THE INDIAN HEALTH care sector has been growing rapidly over the past few decades; the sector generates enormous revenue and widespread employment. Data from 2014 and 2015 reveal that the current health expenditure in India is estimated to be about 93.4% of the total health expenditure.1 Additionally, active involvement of the public and private sectors through financial investments is providing new avenues for health care services. Hence, the cumulative effect of technological improvement in addition to increasing expenditure capacity has resulted in the rapid expansion of health care infrastructure and allied services.
Indian health care services are broadly categorized into 2 groups—public and private. The public sector, or the government hospital, focuses on providing secondary and tertiary care in urban areas and basic health care facilities in rural areas. Until very recently, the private sector predominantly comprised stand-alone clinics, private nursing homes, or small hospitals. However, the private sector has now made impressive progress due to technological advancement, increased treatment affordability, and medical tourism.2 It has started providing secondary, tertiary, and quaternary care in tier I and II cities.2 Hence, the hospital workforce is seen grappling with newer challenges due to the dynamic health care environment and the growing burden of the patient population.3
In a typical Indian private hospital of more than 250 beds, in addition to physicians several other stakeholders, such as pharmacy and procurement heads, clinical heads, hospital administrators, and nursing heads, ensure smooth functioning of the administrative system and contribute to the efficient delivery of health care services. All of them have multidisciplinary responsibilities that involve extensive communication and coordination with internal and external stakeholders in addition to their professional contributions In this regard, even the World Health Organization (WHO) has identified human resource management as one the most important aspects of the health system.4
Most hospital workers are unaware of the growing complexity of these added responsibilities, because of their hectic daily schedules. Thus far, the definitive roles, responsibilities, and challenges of the health care workforce have not been assessed in India. By identifying these, tailored solutions can be designed to effectively tackle key challenges faced by these stakeholders.5 Furthermore, this will also help the private hospital industry to institute the necessary initiatives or partnerships for the attainment of desired outcomes. Keeping this objective in mind, we conducted a questionnaire-based survey of stakeholders involved in various important functions in private hospitals of more than 250 beds located across the country to develop a clear understanding of the roles played by them and to assess challenges they face while executing these roles.
MATERIALS AND METHODS
We assessed 5 primary stakeholders, viz. hospital administrators, pharmacy heads, procurement heads, nursing heads, and clinical research heads of privately owned (corporate chain or standalone) Indian hospitals having more than 250 beds. The key functions of each stakeholder were studied under the following categories: management, administrative, and additional functions (if any).
This study was conducted in 60 private hospitals (40 corporate and 20 standalone), located in 12 cities (Delhi, Mumbai, Kolkata, Bangalore, Chennai, Hyderabad, Ahmedabad, Jaipur, Mohali, Kochi, Pune, Chandigarh) in India. Adequate distribution of stakeholders across the various states was ensured, to obtain balanced and unprejudiced opinions about the overall private hospital scenario in the country.
A 2-stage approach involving in-depth qualitative discussions in the first stage followed by structured quantitative interviews using a predesigned questionnaire format was adopted. One-on-one, in-depth face-to-face interviews with stakeholders were carried out using a discussion guide. In this regard, different variables were used to assess the status of and the challenges encountered by the respective department heads.
- Qualitative Phase: In-Depth Interviews
Stakeholders were asked to define their top 2 major challenges/need gaps, those that need improvement. Every stakeholder's responses/challenges were recorded verbatim and later grouped under common themes in a spreadsheet (Microsoft Excel 2010; Microsoft, Redmond, Washington). Percentage responses for each theme were calculated using the frequency of each response with respect to the total number of responses. The interview length was approximately 45 minutes.
The insights gathered during the qualitative phase not only were used in the final analysis but also formed the basis of the quantitative phase questionnaire. Data were collected during a 6-month period from March to August 2016.
- Identifying the top 3 challenges
We presented stakeholders with a list of challenges/need gaps that were relevant to their daily functioning. They were asked to indicate the top 3 challenges/need gaps from the presented list that according to them needed higher attention for performance improvement.
- Utility of internal or external programs for resolving challenges
One of the objectives of this study was also to evaluate the utility of various continuing medical education (CME) and training programs toward knowledge enhancement of hospital stakeholders. Through this questionnaire-based survey, we collected information from respondents on their feedback about such training programs. Stakeholders were asked to rate (on a Likert 7-point scale) such programs or to indicate their willingness to attend such a program (on a Likert 7-point scale). Responses were collated in a spreadsheet, and the mean of every response rating was calculated with respect to the total number of responses.
Roles and Responsibilities of Individual Stakeholders
Major variations in roles and challenges were observed across stakeholders; hence, quantitative and qualitative analyses were performed at the individual stakeholder level. The key functions of each stakeholder were identified as follows:
The key role of the pharmacy head includes inventory management, which primarily focuses on the generation of purchase orders and good receipt notes; Management Information System maintenance and compliance; maintenance of patient and prescription records, specifically for schedule H drugs; and maintenance of drug inspector reports and cash flow within the pharmacy. The main role of the pharmacy head is to ensure efficient and timely delivery of drugs through communication and coordination with internal and external stakeholders (vendors, pharmaceutical/device manufacturing units, and drug inspectors).
Negotiation with vendors is the primary managerial responsibility of the procurement head. Most procurement heads act as liaisons between internal departments (human resources, finance, clinical heads of department, and nursing staff) and vendors. They also handle grievances and are responsible for crisis management in case of shortage of goods. The procurement head plays a crucial role in communication and coordination between drug and therapy committee (DATC), clinicians, hospital management, and the supply-chain management committee, to ensure efficient and timely delivery of drugs.
- Clinical head of department
The clinical head of department mainly ensures proficient supervision of daily operations across inpatient department, outpatient department, emergency, and educational activities in the hospital. The clinical head also initiates CME programs.
The hospital administrator acts as a liaison between the governing board, clinical staff members, and department heads, to implement policies for smooth functioning. They also coordinate activities related to the quality assurance of the hospital, public relations, corporate relations, hiring and managing staff, biomedical waste management, and radiation safety. Hospital administrators are also responsible for generating a status report on infrastructure, staff, procurement, and maintenance of equipment, in addition to discharging their administrative duties. Hospital administrators are the public face of the institution; hence, they are responsible for collaborating with government and regulatory authorities, pharmaceutical/medical device companies, insurance companies, and nongovernmental organizations.
This managerial role involves admission, discharge, and general flow of patients; assigning duties to nurses and support staff; and coordinating with various departments for resource allocation (nurses, medication, doctors, or equipment), as needed. Hence, this role involves interaction with all other health care professionals (doctors, physiotherapists, nutritionists, etc) in the hospital. Nursing heads are also responsible for maintaining documents pertaining to standardized operating procedures, norms and routines for ensuring organized handover among nurses/staff. Improvement in the overall performance of the hospital relies greatly on the quality of staff. Hence, conducting interviews, making hiring decisions, and training the new recruits are an integral part of the nursing head's role.
Through these interviews, we recorded the stakeholders' verbatim responses expressed as the top 2 challenges/need gaps that needed attention.
Many pharmacy and procurement heads indicated that maintaining inventory and managing logistics were the top challenges. Additionally, keeping the inventory within budget, ensuring workflow as per guidelines, and managing waste disposal were some of their other challenges. On the other hand, clinical heads were concerned about losing the trust of patients and their family members, due to the negative publicity created by media reports on incidents occurring in private hospitals. Both clinical heads and hospital administrators voiced their concerns about the miscommunication or lack of communication among internal stakeholders when faced with a heavy workload. Additionally, hospital administrators identified monetary constraints and management of available resources in limited infrastructure as challenges. Nursing heads indicated high attrition rates resulting in inadequate experienced staff, as well as a lack of soft skills or empathy among health care providers (especially young nurses), as a challenge.
As the questionnaire and the lists generated for quantitative responses were based on the responses gathered from the qualitative analysis, we observed some overlap and data supportive to qualitative responses.
Top 3 Challenges
During this study, pharmacy and procurement heads (n = 31) were asked the same set of questions, as their duties and responsibilities tend to overlap to a certain extent. More than 50% of the pharmacy and procurement heads reported communication and coordination as their top challenges (Table 1). Inventory and logistics management and the constant need for communication and coordination among stakeholders were termed as level 2 challenges by 58% and 48% of respondents, respectively (Table 1).
The top challenge faced by clinical heads was mainly related to planning training schedules. High attrition rate and time spent on creating patient awareness and counseling were voiced as level 2 concerns by 71% and 50% of clinical heads, respectively. A detailed analysis of these responses is presented in Table 2.
Hospital administrators indicated extensive communication and coordination with different teams and vendors, resource management in limited infrastructure, and lack of accountability on the physician's part as the top 3 challenges (as indicated in Table 3) affecting smooth functioning.
About 91% (10/11) of the nursing heads mentioned that lack of communication, or miscommunication, between nurses and doctors during high patient load was a level 1 challenge. On the other hand, 36% (4/11) of nursing heads felt that internal training modules were lacking in novelty and innovation (Table 4).
Utility of Internal or External Programs for Resolving Challenges
Procurement heads indicated that the introduction of an advanced inventory management system (Hospital Information System), the addition of key account managers to the team, and certificate courses on new drugs and devices will be very helpful (average scale, 5.7) for efficient workflow.
Clinical heads strongly supported (average score, 6.1) CME courses and incorporation of the digital platforms for resource allocation and management (average rating, 5.8) for addressing their current challenges.
Hospital administrators indicated that pharmaceutical companies can help them in conducting audits, analyzing patient feedback, and implementing a corrective action and preventive action plan, thereby adding high value (average rating, 6, 5.9, and 6, respectively) to their daily workflow.
Nursing heads reported that their current work-related challenges will be reduced if pharmaceutical companies share knowledge on patient education or training sessions.
This nationwide study could objectively identify the roles of individual stakeholders (pharmacy and procurement heads, clinical heads, hospital administrators, and nursing heads) and gathered an in-depth understanding of key challenges encountered by them through information directly provided by them. To the best of our knowledge, this is the first qualitative and quantitative study on identifying challenges and need gaps experienced by a wide range of stakeholders directly associated with private hospitals in India. The preliminary findings of this study can serve as the first step toward planning robust and effective measures to address these specific issues faced by private hospital stakeholders.
This study identified overarching challenges evident through interactions with stakeholders, such as high attrition rate, communication and interaction across departments, training of self and team, supply and inventory management, patient interaction, knowledge update, and formulary compliance within stringent budget, and hence the need of new revenue generation. We can broadly classify these challenges into 3 categories, viz. resource shortage, inadequate skill development, and stringent budget—which are directly or indirectly interlinked. These observations are consistent with a previously published Ethiopian study, which identified gaps in the Ethiopian clinical pharmacy system.6 The Ethiopian study also identified high attrition rate, lack of interest, and underdeveloped soft skills as major challenges of the clinical pharmacy department.6 Lastly, these challenges affect the productivity of these stakeholders, resulting in compromised patient care.
One of the challenges unequivocally identified by clinical heads, nursing heads, and hospital administrators was a scarcity of skilled professionals. This challenge is in line with the facts mentioned by the WHO survey, which highlighted the scarcity of health care professionals in India compared with China (79.7 vs 130 doctors per 100 000 population and 61.3 vs 96 nurses and midwives per 100 000 population).7 Additionally, the WHO report observed that the urban density of doctors and nurses was around 4 times higher than the rural density.7 This problem is further aggravated when prevailing trends such as higher salary expectations or a lack of empathy are observed in the current workforce, as stated by one of the stakeholders.
Another challenge identified by most stakeholders was the competency of the available workforce. Incompetency or expectation mismatch or skill-mix imbalance against the negative work environment is a global challenge. Hence, the Lancet Commission report entitled “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World” was developed to identify need gaps in current medical education.8 In developing nations such as India, training and up-scaling of knowledge should be urgently addressed. Additionally, career/professional development of the current workforce of all levels should be introduced. A combination of updated knowledge, adequate skills, and the right approach will help enhance patient outcomes.
The challenge indicated by pharmacy and procurement heads was about inventory and supply chain management within a tight budget and about inadequate knowledge of systems and software. A study by Aptel and Pourjalali9 advocated the use of the just-in-time principle for inventory cost reduction. Just-in-time is an inventory strategy that ensures high efficiency and reduces waste by receiving goods only as needed. Hence, implementing just-in-time may be helpful in Indian private hospitals, where budget constraints are a serious issue.9 Additionally, implementation of information technology tools can improve services and further help lower the cost of operations.10
Role of the Pharmaceutical Industry
The pharmaceutical industry owing to its greater outreach and available infrastructure can provide quality medical education as well as need-based training support to bridge these gaps in health care. Value-based scientific partnerships between the pharmaceutical industry and hospitals will be instrumental in offering high-quality patient-focused care in the country.11 The findings of the study can help the industry drive individualized and differentiated programs for hospital workforce, thus adding substantial value to these institutions. Knowledge-sharing sessions organized for hospital administrators can aid hospital administrators understand new drugs and therapeutics. To avoid the conflicts between physicians and DATC about using drugs, updated, unbiased outcomes of scientific studies or research activities for capacity building of the physicians can be provided. To ensure easy access to medications for all, the industry can play an integral role in developing pricing models. The awareness of the challenges faced by various stakeholders in private hospitals can help the government and policymakers draft policies, provide expertise, and even help them analyze the outcomes of their implementation.
Considering the current scenario, wherein the hospital market is getting more and more competitive, and amid the backdrop of increased awareness among patients, there is a need for medical staff to keep themselves updated with the latest developments. This survey identified some of key challenges/need gaps currently faced by important stakeholders of private hospitals in India. In this regard, industry can work collaboratively with institutions offering a customized approach to provide relevant solutions by focusing on 3 major areas that majorly impact work and productivity in a hospital: improving collaboration via the creation of a digital platform, enhancing communication between stakeholders, and extension of capabilities via training programs.