program is the process by which an organization ensures

that it has the right number and kind of people, at the right places, at the right time,

capable of effectively and efficiently completing those tasks that will help the

organization achieve its overall objectives.

We are aware of the fact that in hospitals, a number of personnel of different categories

are found working requiring multidisciplinary expertise and excellence. The doctors,

para-medical staff, nursing staff and staff of managerial cadre have been found playing an

important role in offering the health care services. It is essential that a hospital manager

knows about the qualitative-cum-quantitative requirements of different departments and

manages different dimensions of people management in the required fashion.

Recruitment or selection is considered to be an important dimension of human resources

management and the recruitment processes are to be managed professionally so that

hospitals succeed in getting quality people with rich credentials. It is also essential that

the process of recruitment is cost effective. Since we find use of information and

communication technologies even in hospitals, the recruitment process can be made more

scientific, cost-effective and result-oriented.

Since we find sky the only limit for perfection, it is pertinent that a hospital manager

organises different types of training programmes and behavioural management to enable

the personnel to develop their knowledge and credentials. The development of personnel

should have a correlation with the development and adoption of technologies.

Compensation and motivations play an important role in managing the human resources.

In this context, it is essential that we offer to the hospital personnel handsome financial

and non-financial incentives.

Therefore, we need human resources having world class professional excellence; we need

human resources having personnel commitment; we need human resources having ethical

and human values and only then we are found successful in making human resources

high performer.

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The strength of the hospital is the strength of its medical staff. In considering the setting

up of a new hospital, one of the first things to which the planning authority should give

serious thought is the question of staffing. It should be ensured beyond all reasonable

doubt that medical, nursing and technical staff with suitable qualifications and in

sufficient numbers will be available. However, to ensure smooth operations in a modern

hospital, the services of support and administrative staff is of paramount importance.

Manpower for a hospital can be broadly classified into four categories : -

Top management.

Medical Personnel.

Nursing personnel.

Equipment Planning Need for Medical Equipment Planning:

Advances in Engineering and information technology in the recent years have brought

about several changes in the field of medical science. Medical equipment plays a vital

role in the health care delivery system. Medical equipment and instrumentation forms the

backbone of any modern hospital and forms the most important component of overall

project cost. The following factors need to be borne in mind while evaluating and

selecting medical equipment.

The level of Medicare to be delivered by the hospital is dependent on the medical

equipment.

The cost of Medical equipment is very high.

The changes in medical technology are very rapid, modular design and up gradation

become crucial.

Care has to be taken in selecting the right model from the right supplier to ensure

effective after sales service.

The equipment should be able to provide cost effective treatment to the patient.

Steps For Selection of Medical Equipment :- Define the objective of the hospital.

Research

Teaching

Commercial

Define the medical equipment of the hospital (Doctors brief)

Prepare detailed equipment specifications based on the medical requirement.

Call for technical bids based on the specifications prepared.

Analyze the technical bid and bring all suppliers on the same platform for technical

comparisons.

Call for financial bid on the financial, technical and commercial conditions.

Prepare a list of selection criteria and priorities.

After selecting the supplier, preparation of detailed purchase order, which includes all

points of technical and commercial value.

Process of equipment selection :-

In order to make the decision cost-effective and optimal, a multi-disciplinary team of

specialists with co-ordination by experts should be formed.

The team should consist of

Practicing Doctors / Specialist Consultants for respective clinical discipline.

Application Specialist.

Materials Manager.

Biomedical Engineer.

Project Manager.

Hospital equipment falls into an extremely wide spectrum ranging right from a hitech

cath lab and CT scanner to a simple patient trolley. Equipment needed for a new hospital

can be classified into the following three groups based on the usual methods of

acquisition and on suggested accounting practices in regard to depreciation.

Top

Built - in Equipment

This is usually included in the construction contracts. Examples are cabinets and counters

in pharmacy, laboratory and other parts of the hospital, fixed kitchen equipment, laundry

(linen) chutes, elevators, dumb waiters, boilers, incubator, cold rooms/walk-in coolers,

deep freezers, fixed sterilizing equipment and surgical lighting. The planning and design

of fixes equipment built in to the hospital facility is the architect's responsibility.

Depreciable Equipment

Equipment that has a life of five years or more is not normally purchased through

construction contracts. These large items of furniture and equipment have a reasonable

fixed location in the hospital building but are capable of being moved. Examples are

surgical apparatus, diagnostic and therapeutic equipment, laboratory and pharmacy

equipment, office equipment, etc.

Non-Depreciable Equipment

Equipment having less than five years life span is purchased through other than

construction contracts. These are generally small items of low unit cost under the control

of the storeroom. Examples are kitchen utensils, chinaware, tableware, surgical

instruments, catheters, linen, sheets, blankets, lamps, wastebaskets, etc.

The consultant must prepare a list of all the items of equipment under groups 1, 2 and 3

given above. The first step in preparing this list is to consider each room as separate

entity in the plan and prepare a comprehensive room-by-room equipment list, which

should include additional items that may be required for the hospital. Detailed

specifications must be given. This task must be undertaken during the design stage itself.

Working in close association with the architect, the consultant should test the space

needed for each item of equipment on the list.

The selection of technical, scientific and medical equipment requires careful analysis of

the needs of each department and continuous study that will result in the selection of

equipment that will best meet the needs of the department. The present day high-tech

medical equipment is so mind boggling even to medical experts that the consultant or the

administrator, being an unwary layman, may be easily stumped in the selection process.

Department heads and staff members should be fully satisfied with the type and quality of

the equipment. For this reason, they should be consulted before purchase. It is not

unusual, particularly in a new hospital, that a consultant has selected equipment for a

department only to find the chief user of the department rejecting it as unsuitable.

Survey should also be made to ascertain as to how a particular piece of equipment is

performing in other places. Money often gets wasted by purchasing equipment that is

either not utilized, or not fully utilized, or is of inferior quality. All those who are

involved in the selection and purchase of equipment should exercise extreme caution and

avoid procurement of equipment that will be a loss or liability to the hospital.

Adequate arrangements for storage of equipment on the site should be made. These

arrangements, while providing for protection against weather, theft and damage, should

also not interfere with the construction work.

If a systemic and logical approach is adopted in hospital planning, a method can be

devised whereby foreseeable maintenance problems can be eliminated at the very

inception.

Top

List of selection criteria Level of technology and cost of the equipment (high/mid/low)

Service capability of supplier to guarantee minimal downtime.

Ability to render service manuals and assist in-house Bio-medical engineers as and when

required.

Providing vital spare parts as stand-by on a priority basis.

Running cost of the equipment.

Annual service contract, etc.

Uptime guarantee.

Availability of consumables required.

Generation of adaptability / up-gradability.

Considering a particular model, period of introduction and usage in other similar set ups.

FDA and other approvals.

Display in latest international medical equipment exhibition.

Training And Application Support The supplier should at the time of delivery and installation, provide proper training and

associated manuals for personnel slated to utilize the equipment. The training should be

of sufficient scale so as to familiarize to the end user and all concerned. All

documentation regarding circuit diagrams and associated manuals should also be supplied

at the time of installation.

Equipment :

The essential medical equipment for a cardiology set up is included in the following list:

Electro cardiogram – which detects the electrical activity of the heart muscle.

X- ray chest – shows the size, shape and position of the heart, lungs and bone structures

of the chest.

Echo gives information about the heart pumping efficiency and status of the valves.

Treadmill test helps in detecting blockages in coronary arteries.

Cardiac catheterization lab or commonly known as cath lab where catheterization is

performed in which catheters are inserted through the blood vessels upto the heart and

information is obtained about the blockages in the blood vessels of leg, brain, kidney and

various organs in the body and also used to know whether there is any defect in the heart.

Ambulatory ECG (Holter monitoring) in which continuous recordings of one or more

ECG leads may be obtained by attaching them to a small portable tape recorder. This

technique is useful for detecting transient episodes of arrhythmia.

Resuscitation cart containing readily accessible, easily identifiable, necessary emergency

drugs and resuscitation equipment.

Defibrillator is a medical device used in the defibrillation of the heart.

Ventilator is a device designed to provide mechanical ventilation to a patient. Ventilators

are chiefly used in intensive care medicine, emergency medicine and in anaesthesia.

Monitors for evaluating the vital functions and parameters of the patients.

Pulse oximeters are medical devices that indirectly measure the amount of patient’s

blood. It is often attached to a medical monitor so that the staff can directly read a

patient’s oxygenation at all times.

Marketing Hospital Services

Need for Marketing Hospital Services Today's market has become consumer driven, and the health care market is no exception.

The hospital industry is booming today. This has led to an increased competition and

ultimately it is the survival of the fittest. Patients are better informed and know more

about health care services. As a matter of fact, at no time in history have people known so

much about health care and medicine as they do today. Having become cost conscious,

they demand quality care for a reasonable price. An informed patient would like to get

value treatment for his money. He wants to be told about medical and surgical procedures

and given choices for alternatives if any. Hospitals, for their part are introducing new

programmes to catch the consumer's attention. Competition, surplus of supply in the form

of mushrooming of hospitals and nursing homes, diminished demand; informed

consumers who demand better standards of service and quality have forced hospitals to

turn to marketing. Through the process of marketing the society and the health care

system can be brought together. Marketing is thus an excellent competitive weapon that

can be used in hospitals to achieve the aforesaid goals.

Marketing Medicare-A Conceptual Framework At the outset, let us go through the conceptual aspect of marketing medicare. By

marketing medicare services we mean making available the medicare services to the

users in such a way that they get quality services at the reasonable fee structure. The

social marketing principles focus on making available the services. It is in this context

that we find marketing medicare a managerial approach to formulate a sound service mix

in the face of latest developments in the medical sciences. The societal marketing also

focuses on promoting the services in the face of target users. The principles throw light

on inculcating mass awareness so that the prospects change their living conditions,

lifestyles, preferences, food habits, found prone to disease. Thus contrary to other

organizations, the hospitals responsible for making availabe to the users the quality

medical aid are supposed to minimize the number of prospects.

Marketing Medicare is well supported by innovations in promotion. Since we consider

hospitals or healthcare centers to serve as social institutions, it is not just that they make

profits. Against this background, we call them not-for-profit making organizations.

Quality inputs can only deliver quality outputs. If hospitals invest on quality inputs, the

costs on services go up. According to the general marketing principles, we have a

freedom to generate profits and therefore the price setting process is not so difficult. The

price fee setting process in found a challenging task. Against this background, we

advocate in favour of a rational fee structure, which would be adjusted in proportion to

the incomes of the different categories of prospects. The marketing principles for

Medicare services also focus on distributing the services to the users in a decent way and

essentially on time. This draws our attention on the distribution channels. There are a

number of agencies for extending financial and technical support to hospitals. In addition,

we find involvement of a number of core and paramedical personnel. A minor gap in the

distribution process may result in grave consequences. The societal marketing principles

suggest, a small channel with the minimum possible gap between the provider of services

(hospitals) and the users (patients).

In view of the above, it is right to opine that marketing medicare is a managerial device to

satisfy the users so that they help in promoting the business and the hospitals are found

successful in projecting a positive image.

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Users are found satisfied.

Time honoured service mix.

Inculcating mass awareness.

Thrust areas can be identified.

Vulnerable segment can be identified.

Behavioral dimension can be given due weightage.

Services can be made cost - effective.

A rational fee structure.

For motivating personnel.

Promotion is an important dimension of marketing which simplifies the task of

motivating the prospects and transforming them into actual users. In the medicare

services, we focus on two components, e.g. innovating the promotional measures and

inculcating mass awareness.

Advertisement and publicity Of course, we find advertisement and publicity measures sensitive to promote medical

services but in no case we need to welcome the use of these tools for making profits. At

the very outset, it is clarified that hospital is a not for profit making organization. If we

find consultancy organizations or hospital planners advertising in favour of profit

generation process the masses would suffer sizably which would be against the principle

of social marketing. No doubt, the hospitals can focus on the quality of their services,

they can also throw light on their contribution to the social transformation process but in

no case are allowed to advertise for generating profits.

Service Promotion It is also an important dimension of promotion which is found instrumental in the

generation of efficiency, formation of a team spirit, establishment of a work culture and

more so a personal-touch-in-service. Offering of quality services is of course a teamwork,

which requires involvements of the entire medical and para medical personnel and other

staff. Here it is essential that we link the incentive plan to the performance of hospitals.

In view of the above, we find innovation in the process is a must. The motive is to serve

the society. The motive is to improve the quality, the motive is to make the services cost-

effective, and the motive is to minimize the medicare needs and in due course to

minimize the pressure on hospitals. A solution is to market the services in a right fashion.

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Place Mix The need of the hour is to minimize the existing gap in the distribution of medicare

services.

Strategic Marketing To make an assault on short and long run problems, it is essential that we have an action

plan and the strategies are formulated accordingly.

Marketing Strategies for the Hospital Marketing strategies for the hospital have been designed systematically using research

both to identify the audience and to assess what the audience currently want regarding the

health issue. The strategies will enable appropriate audience-centered communication

planning.

Brochures

Brochures go a long way in promoting the hospital. A general brochures and speciality

brochures for the various specialities should be designed. The general brochure can

contain a write-up of the hospital, services covered and specialists on the staff.

Billboards or hoardings

A large billboard must be created and displayed in two to three locations throughout the

city. In certain strategic locations, a large billboard will be passed by some thousands of

people everyday.

3. Tie-up with neighbouring clinics

Develop a tie-up with the neighbourhood clinics, so that the patients with heart problem

can be referred to the speciality Hospital.

Newsletters

An external newsletter can be sent periodically to the neighbouring residential complexes

(fortnightly or monthly) containing news about the hospital and the service it provides,

and articles on hot medical topics.

5. News release and press coverage

Hospital events, public interest topics, public service messages, community health

programmes, photographs of the interior of the hospital etc. can enhance public

awareness. The medical experts of the hospital can write a weekly/monthly column in

newspapers and publicize the competence and expertise of hospital cardiologists which

helps to attract people to the hospital.

Exposure through local channels

Advertisements and health messages sponsored by the hospital can be scrolled on the

local channels (on zonal basis) and in newspapers in order to create additional exposure

of the hospital. This will also reach a larger audience. Talks by medical staff on various

health topics could be presented on television.

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Centralised patient service center

One way of providing friendly patient service is to set up a centralised service center. It is

a marketing system, which combines telecommunications technology with Management

Information System for marketing hospital services. The centralised patient service center

should offer patients a direct line to trained, well-informed and knowledgeable

representative of the hospital with immediate access to any information they seek. Quick

authoritative information all in the course of a brief conversation, will result in first class

patient relation, build hospital loyalty, spread good word of mouth and finally expand

patient base. To respond to these enquiries effectively, the patient service staff must be

specially trained and efficient. They should have good telephone etiquette and be aware

of the specialities and specialists in the hospital. They must have information on every

aspect of the hospital at their fingertrips.

Health awareness programmes

Health awareness programmes can be conducted in the residential complexes of the

neighbourhood. Healthcare services available at the hospital can thus be introduced to the

public. Provision can be made to refer patients to the physicians for follow-up wherever

necessary.

Free health checks

The hospital can conduct free health camps periodically. The date and timings of such

programmes should be advertised in the local newspaper.

Saturday evening club talks

One day of the week (preferably Friday or Saturday) can be devoted for conducting

special clinics and educational programmes, which can include.

Awareness about heart diseases and their prevention.

Dieting and stress relief programmes.

Regular exercise and practice of Yoga.

Adult Fitness Programmes.

Speakers' bureau

The CEO and the medical staff should use every opportunity in the city and outside to

speak to service organizations like clubs, schools, colleges, professional and business

organizations and associations about the hospital and on health matters. Letters may be

sent to various organizations intimating the names of speakers in the bureau and the

topics of discussion. A valedictory dinner can be sponsored by the hospital at the end of

the talk. Referral Cardiologists and Doctors can also be invited to such functions. This

will ensure that even the medical community is aware of the hospital.

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Marketing the hospital to districts

The various facilities provided by the hospital can be marketed to the districts like

Nalgonda, Medak, Rangareddy, Mahboobnagar, Warangal, Karimnagar and Khammam

etc., This can be made more effective if the consultants conduct camps and promotional

tours at the respective districts and conduct check-ups (either free or for a nominal

amount). This strategy will increase the patient base and awareness of the hospital.

Patient education material

The hospital should have sufficient Patient Education Material placed strategically

throughout the hospital. The patient education materials can either be in the form of

flyers or posters. A Patient Guide should also be designed which should contain the

following.

History of the hospital

Admission information

Services available

Consultants available

Instructions to patients

Tariff rates

Visiting hour details

Diet and nutritional details

Important telephone numbers

Instructions to attendants.

Direction boards

Direction boards have to be strategically placed to enhance awareness levels and

easy accessibility for the patients coming from various parts of the twin cities and

other districts.

Signage system within the hospital

As effective and easy to follow signage system in the hospital will help the

patients in fading their way around. Floor plans of the building should be

displayed in strategic places. Areas like the Laboratories, Operation theatres,

ICUs, etc. should be clearly marked. A directory of doctors and specialists should

also be displayed permanently in the lobby.

Medical insurance programme

With the insurance sector under the liberalization scheme promising to open up to

other players outside the national insurance companies, healthcare industry

appears to be poised to play a bigger role in this area. The hospital can start its

own insurance scheme or the one linked to insurance companies.

Ambulance services

Based on the analysis conducted, an ambulance can be devoted for the Hospital

equipped with all the life saving machines and monitors. Transportation can be

arranged for a fee for out of station patients and their relatives from and to the

airport, railway station and for local patients before and after day surgeries and on

discharge. This can be an effective public relations and marketing programme.

Rehabilitation facility

Cardiac rehabilitation services provide comprehensive services which include

physiological, psychosocial, vocational and educational components. This facility

creates awareness among the general public about the primary prevention of the

disease.

Hospital Planning Selection of the site :

The site for a new cardiology super speciality hospital would be selected and purchased

after analyzing the market survey report. The following factors must be taken into

consideration while selecting and purchasing the site :

The hospital should be centrally located in a way that, it should be easily accessible for

transportation and communication lines.

There should be adequate parking facilities.

Availability of public utilities like water, sewerage, electricity, fuel and telephone lines.

Proper elevation for good drainage and general sanitary measures.

The hospital should be free from any kind of pollution.

Supply of manpower.

The infrastructure should be properly planned.

The hospital should be built keeping in view for future expansion.

Cost is also a prime consideration while building a hospital.

Climatic conditions should be considered.

Site survey :

After the site selection, a survey and soil investigation must be made to obtain all the

information necessary for the design of the foundation, mechanical service connections

and development of the site.

A map or plan of the piece of land will be prepared. The map indicates complete details

and location of the building, structure, easement, right of way or encroachment on the

site, details of boundary walls, foundations, etc, adjacent to the site and trees that will be

affected by the proposed building.

The map or plan would then be certified by appropriate authorities, like the Municipality

of the city.

The architect will be arranged for an in depth study to determine subsoil conditions. The

study includes a sufficient number of test pits or test borings to determine the true

conditions. The architect would also detain detailed information relating to subsoil

conditions such as soil bearing capacity, thickness, consistency, character, etc. of various

strata, amount and elevation of ground water in each pit, elevation of rock, high and low

water levels, whether the soil contains alkali in sufficient quantities to affect concrete

foundation, etc.

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Design and Layouts :

A successful hospital is built on three principles:

Good planning

Good design and construction

Good management

Planning and design of the hospital must result in a functional, efficient and economical

unit. Even a minor defect in designing can result in capital costs and maintenance costs

escalations.

The key to a good design can be summarized as follows :

Due consideration has to be given to the patient’s emotional and security needs along

with functional aspects of functioning of the hospital operations.

Establish the shortest possible traffic routes. Unnecessary steps increase the complexity

of operations, cost money, time and human fatigue.

Separation of different types of activities and different kinds of traffic should be

followed.

Control over the different areas of the hospital is vital.

External traffic

As seen from the above consideration the internal and external traffic flow plays a

significant role in designing the hospital. The most effective way of regulating different

types of traffic that traverse the hospital is to separate it even before it enters the hospital.

This end is achieved by providing three entrances:

Main entrance for emergency patients, visitors and staff

Emergency entrance for emergency patients and ambulance cases

Service entrance for delivery of supplies, and for pick up or removal of trash and garbage

from the facility.

Parking area

The parking areas for patients, staff, ambulances and delivery trucks are planned

differently, so as to avoid conflicting lines. Keeping the entrances to the hospital at a

minimum reduces the cost of maintenance and provides increased security.

Internal traffic

There are mainly three traffic routes that are found in a hospital:

Patients and visitors

Staff

Materials

Separating the different departments and yet decreasing the horizontal travel can avoid

internal traffic flow congestion.

HOSPITAL PLAN

According to the plan the area of land is 9,500 square yards with a built up area of

approximately 1,00,000 square feet. The entire set up has been divided into 6 floors and a

basement.

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Facilities Available in Various Floors :

Basement :

Food and Beverages

Stores

Medical Records

Bio- medical department

Laundry

Hospital Information System

Ground Floor :

Reception and Billing

Waiting area

Consultation rooms (OPD)

Emergency

Diagnostics - X – Ray

ECG

2D ECHO

CT Scan

Phlebotomy room

Florist and Gifts shop

Rehabilitation

Coffee shop

First Floor :

General ward

Nursing station

Waiting area

Stores

Biochemistry Lab

Blood Bank

Superintendent's room

Second Floor :

Cath Lab

Cath Stores

Medical ICU

Step down unit

Semi private rooms

Nursing station

Doctors rooms

Third Floor :

Operation theatre complex

Central Supply and Sterilization Department

Waiting area

Surgical ICU

Step down unit

Doctors conference hall

Medical records room

Doctors rooms

Fourth Floor :

Single rooms

Deluxe rooms

Coffee shop

General stores

Nursing station

Doctor's room

Fifth Floor :

Administration wing

Main conference hall

Auditorium

Library

Accounts and Finance wing

Pantry

Lockers