The need for an institute of hospital management

The monitoring mechanism of activities of the government preventive health sector is better than that of the curative sector, although much more money is spent on the latter. Recent initiatives for monitoring the curative sector should be strengthened by establishment of an institute of hospital management. The need for such an institute has been recognised for about 15 years. This need has been further emphasised by recent studies and discussions.


Introduction
The government health service functions under two broad sectors, preventive and curative.Medical Officers of Health have to send regular reports to the Epidemio logical Unit and the Family Health Bureau (FHB).These ensure some monitoring of the activities of the preventive health sector.The larger proportion of money is spent on the curative sector.However, an effective mechanism of monitoring of performance of the curative sector is still in its infancy.During the last 10 to IS years, there have been some ad hoc activities on quality assurance conducted by the Ministry of Health.The monitoring has been in a few basic areas.This activity has had very little effect on improving the performance of the curative sector.

The present situation
From March 2000, the Director Tertiary Care Services of the Department of Health has monitored 10 readily avail able performance indicators in the line Ministry institu tions which are mostly tertiary care facilities (1).The fol lowing areas have been covered: management commit tees, in-service training, drug review committees, infec tion control committees, capital expenditure, bed occu pancy, audit of maternal deaths and stillbirths, operations performed, laboratory and radiological investigations, and fuel efficiency of vehicles.

The proposal
A good start has been made.However, the above activities have to be expanded to cover all curative sector institutions.This is important because the problems appear to be greater in the smaller hospitals.The range of activities monitored also have to be expanded.Some addi tional areas of work that have to be undertaken include the following.

(a) Monitoring the utilisation of medical officers
In 1999 the government agreed to the recommenda tions of the Committee on employment opportunities for medical officers (2).It agreed to the recommendation to employ all medical officers who qualify from the local medi cal faculties and from abroad up to the year 2010.The Com mittee also made another recommendation, viz."The com mittee recommends the establishment of a monitoring unit in the Department of Health Services which will ensure that medical officers are utilised' optimally.The policy of ab sorption of medical graduates could be reviewed depend ing on the findings of the above unit".Such a unit has not been established still.It is essential that the government ensures that the staff it employs, especially medical offic ers, are optimally utilised.To take just one glaring example, about 1000 medical officers undergo training in the Post-Graduate Institute of Medicine at any given time.There is no effective mechanism to monitor their movements and utilisation.

(b) Training of managers in the hospital sector
Except the Teaching Hospitals and General Hospitals, which are managed by full-time medical administrators, the other hospitals are managed by medical officers who are not trained in management.Some of them are not even in terested in the management of their institutions.Among the other categories of staff involved in management of the hospital sector, only nursing sisters amd matrons are trained in management.
In a recent study, the Institute of Policy Studies made two important observations (3).'First, facilities appear to be relatively under-managed, and the skills necessary for managing complex facilities such as hospitals are not yet in place in most facilities.Second, there is very little perfor mance monitoring of hospitals by the Ministry of Health.Furthermore, the initiatives that are being taken focus primarily on tertiary hospitals; and the basic and intermedi ate hospitals, where the problems appear to be greatest, are not included in the plans to strengthen hospital management.

The need for an institute of hospital management
Lucian Jayasuriya 1

It is essential to ensure efficient and effective utilisation of scarce resources in the government health sector. (c) Ongoing studies of costs of patient care
This study also found that "The average costs of care in 1997 continued to be below international norms, but there remained an important degree of variation among similar facilities, with ratios of high: low cost facilities rang ing from 4.3 to almost 30."Therefore, there is a urgent need for the establish ment of an Institute of Hospital Management (IHM).The establishment of an IHM was also recommended by the Biennial Conference on Science and Technology organised by the National Science and Technology Commission (4).
The idea of establishing an IHM was mooted about IS years ago during the time of the Ministry of Teaching Hospitals.The Ministry requested a firm of chartered ac countants to produce a draft document for this purpose.They proposed that a company under the name of Na tional Institute of Hospital Management be incorporated under the Companies Act No 17 of 1982 (5).They pro posed that it should be managed by a Board, and that the share capital be both from the government and the private sector.The main areas of work they envisaged were train ing in management for all relevant hospital staff in the gov ernment and private sectors, and research in hospital man agement.
The alternative is for the IHM to be on the lines of the FHB.Even though it would have resource constraints, and would be able to monitor only the government sector, it will be a step in the correct diection.The Director, Tertiary Care services could be its first Head, but could have a large remit to cover all curative care institutions.His name could be changed to the Director, IHM.A separate insti tute with dedicated staff would have to be provided.
The establishment of an IHM is necessary to ensure that the available resources of the government health sector are efficiently and effectively utilised.