Challenges Hospital Management In Nepal

The WHO defines health as ” A complete state of physical, mental and social wellbeing, not merely the absence or disorder” (WHO, 1948). It means that complete state of wellbeing is health and hospitals one of the major tool for promotion of health. WHO in 2010 has addressed the role and importance of hospital management for a quality health (WHO, 2010).

There is no internationally accepted clear definition for hospital. There are several types of hospitals based on the facilities, equipments and services, i.e. district hospitals, provincial hospitals, speciality hospitals and referral hospitals, teaching University hospitals and other types of health care facilities. There is no international standard defining what should be the minimum services that each hospital should provide during a health crisis. Each country has to develop a national policy and technical guidelines to deal with a health crisis. Before defining the essential services, the ministry of health has to define the essential health services that the health sector will provide to the community in order to identify what more specific services will be delivered by hospitals (WHO, 2009).

Management is defined as the organization and coordination of the activities of an enterprise in accordance with certain policies and in achievement of defined objectives. Management is included as a factor of production along with machines, materials and money. Renowned guru of management Peter Drucker (19909-2005) has said that the basic task of management is two fold: marketing and innovation. Practice of modern management owes its origin to the 16th century enquiry into low efficiency and failures of certain enterprises, conducted by the English statesman Sir. Thomas Moore (1478-1535). As a discipline, management consists of the interlocking services of formulating corporate policy and organizing, planning, controlling and directing an organization’s resources to achieve the policies’ objectives (Walden University, 2011).Hospital managenmnet.net suggests that Hospital Management provides a direct link between healthcare facilities and those supplying the services they need ( Hospital management.net 2011) .

WHO in 2009 suggests understanding by hospital management as an effective and combined management of, the following factors:-

(a) Acute care for emergency patients;

(b) Out Patient Department (OPD) activities;

(c) Investigation (laboratory; X-ray; other diagnostic elements);

(d) Referral for primary health care (PHC); specialized consultations or services;

(e) Contribution to public health programmes;

(f) Part of health information system (surveillance system, including a EWS

Component);

(g) Public information and education; and

(h) Preparedness for health crisis management.

Nepal is a landlocked country which is mostly covered by hills and mountains and it has a population of 25.8 million as estimated in 2006. It is in the south Asian continent, north to India and south to China. Its area is 147,181 sq. km (WHO, 2007). It has been facing several challenges to establish a functional health management system (Thapa, 2010).

This proposal deals with the challenges which Nepali health system is facing at present and suggests the possible ways for its improvement.

Statement of the problem

Nepal’s health system is in transition. Nepal is an underdeveloped country where most of the geographical part (85%) is covered by mountains and hills. India is in the south and China is in the northern part of the landlocked country. The southern boarder is open where the northern part is separated by the high mountains called Himalayas. The health indicators are very poor. The health service facility is not adequate to Nepali people. So the hospitals are (Dixit, 2005). Nepal’s hospital bed per ten thousand populations is 4.26 (2001/02), physician per ten thousand populations is 2 and Nurses per ten thousand population is also 2 as per the data of 2004 Similarly, Total Expenditure on Health (THE) as % of Gross Domestic Product (GDP) 5.3% and Public Expenditure on Health (PHE) as % of Total Expenditure on Health (THE) is 28 while Private Expenditure on Health (PvtHE) as % of Total Expenditure on Health (THE) 72(WHO, 2007). If it is compared with the other developing countries in the same region i.e. south east Asian region, the level of the problem may be perceived. Maldives, a small tiny country with population 298 thousand has Total Expenditure on Health (THE) as % of Gross Domestic Product (GDP) 6.2. Maldives’ Public Expenditure on Health (PHE) as % of Total Expenditure on Health (THE) is 89 as compared with 28 of Nepal. Private Expenditure on Health (PvtHE) as % of Total Expenditure on Health (THE) in Maldives is 11. It shows that the state has better involvement in Maldives than in Nepal. More over, the population per hospital bed is 381, which are 26.2 hospital beds per 10000 populations. Similarly, number of populations per physician 959 and nurses per 10000 populations are 33 (WHO, 2007). It clearly shows the scenario of health development of Nepal.

As part of health, curative health services have a major role in providing quality health service to the people. Until the health care provider organizations are strong, the curative health service can not be delivered to the beneficiaries properly (Edelman and Mandle 2006). Hospitals are the key component of health care delivery system and they needs to be reformed to ensure a quality health care system (McKay and Healy, 2000).Unfortunately the hospitals in Nepal have very poor in quality management and they are not able to deliver quality health services to the people (Dixit, 2005).

To address the needs and requirement of the hospital, the government of Nepal ( GON), Ministry of Health and Population ( MOHP) has published ”The guideline on the establishment, Operation policy and standard and infrastructure for Private and Public Health Hospitals” in 2004 ( MOHP,2004). But it is still lacking in the formulation of the standard for the hospitals run by the government (Dixit, 2005). However, the policy published by the MOHP tries to clarify on the basic parameters of the infrastructures required for the hospitals which may be applied for the general hospitals as well. But the document does not speak about the application in the government run hospitals (MOHP, 2004). That is why; there is a lack of clear cut guideline for the management of hospital.

Nepal’s health sector is facing a challenge regarding the management (Dixit, 2005). As part of whole system of health in Nepal, management of the hospitals is also a sever challenge for the country.

1.2 Summary of the problem

Nepal has set a target to achieve the millennium Development goals by 2015. It has to meet the target in all health indicators. Goal no 3 and 4 are c loosely related with health and as part of curative health, hospital and hospital management have crucial role in health promotion. In Nepalese context, hospital management skill and concept of hospital management is still beyond the priority of the government and the government still does not have any policy guidelines over the hospital management sector (Dixit, 2005).

People skill is a key asset for the development of key management styles. Dealing the people is a professional skill in itself. Being able to see from the perspective of others is essential, and caring for their welfare is also of prime importance. There are many high-profile examples of how to develop a successful management style. Managers like Bill Gates and Warren Buffett have famously developed their own distinctive management style from which others can learn. However, the fact that the two examples are very different management styles shows that there is no single route to success (Bono and Heller’s, 2009). But unfortunately, there are no clear guidelines or policy found in the government documents. The recent document on the guideline on the requirement of a hospital, government does not speak about the hospital management, its skill development and transfer for the improvement of a hospital (MOHP, 2004).

Lack of professional skill in the person responsible to manage the hospitals has created a problem in hospital management. The government run or supervised hospitals still do not have positions for the hospitals. MOHP in its policy document has not mentioned anything about the hospital managers (MOHP,2004). However, the private hospitals have started hiring them which is still out of the government policy (Thapa, 2010).

Nepal is an underdeveloped country where the literacy rate is only 62.7% for male and 34.9% for female as per the report of census 2001 (CBS, 2001). It means still 64.1% women are out of literacy coverage. Nepal has poor health facilities all over the country except in capital Kathmandu and other urban areas. Most of the doctors are not willing to go to the rural areas hospitals and they are often running without (qualified) doctors (Dixit, 2005).

In conclusion, the poor socio-economic conditions, hard geographical conditions and lack of awareness of the people and traditional beliefs and superstitions, lack of will in the political parties and their leaders are the main burning issues for the improvement of health sector in Nepal (Chaulagain, 2004). These all are problems associated with the hospitals and ultimately with their management.

The factors associated to hospital management are still not uncovered in Nepal (Thapa, 2010). So, it

Purpose of the study

As mentioned above, it has been obvious that Nepal is facing the problems to strengthen the management of the health sector. The documents are not found to have been lacking regarding the strategies and policies on the health management. So, the proposal aims to identify the hindering factors affecting the hospital management in Nepal. It will study the existing policies and strategies of the government of Nepal on hospital management, international principles, theories and practices on hospital management and identify the factors which are affecting the betterment for hospital management sector of Nepal.

So, the purpose of the study is to identify the hindering factors of hospital management in the case of Nepal and suggest the concerning authorities about improving the hospital management system, formulating the policies and implementing them. This proposal will analyse the strength and limitations of the hospital management system in Nepal and help all the concerned to mitigate and minimize them.

Main research question

The study can not answer all questions that come on surface while studying about the issue. So, to narrow down the study area and sharpen the focus, the study has defined the main study questions as follows:-

What are the hindering factors that effect the hospital management in Nepal?

Subsidiary Questions

To supplement the main research question, these questions are defined as subsidiary questions as follows:-

What will be the appropriate modality or best practices of hospital management that are applied in the world by other countries and

What are the factors that are hindering in the betterment in the hospital management in Nepal?

What is the most influential factor to promote the hospital management in Nepal?

Hypothesis

Lindsen and Jong (2005) have defined hypothesis as an alternative explanation of residual switch trial costs or, more precisely, of the empirical finding that the repetition trial (RT) distribution for switch trials with a long preparation intervals can be modelled as a mixture of the RT distributions for repetition trials and for switch trials with a short preparation interval (Lindsen and Jong, 2010). In here, the hypothesis tries to establish an alternative factor that might be supposed to be the commonest hindering factor for the management of hospitals in Nepal. The hypothesis taken here is the lack of professionalization of hospital managers or the persons who are involved in the management of either government run or private or community run hospitals in Nepal is the most influential limiting factors in hospitals in Nepal.

Significance of Study

As mentioned above there are no special policies and practices established for hospital management in Nepal. The hospitals are managed by the medical doctors or surgeons so far (MOHP, 2004). The doctors are not entitled to diagnose the patients, treat them, run medical and surgical and public health cams campaigns in the hospitals or in the periphery of the hospitals. The Medical council is liable to assign the job responsibilities of the doctors in the case of Nepal. But it has not mentioned about the management part of the hospital and its regulation, Nepal Medical Council Act, 1964 (amended in 2001).It does not speak who is responsible for that (Nepal Medical Council, NMC, 2001). There is no one professionally responsible for the hospital management in the present context. In the country where the government policy about the medical sector does not speak about the role of hospital management, it becomes obvious that the hospital management sector is not running smoothly. No presence of the monitoring body to supervise and evaluate the hospital management is found in the present documents whether published by the government or private organizations. So, the studies’ significance is in establishing the fact what are the main barrier and other minor barriers in the hospital management of Nepal. That is why this study is has a significance value.

Literature Review

2.1 Concept of Hospital Management

Hospital management provides a direct link between health care facilities and those supplying the service they need. This enhances the capacity of deciding and managing hospitals and health care centres and all other health care providers and other health care industries (Hospital management.net, 2011).

The discipline ” hospital management” is found to be conceptualised from the ”WHO Ottawa Charter for Health Promotion” in 1986. It was introduced in the name of ” Health Promoting Hospitals (HPH)” in the beginning since hospital was regarded a mean of health promotion. So, this concept is only 25 years old and newer to other disciplines. The Ottawa Charter recognised five areas of hospital management i.e. health promoting hospital setting, health promoting workplaces, the provision of health related services, training, education and research. It has identified the hospital sector as the change agent and advocate for health promotion (WHO, 2011). From the declaration of WHO, it becomes obvious that hospital is not only a place of treating the patients, but also a place where the activities for health promotion are run, all heath services are provided, trainings are conducted, education is given and researches are carried out. It rules out the understanding of the government on hospitals. The Bir Hospital, which is one of the units or part of the Ministry of Health and Population and the biggest government run hospital (MOHP) of Nepal has defined Bir Hospital only as a treatment and diagnosis service centre. In this definition, the other four parts defined by the Ottawa Charter are missing. However, it adds something in its website as its activities. According to it, Bir Hospital offers training to the students through its Post Graduate programme of its Medicine School (Bir Hospital, 2008). It clearly shows that the government of Nepal has some how realised the integrated approach of the hospitals, but not mentioned in its policy or strategy. There seems a gap between the Ottawa Charter and the understanding of the Government of Nepal in terms of its concept.

National Health Service (NHS) of the UK has presented a model of its Week Hospital in its journal. It says that it has developed and validated an innovative integer programming model, based on clinical resources allocation and beds utilization. According to NHS, the model aims at scheduling Week Hospital patients’ admission/discharge, possibly reducing the length of stay on the basis of an available timetable of clinical services. The performance of the model has been evaluated, in terms of efficiency and robustness, by considering real data coming from a Week Hospital Rheumatology Division. The experimental results have been satisfactory and demonstrate the effectiveness of the proposed approach (NHS, 2011). We can see the factors that contribute in hospital management by this example mentioned above.

The hospital management has become an emerging field in India, the neighbouring of Nepal and a developing country in the south Asian sub-continent. India education in its home page of its website says that hospital management and administration has become a priority and importance for healthcare industry and providing health and hygiene care in India. The government of India is paying attention on providing healthcare in both rural and urban areas by improving the management of the hospitals. It further adds that hospitals are expected to deliver quality service 24 hours a day at a minimal cost. The urgent nature of its work and the level of efficiency that is expected have increased the need of well-formulated hospital management system throughout the world (India Education, 2011). It shows that India has seriously taken the hospital management stream to upgrade the quality of the service delivery of the hospitals in India. These literatures presented above describe the concept of hospital management.

2.2 Benefit of Hospital Management

World’s renowned management ‘Guru’ Peter Drucker developed the concept of Management by Objective (MBO) in 1954. He has defined MBO as a systematic and organised approach that allows management to focus on achievable goals and to attain the best possible results from available resources. He has further said that the strong management system of the organization increases its performance by aligning the goals and subordinate objectives through out the organization. He adds that the employee get strong input to identify their objectives and timeline for completion. He has described the benefits of management to have supporting in setting objectives, organising groups, motivating and communication, measuring performance and developing people ( Peter Drucker,1954).

NHS has defined its hospitals as organizations where high qualities of health care services are delivered to the clients (NHS, 2011). So, all the theories of the organization may be applied in hospitals and the importance of the hospitals may be assumed based on the benefits of a good management system as described Drucker. So, it has become obvious that to achieve the goals of the nation, the hospital management sector should be regarded as an important discipline in the context of Nepal as well.

Limitations of Hospital Management

Management is not a solution, but only the means of the solution which organises the resources in a proper way. For the effective management, every surrounding factor should be appropriate. Verzuh (2001) has identified five sectors that are required for effective management. They are good agreement between service providers and clients, an effective and realistic plan, constant and effective communication, a controlled scope and upper management support (Verzuh, 2001). Hospital as an organization can not provide its best services if the factors mentioned above are not available. In Nepalese context, the hospital management can not take the hospitals in the position to achieve its goals until there is an effective service giving and taking culture, until the planning body is capable enough, until the inter and intra organizational communication is strongly developed and there is a political commitment to prove upper support toward the bottom. So, these are the limitations of the hospital management.

Barriers of Hospital Management in Nepal

Nepal’s literacy rate is low, the national income and per capita income is also low. The difficult geographical situation is not also favourable for rapid development in Nepal. The socio-economic development is far behind as compared with other developed and even with developing countries (Dixit, 2005). As mentioned above, financial strength, political commitment, social culture and context need to be favourable for the good management of every development sector and the hospital is not an exception. The people can not consume the facilities well if they are not aware about the facilities they have been provided with (Thapa, 2010). But hospitals are managed by the Department of Health Services under the Ministry of Health Population and the, So, for the hospital management, this context has become a barrier.

Hospital management practice in different countries i.e. Nepal, USA, UK, India, Japan and Thailand

Hospital management is a new discipline. In Nepal, the Pokhara University strated Hospital Management course in 2001 only. Then it has put a milestone in the way of hospital management. Then some private hospitals have started to recruit hospital managers due to its influence and the government is in the way to start thinking on the need of separate hospital management stream under the health service (NOC, 2011).

In USA, the hospitals are governed by the United States Department of Health. Its history goes to 1798 from when USA has started on managed health service (USDHHS, 2001). UK established National Health Service ((NHS) in 1948 from which it has been running the hospitals. All together, 12000 doctors are working in its hospitals all over the UK (NHS, 2011). Ministry of Health and Family Welfare is responsible for hospital management in India. It has Department of Health and National Rural Health Mission for managing the hospitals (Ministry of Health and Family Welfare, India, 2011). Likewise, Ministry of Health, Labour and Welfare looks health activities in Japan. It has Health Policy Bureau under the ministry and it looks after the hospitals and it has prepared a policy to manage the hospitals properly (Ministry of Health, Labour and Welfare, 2011). In Thailand, Ministry of Public Health looks after the hospital management. Under the ministry, there is Department of Health and under this, there are 9n divisions. They are supporting the hospitals for their management in an integrated way (Department of Health of Thailand, 2011)

2.6 Previous empirical research findings on challenges in hospital management

The Hospital; of St Raphael in UK has written in its website about the challenges it suffering in terms of the management. It says that the demand is growing and the challenge is increasing. Patient satisfaction concerns, hospital management demand, smart mind and smart technologies to keep healthcare system smoothly are the challenges seen in the present context. Likewise, recruiting hospital management and their turnover are other challenges (St Raphael Hospital, 2011). In Nepal context, There are no special resources are found either in published copies or in the websites. The National Open College has written about the importance of the Hospital Management course which is like an advertorial (NOC, 2011). But it does not speak about the challenges of the hospital management. So, relevant literatures are not enough as per the topic.

Discussion and Conclusion

After studying the literature and analysing the present hospital management system in Nepal, the points come into mind to be discussed:-

The Government of Nepal has still not considered the ‘hospital management ‘as a separate sector.

There is a lack of Hospital management professionals.

There is no proper policy addressing hospital, management issues in Nepal.

Hospital management sector has not been regarded as an integrated issue so far.

Public and private sector are also not actively participating for the professionalization of hospital management human resources.

In conclusion, we can say that hospital management is a new discipline. The developed countries like UK have already started to think on the management issues of hospitals as a separate sector. But in Nepal, the hospital management sector is not visible separately and it has not been regarded as a separate need or requirement. The hospital has not felt the need of hospital managers to manage the hospital smoothly. Lack of awareness, culture and customs low literacy rate, low income and difficult geographical situation are the factors which are hindering the hospital management sector to grow and become strong.

Methodology

3.1 Instrument

The study was carried out by using systemic literature review method. The literatures were searched in the website of the Universities of UK i.e. Bournemouth. The Medical Journal of America and USA were searched. The government policies of NEPAL, India, USA, Japan, Thailand and UK were other sources. The documents were collected, materials were searched and the materials retrieved were analysed before applying them in this search. The WHO website and other journals were considered as most reliable sources. Library use was the mostly used mean for search and writing the paper. This study will apply qualitative methodology to find the hindering factors of hospital management in Nepal where face to face interviews will be arranged during this study.

4 Conclusions

The hospital management is a new term which is derived from the separate words hospital and management. Hospital is a mean of healthcare delivery while management is a way to utilize the resource in an efficient way. The hospital management is not very old concept in even in the developed countries while the countries while Nepal is very far behind in the development of this sector. Lack of professionalization of the existing human resources, less availability of skilled human resources, poor socio-economic situation, low interest of government towards the hospital are the hindering factors for the development of hospital management in Nepal. These all information was collected through literature review available in the library and websites developed by the governments, universities and academic institutions.

It recommends the government of Nepal to recognise the hospital management as a separate and independent discipline under the health service. It suggests the academic institutions to focus on the development of hospital management professionals in their course and curriculum. It also suggests the private sector involved in running private hospitals in Nepal to start hospital management principles in their management.