CHAPTER - 2

REVIEW OF LITERATURE
 CHAPTER - 2

REVIEW OF LITERATURE

INTRODUCTION:

For the purpose of the proposed study, a thorough study of all possible
academic and non-academic work in the field has been done. The main aim
for reviewing of the earlier research work is not only to studying the historical
background of the present work but also to understand some more variables
which can be included in the study. It also helped the researcher to design
the present study in such a way so that recurrence of shortcomings and
pitfalls that may be observed in any earlier study might be rectified.

In the process of reviewing literature, it has been observed that no

doctoral thesis have been submitted on application of management principles

in health care sector. Same as with the case of dissertations. Taking
management aspect in the view no academic work has so for been done in
the area of health care. Now by observing the articles published in non-
academic journals, most of the articles concentrate on slow growth of health
care issues in India and hardly anyone touched upon the application of
management principals. However, the researcher has collected various articles
appeared in different books/magazines covering various aspects of public
health.

In view of above stated facts the researcher has categorized the present
review of literature in two categories:

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1. · Researches related to management of private sector health
organizations.

2. Researches related to management of public sector health

organiza tions.

The above researches related to management of private and public

health organizations are briefly described below:

2.1: RESEARCHES RELATED TO MANAGEMENT OF

PRIV ATE SECTOR HEALTH ORGANISATIONS:

In this part, the researcher has tried to present the studies based on
management of private sector organizations in the field of health and family
welfare services. Some studies from such category are presented below;

Ramesh Bhat (2006/1) in his paper entitled "Financial health of private

sector hospitals in India" examines the financial health of hospitals in the
private sector. This paper empirically identifies relevant dimensions such as
profitability, financial structure, overall efficiency, cost structure, profit
appropriation, technology advancement, credit management, fixed assets
intensity, liquidity and current assets efficiency of hospital financial health.

V.R.Muralidharan and Sunil Nandraj (2003/ 2) in their paper entitled

private health care in India: policy challenges and option for partnership"
examine the behavior of privet health sector in India and how the government
should intervene in the private sector. The analysis is based on an extensive
review of the literature in India by taking six major studies in which Uttar
Pradesh is one of them. Focusing on contracting and regulation, the literature
point out that the government has limited capacity to regulate private health

__________________--J/ (29)
provides and to monitor contracts. Various examples are given to support
that government collaboration with private sector has been shown to work
or has the potential to work well. This paper suggest that government can
play better role in managing health care services through collaboration with
private health sector.

Dileep Mavalankar and K. V.Ramani (2003/3) in their paper entitled

"Management of reproductive health services in India and the need of health
system reform" focusing on various issues related to the management of RH
services in various districts of India. The failure in the management of RH
services is complex and multi factorial, and cannot be addressed through
health system reform. The researcher identifies those causes, which could be
corrected through reforming the health system and proposed some concrete
steps to expedite the reform in the health system to enable the improvement
in the health system in India.

S.Chakraborty (2003/4) in his research article entitled "Private health

provision in Uttar-Pradesh" examines how the private health sector is
functioning in Uttar-Pradesh and what are the opportunities for collaboration
between public and private sector. For the above purpose, three districts of
Uttar-Pradesh were chosen with the different types of private health providers-
solo practitioners, small and large hospitals and diagnostic centers. The
research suggested that private sector is better in providing health services
but they are facing labor and infrastructural problems. Thus this sector wants
further collaboration through training, contracting and to contribute together
in national health programme and there is a considerable potential for public
-private collaboration in Uttar-Pradesh.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _- - - ' / (30)
 Brijesh C.Purohit (2001/ 5) in their paper entitled "Private initiatives
and policy option; recent health system experience in India." Studied the
structural framework of Indian health system and find out why central
government is not able to provide aid to the states for public health and
disease control programme and how this impacting on the regulation of the
health services in the state. He noted some trends that are appearing in the
Indian health system. These trends includes increasing investment by non-
resident Indians (NRIs) in the hospital industry, leading to a spurt in
corporatization in the states of their origin domicile and an increasing
participation by multinational companies in diagnostics aiming to capture
the potential of Indian health insurance market. These private initiatives are
reflected in measuring comprising strategy to attract private sector
participation and management inputs into p1jmary health care centers (PHCs),
privatization or semi privatization of public health facilities such as non-
clinical services in public hospitals. Some new ways to finance health facilities
through non-budgetary measures and tax incentives by the state government
to encourage private sector investment in the health sector. This paper
examines the aspect of private initiatives and their implication for the Indian
health sector market.

Akbar Ali Khan (1999/6) in his book entitled "Hospital management"

reveals with the financial pattern of health care and hospital of health care
and hospitals and cost efficiency of public hospital in Gujarat. The stUdy
empirically examines the allocation of expenditure for health care and hospital
s and evaluated the cost efficiency based on cross sectional analysis. It helps

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in developing a mechanism for suitable criteria for allocating resources. It
evaluates the efficiency of their operations and recovery of costs. Here an
attempt has been made to observe the relationship of cost and hospital service
indicator by using statistical tools.

Rama V. Baru (1998/1) in her book entitled "Private health care in

India" examines the trends in privatization in health care and its social
basis. The book also dealt with future of public health services in India. It is
based on empirical study of private hospital in Hyderabad, Andhra Pradesh.
It delineates the emerging patterns of medical care in the private sector with

a historical and global perspective. It tracks the growth of the private sector
in India and examines the role of professionals, certain classes and
international capital, which have shaped the contents of privatization. The
author demonstrates, through an in depth study of background of medical
entrepreneurs, that there have been a movement of capital away from
agriculture and business in to the medical sector. Dr. Baru shows how the
growth of the private sector has had a negative impact on the public sector.

P.K.Halverson,A.D. Kaluzny, G.P. Mays, T.B.Richards (1997/8) their

articles entitled "Privatizing health services: alternative models and emerging
issues for public health and quality management" was basically concerned
about the cost, quality and efficiency of services provided with in public
sector health care system, leading policy makers and health care administrator
to reinvent government and develop alternative methods for the delivery of
services traditionally offered in the public sector privatization structure that
incorporate strong quality management principals, both risk sharing

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _/ (32)
arrangements, appear to hold the greatest promise for archiving quality and
efficiency goals.

Sheela Prasad (1997/9) in her paper entitled "A study of public and
corporate hospital" reveals the functiOning of both private and public health
care system in Hyderabad, Andhra Pradesh. She examines the performance
of each sector through perception of users. The basic objectives of this paper
are to test the hypothesis that growth of corporate sector in urban health
care widens in equalities in the quality of health care. The paper preliminary
investigates the dynamic of urban health care. It also observed that healthcare
is becoming capital intensive and this is truer of corporate healthcare. The
paper states that the public hospital is now identified as largely for the poor
while the corporate hospitals are for the rich.

C. A. K. Yesudian (1994/10) in his research article entitl~d "Behavior of

the private sector in the health market of Bombay" analyses the Bombay's
health market and find out that that in Bombay private health market is
playing a major role in all strata of the society. But the quality of the services
provided by the private health sector was not satisfactory. There are
inadequacies in the medical infrastructure and manpower and employees
are involved in unethical medical practice. The research also highlighted
existing regulatory mechanism and their inability to control the quality of
private sector medical care. this research suggest that there is a need for a
holistic policy approach to increase and strengthen the public sector health
services in the required areas and to develop norms to maintain quality in
medical infrastructure and manpower and to control unethical professional
behavior in health sector.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _/ (33)
 Miles Hardie (1981)(11) in their article entitled "Hospital management
training" discusses the issues and approaches to health services management
training. Opinion was collected from 500 senior doctors, nurses, and
administrations from eighty countries, who have attended a ten week annual
source. It emphasized on the managers' role in perception of profiles, policies,
rogrammes and their implementation. The need for developing appropriate
management training facilities was explained.

R.S.Bhola and T.R.Anand (1978/12) in their article entitled "Some aspects

of hospital management requiring personnel attention of a hospital
administrator" highlighted the areas needing personnel attention of the
hospital administrator. This article concentrates on the aspects like application
of management principals to meet existing conditions, doctor -patient and
staff- patient relationships, patient care and community satisfaction and
optimizing the utilization of supportive hospital services.

2.2: RESEARCHES RELATED TO MANAGEMENT OF

PUBLIC SECTOR HEALTH ORGANISATIONS:

In this part of the study, the researcher has presented the brief summary
related to the work done earlier in the field of public sector health
organization;

R.S.Balgir (2006/ 13) in his paper entitled "Medical genetics in public

health administration in India: A handicap of bureaucracy, bias and
corruption" wrote that the public health and health administration have
attracted consideration attention in the past years in a public welfare state

__________________----J/ (34)
like India. Application of genetic knowledge for genetic/ marriage counseling,
community health, prevention and control of genetic diseases, and promotion
of health strategies of the amelioration of suffering of the people. This paper
can be suggested with the result that there is lack of training in undergraduate
as well as postgraduate level in medical education for medical genetics and
public health administration.

Swapan Kanti Chaudhri (2006/ 14) in his paper "health sector in West
Bengal" highlighted on the status and government policies in the health
sector in West Bengal. According to this article, the health sector financing
in west Bengal reflects in adequate budget sends on health and family welfare
services on the one hand and number of structural inefficiencies on the other.
The overall findings of this paper suggested that the government would require
to committing a significant level of additional resources on a sustainable
basis and look for sizable funding support from donor partners to build
financial capability and ensure sustainability to increase health spends.

Gurjeet Kaur and Neena Gupta (2006/ 15) in their paper entitled
liE-Health: A new perspective on global health" highlighted the rising
profile of e-health on the international policy agenda and the emerging Indian
programme for information technology and related development in the
national health services. Health is a process of providing health care via
electronic means, in particular over the internet. The term E-Health has been
used to describe the variety of activities related to the electronic exchange of
health related data, in the form of voice or video.

__________________----J/ (35)
 Alvaro Alonso and Ruairi Brugha (2006P6) in their article "Rehabilating
the health system after conflict in East Timor: a shift from NGO to government
leadership" discussed that the efforts to rehabilitates health system after
period of prolonged conflict have often been characterized by poor
coordination of external actors, multilateral agencies, donor and non
governmental organizations (NGOs). This paper describes the process of
analyzing the roles of different stakeholders in the establishment government
led districts health system in East Timor, between 1999 and 2002, and after
decades of chronic conflict and Indonesian occupation. During the emergency
phase, from September 1999; when violence erupted to march 2000, NGOs
played a major role in the provision of relief to the population, coordinated
by United Nations agencies. An interim health authority, led by local Timorese,
was established in March and the major donor began to shift funding from
NGOs to the newly established Ministry of health. The ultimate result of this
paper suggests that health service utilization continued to grow during and
after implementation.

Thomas R.Oliver (2005/ 17) in his review article entitled "The politics
of public health policy" focused on the role of politics in the health affair of
any countries. He wrote that politics in the health affair could be used in
both ways for its betterment and for worse also. It considers how bounded
rationality, fragmented political institutions resistance from concentrated
interest and fiscal constraints usually lead political representatives to adapt
incremental policy changes rather than comprehensive reforms even when
they faced some serious public health problem. It reviews the challenges

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _--'/ (36)
confronting officials and agencies that are responsible for implementing and
administrating health policies. According to this article 'public health
professionals who understand the political dimensions of health policy can
do better in diagnosing policies and programme in the health sector. The aim
of this article is to articulate a role for political analysis of public health
servIces

John Frank, Vera Etches, Doug Manual and others (2005/ 18) in their
review article entitled "Measuring population health" reviewed the historical
development of population health indicator and their uses and importance
in measuring the population health of a country. They said that regular
national health interview surveys and applications of administrative data
contributed information on morbidity, health services use and some social
determinant of health. More recently, traditional health data databases and
data sets on "non health" sector determinant have been linked. In this article,
the conceptual framework for using indicators to report on all the domains
of population health has been suggested. Future ethical development of
indicators will incorporate principles of justice, transparency and
effectiveness.

Paula Braveman (2005/ 19) in her paper entitled "Health disparities

and health equity: concept and measurement clarify the concepts of health
disparities/inequalities (used interchangeably here) and health equity,
focusing on the implications of different definitions for measurement and
hence for accountability. Health disparities do not refer to all differences in
health. It is a particular type of differences in health. It's a difference in

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _/ (37)
which disadvantaged social groups-such as the poor, racial/ ethnic minorities,
women or other group who have persistently experienced social disadvantage
or discrimination-systematically experience worse health or grater health
risks than more advantaged social groups, ("social advantage" refers to one's
relative position in a social hierarchy determined by wealth,power,and
prestige.) Health disparities include differences between the most advantaged
group in a given category-e.g., the wealthiest, the most powerful racial!
ethical group-and all others, not only between the best-and worse- off groups.
Pursuing health equity means pursuing the elimination of such health
disparities / inequalities.

Manoj Shanna and Gayatri Bhatia (2005/ 20) in their article entitled ·
"The voluntary community health movement in India: a strengths,
weaknesses, opportunities and threats (SWOT) analysis" focusing on the
development of voluntary organization in the field of community health.
The purpose of this article is to historically trace the voluntary movement in
community health in India, analyses the status and predict the future trends
of voluntary efforts by using the tool of SWOT analysis.

Sonya Grier and Carol A. Bryant (2004i 21 ) in their paper entitled "Social
marketing in public health", provided some ideas related to social marketing
in public health, the use of marketing to design and implement the programme
to promote the behavioral changes that is useful for the society. In their
paper they written that many professional related to public health have an
incomplete understanding of the social marketing field, which help them to
advance current knowledge, practical definition with several case studies

_________________----J1 (38)
that how to apply social marketing applications in public health. The overall
study of this paper focusing on how social marketing may be used to plan
public health interventions.

Lalit Dandona, Yegnarana S.Sivan, Mukkamala N.Jyothi and Rakhi

Dandona (2004/ 22) in their paper entitled "The lack of public health research
output from India" highlighted the systematic assessment of recent health
research output from is inadequate. This paper suggested that Researches in
public health could playa vital role in controlling the various diseases burden
in India. Thus, it is important for the government of India to do more efforts
to develop and improve the research work in India.

Nirupam Bajpai and Sangeeta Goyal (2004/23) in their paper entitled

"Primary health care in India: coverage and quality issues" evaluated the
India's primary health services in terms of quality and coverage of the
population. According to them, India's achievement in the field of health has
been less than satisfactory and the burden of disease among the Indians
population remain high. An extensive primary health care infrastructure
provided by the government is inadequate in terms of coverage of the
population, especially in rural areas. This research shows that most public
health centers, which provide primary health services, have poor quality in
infrastructure, services and their numbers are not according to the population
of that particular place.

David H.Peters, K.SujathaRao and Robert Fryatt (2003/ 24 ) in their paper

entitled "lumping and Splitting: the health policy agenda in India" focused
on factors challenging the health system to respond in a new ways. These

__________________-----.J/ (39)
factors are Disparities in life expectancy, disease, access to health care and
protection from financial risks. The old approach to national health policies
and programmes was not finding appropriate, so there is a need to change
in the national health policies to be more diverse and accommodating to
specific state and districts. More "splitting" of India's health policy at the
state level would better addressed their health problems and would open the
ways to innovation and local accountability. Better "Lumping" of policy issues
at the central level s also needed but not as was in the past. This paper
suggested that at present the central government needs to focus on
overcoming the large inequalities in health outcomes in India and also develop
a systematic management to tackle growing challenges in the health sector.

Robert Beaglehole and Mario R Dal Poz (2003/25) in their paper entitled
"Public health work force: challenges and policy issues" reviews the challenges
facing the public health workforce in developing countries and the main
policy issues that must be addressed in order to strengthen the public health
workforce. The key question was- should government invest more in building
and supporting the public health work force and infrastructure to ensure the
more effective functioning of health system? The paper concerned about the
nature of the public health workforce; including its size, composition, skills,
training needs, current function and "performance; the appropriate role of the
work force and how the workforce can be strengthened to support new
approaches to priority health problem.

Jill Schofield (2001)(26) in his research article entitled "The old ways
are the best?" The durability and usefulness of bureaucracy in public sector

__________________---J/ (40)
management" conducted the research in the British National health services
to find out why the old ways are the best. The finding of this research
suggested that the bureaucracy is both useful and durable because it means
that government can rely upon the obedience of beaurocrats. It is a function
of bureaucratic vocation and protects the professional reputation and a form
of instrumental motivation.

C.P.Chandrasekhar and I.Ghosh (2001)(27) in their paper entitled

"Information and communication technology and health in low income
countries: potential and constraints" outlines the potential offered by
technological progress in the information and communication technology
(ICTs).Industries for the health sector in developing countries present some
examples of positive experiences in India, and considers the difficulties in
achieving the potentials. This technology can develop health sector in
developing countries in at least three ways:-

1. as an instrument for continuing education:- that enable health

workers to be informed of and trained in advance in knowledge;

2. they can improve the delivery of health and disaster management

services to poor and remote location;
3. In addition, they can increase the transparency and efficiency of
government, which improve the availability, and delivery of
publicly provided health services.

This paper suggest creative ways of using leTs to improve the health
conditions of local people with highlighting the substantial cost involved in
providing wider access and the problem of resource allocation in poor
countries where basic infrastructure for health and education is still lacking.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _/ (41)
 Marilyn Wise and Louise Signal (2oool 28) in their paper entitled
"Health promotion development in Australia and New Zealand" describes
and analyses the development of health promotion in above two countries.
They said that there is a notable improvement in the health of these two
country's population over the last decade but still there are some areas i.e.
(workforce development and research and evaluation) are still weak. This
paper suggest that by the help of collaboration with the public in the health
sector and other can give strength to develop health promotion activity in
both nations.

R.Paul Shaw (1999l 29 ) in his article "New trends in public sector

management in health" discussed the role of new public sector management
in health care sector. The new public sector management is concerned with
injecting business like practices in to public agencies with. the expectation
that efforts to implement change will be easier, more effective and more
permanent as a result. It gives emphasis on the roles, responsibilities,
accountability and performance of the employees. This article focuses on the

aim of NPSM and their role in policymaking process and makes implementers
to be more formal of choices about what aught to be done to improve health
outcomes.

David Peters (199Sl30) in his review article entitled "The sector wide
approach in health; what is it? Where is it leading? Describes early experience
with sector wide approach (SWAp), which is an emerging trend of
development practice in low-income countries. In this, the researcher also
described the term "SWAp" means and why it is now being perused. The

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _/ (42)
term "SWAp" is characterized as a sustained government led partnership
with donor agencies and other groups. The approach has changed the dynamic
between government and donor agencies, requiring systematic changes in
policymaking and management in both government and donor agencies. With
the SWAp, ongoing joint assessment and negotiations around sectoral plans
and review of performance replaces the old way of preparing and supervising
project. The paper suggested the past, present and future approach of SWAp
with some of the key challenges of SWAp approach in future and their
importance in management of health services.

David J.Hunter and Philip C.Bennan (1997)(31) in their article entitled

"Public Health Management: time for a new start?" has discussed the need
for public health physicians, non clinical public health specialists and health
services managers to find an intellectual focus for joint working. According
to the writer the concept of public health focuses on the mobilization of
society's resources including the health service sector to improve the health
of the population through most appropriate means. He said that public health
is suffering from a tension between knowledge and action. The above problem
can be resolved through public health management. This paper basically
exploring the concept of public health management analyses the skills required
for its successful practice and considers the training programme required to
develop public health management.

Sheela Prasad (1997/32) in her paper entitled" A study of public and

corporate hospital" reveals the functioning of both private and public health
care system in Hyderabad, Andhra Pradesh. She examines the performance

__________________--J/ (43)
of each sector through perception of users. The basic objectives of this paper
are to test the hypothesis that growth of corporate sector in urban health
care widens in equalities in the quality of health care. The paper preliminary
investigates the dynamic of urban health care. It also observed that healthcare
is becoming capital intensive and this is truer of corporate healthcare. The
paper states that the public hospital is now identified as largely for the poor
while the corporate hospitals are for the rich.

Sarah J.Atkinson (1993/33) wrote an article entitled" Anthropology in

research on the quality of health services" discussed contributions to studies
of quality of health service provision from the field of anthropology in both
public as well as private sector, the coordination of different service provider
by local manager and the quality of service provided. The current crises in
the health sector have increased research directed towards quality of health
services. This paper explores the contribution of anthropology in the health
services research by including a lay prospective in quality evaluation. The
lay prospective assume that conflict between the provider and users of health
services results only from the different explanatory models and are thus
resolvable through training and education. The anthropology approach
demonstrates that service quality must be located in the wider contexts of
health service structure and socio-economic circumstances of users' lives.

Andrew Cassels and Katja Jonovsky (1992/34) in their research article

entitled "A time to change: health policy, planning and organization in
Ghana" presented the result of rapid health sector policy analysis which was
carried out in Ghana in the year 1990. The main aim behind this research

- - - - - -____________-----J/ (44)
was to examine the dynamic of policy at the time of major change and their
impact on the current policy directions. In this paper, there is a demonstration
of the range and nature of issues concerned to decision makers in the ministry
of health, ministry of state / local government and national development
planning commission. The major issues were restructuring the health
department, resource allocation under decentralization and health planning
responsibilities at different levels. The major emphasis of this paper was on
the process of organizational changes in the health sector resulting from
decentralization policies.

Ashok Kumar (1991) (35) in his research article entitled "Delivery and
management of basic services to the urban poor: the role of the urban basic
services in Delhi" stimulates a discussion about the provision and
management of basic services to the urban poor in the · context of the
metropolitan cities of India. The research suggested that government should
enhance the level of basic services and their management through
implementing various policies.

Rozmin A.Jani (1990/36) in his study "Management control system in

non-profit Organizations with special reference to hospitals" reveals the role
of management control system in achieving the objectives of a hospital. The
present study made an effort to review all aspects of government management
control in non-profit organizations with special reference to hospitals. Here
the author tried to develop working model of management control system in
medium size hospitals. The author intends to study the different control
systems in the two hospitals, one government and one private hospital.

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2.3: CONCLUSION

It is clear from the above discussion that the researcher has included
thirty six studies related to health management in hospitals and other
organizations belonging to both sectors i.e. (1) Private sector and (2) Public
sector. However few studies are common to health management of both the
sectors. In various studies the parameters like financial health, policy
challenges, private health provisions, reproductive health services, behavior
of various organizations in health market, hospital management training,
medical genetic in public health, re-habilation of health system, e-health,
public health policy, community health movement, health disparity and health
equity, primary health sector in India, public health work force, information
and technology management of health, new trends in public sector health
management, health promotion and development, etc. are included for the
purpose. However the researcher noted that there is lack of studies on various
management related aspects like social costing, effect of various health
schemes on individual, measurement of efficiency of health man power,
motivational aspects related to health work force, etc. these all gaps can be
treated as sources for further researches in the health services management
area.

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