Keyur D Vasava Pharmacy+MBA Dist.

Narmada
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SUBJECT-PHARMACEUTICAL AND HEALTHCARE SECTOR

KEYUR D VASAVA

Module.1 OVERVIEW OF HEALTHCARE SERVICES IN INDIA: 1. AN INTRODUCTION TO H EALTH SERVICES IN INDIA THROUGH FIVE YEAR P LANS
Eleventh Five-Year Plan, 20072012 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. 2. 3. 4. 5. general taxation to the state, county or municipality social health insurance voluntary or private health insurance out-of-pocket payments 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 H EALTH 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 H EALTHCARE 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 countrys 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).

P RIMARY 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 subdistricts 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 H EALTH 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 highcaliber 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 NGOGO 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) womens 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 womens and childrens 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 deemphasizing 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, Ive 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 Its 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 Insurance and service delivery are handled by a single public agency. Publ Norway, Sweden, ic Denmark, Finland Private 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, FINANCI NG 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 France, United Kingdom

Priv ate

out-of-pocket

provided in private facilities.

payments) but services United States are provided in public facilities. To our knowledge, no good examples of this system exist.

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 individualsare 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 worlds 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 dont 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 nonstate 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. Private 18.7 Kms. 5.7 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 Public OPD Private 130 Public IPD 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. 535 152 452 49 63

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 nonconformity. 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 worldclass 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., patients 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 Lings 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 patients 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 physicians 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 vendors 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 Data Transferred Voice, Real time, one-way or two-way interactive motion video sound, motion video, images, text Still images or video clips Dermatology Cardiology Otolaryngology * Orthopedics with real-time telephone voice interaction, store and forward with data acquired and sent for later review Distance One-way or two-way Voice, Full Voice, sound, still video images, text Low to Moderate Moderate to High Min. Bandwidt h Reqd.

Applications

Interaction Processes

Telepsychiatry Remote Surgery * Interactive Exams

Education * Training

real-time or delayed video

sound, motion video, images, text

Spectrum: Low to High

Health Info. Networks * Medical Records Computing Processes Transfer of electronic text, image, or other data

Text, images, documents, related data

Low to High

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, patients 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 surgeons 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 Sandias 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 patients 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 meaninghealing. 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 womens and childrens 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 Womens 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 didnt. 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 labourrelated 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 UNFPAs 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 multispeiality 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/ incharge 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, microorganism, 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 22-988; 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 Microorganisms, 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 18 19

See r. 9 of Environment (Protection) Rules, 1986. See r. 8 of Environment (Protection) Rules, 1986. 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 22 23

See footnote 2 on Page 213. See footnote 3 on Page 213. See footnote I on Page 214.

24 25 26 27

See r.6 of Environment (Protection) Rules, 1986. See r. 7 of Environment (Protection) Rules, 1986. See r. 9 of Environment (Protection) Rules, 1986. For the procedure for submission of samples to laboratories and the form

of laboratory report see r. 8 of Environment (Protection) Rules, 1986.

28 29

See r. 10 of Environment (Protection) Rules, 1986. 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 subrule 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 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 Prupose

 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, misrepresentation 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 rerefiners 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 rerefine 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.

CEOs 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 CEOs 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 individuals job contributes towards achieving the vision. The process should entail remaining firmly focused on the CEOs 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 decisionmaking 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

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.

Medical ethics is a system of moral principles that apply values and judgments to the

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 Carakas 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 doctors 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. Top 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 patients blood. It is often attached to a medical monitor so that the staff can directly read a patients 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. Top 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 costeffective, 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. Top

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. Top 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. Top 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. Top 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 patients 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. Top 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