1. Introduction
1.1. In most developing countries, provision
of basic preventive, promotive and curative services is a major concern of the
Government and decision makers. With growing population and advancement in the
medical technology and increasing expectation of the people especially for
quality curative care, it has now become imperative to provide quality health
care services through the established institutions. In public Sector 15,393
allopathic hospitals (Health Information of India 2003) are functioning. In the
rural areas, the secondary level care is being provided through 3222 CHCs
(Bulletin on Rural Health Statistics in India 2005) with 30 beds each with
specialist services of physicians, paediatricians, O & G specialists, and
surgeons being made available. However, these services have not been successful
in gaining the faith and confidence of the people because of lack of
specialists, facilities and accountability, alongwith the paucity of resources
and non-involvement of the community.
1.2. Upgradation
of CHCs to Indian Public Health Standards (IPHS) is a major strategic
intervention under the National Rural Health Mission (NRHM). The purpose is to
provide sustainable quality care with accountability and people’s participation
alongwith total transparency. However, there is a general apprehension that
this may not be possible unless a system is evolved for ensuring a degree of
permanency and sustainability. This requires the development of a proper
management structure which may be called as Rogi Kalyan Samiti (RKS) (Patient
Welfare Committee) / Hospital Management Society (HMS). We have some experience
of these Rogi Kalyan Samities functioning in some of the States like Madhya
Pradesh with good results and feasibility of replication. The project in Madhya
Pradesh was started on a pilot basis and it has now been adopted in over 450
institutions across the State and has proved equally successful in extremely
backward tribal and rural areas, which proves its replicability cutting across
the regions. To take the concept across sections of the community, local
representatives and political regime, the project concept has to be simple,
appealing and easy to replicate across the State.
2. Concept
2.1. Rogi
Kalyan Samiti (Patient Welfare Committee) / Hospital Management Society is a
simple yet effective management structure. This committee, which would be a
registered society, acts as a group of trustees for the hospitals to manage the
affairs of the hospital. It consists of members from local Panchayati Raj
Institutions (PRIs), NGOs, local elected representatives and officials from
Government sector who are responsible for proper functioning and management of
the hospital / Community Health Centre / FRUs. RKS / HMS is free to prescribe,
generate and use the funds with it as per its best judgement for smooth functioning
and maintaining the quality of services.
3. Basic Structure
3.1. The suggested composition of RKS / HMS is
as follows:
RKS / HMS would be a
registered society set up in all District Hospitals / Sub District Hospitals /
CHCs / FRUs. It may consist of the following members:-
§
People’s
representatives – MLA / MP
§
Health
officials (including an Ayush doctor)
§
Local
district officials
§
Leading
members of the community
§
Local
CHC/ FRU in-charge
§
Representatives
of the Indian Medical Association
§
Members
of the local bodies and Panchayati Raj representative
§
Leading
donors
3.2. The
RKS/HMS will not function as a Government agency, but as an NGO as far as
functioning is concerned. It may utilize all Government assets and services to
impose user charges and shall be free to determine the quantum of charges on
the basis of local circumstances. It may also raise funds additionally through
donations, loans from financial institutions, grants from government as well as
other donor agencies. Moreover, funds received by the RKS / HMS will not be
deposited in the State exchequer but will be available to be spent by the
Executive Committee constituted by the RKS/HMS. Private organizations offering
high tech services like pathology, MRI, CAT SCAN, Sonography etc. could be
permitted to set up their units within the hospital premises in return for
providing their services at a rate fixed by the RKS/ HMS.
4. Need for Devolution of Responsibility
4.1. Participation
of local staff along with representatives of local population is considered of
prime importance to improve accountability and keep pace with rapidly growing
service requirements. It is also
necessary to evolve a suitable framework within which the existing staff and
local population along with administration can establish such a motivated
performing asset. The new body or the apex entity has to be responsible for the
singular aspect of provision of services to all classes of the society. The
right of independence for performance and management has to be provided in
order to boost performance.
5. Framework For Rogi Kalyan Samiti (RKS)/Hospital Management
Society(HMS)
5.1 Objectives the RKS / HMS
The following could
be the broad objectives of the HMS
Ř
Ensure
compliance to minimal standard for facility and hospital care and protocols of
treatment as issued by the Government.
Ř
Ensure
accountability of the public health providers to the community;
Ř
Introduce
transparency with regard to management of funds;
Ř
Upgrade
and modernize the health services provided by the hospital and any associated
outreach services;
Ř
Supervise
the implementation of National Health Programmes at the hospital and other
health institutions that may be placed under its administrative jurisdiction;
Ř
Organize
outreach services / health camps at facilities under the jurisdiction of the
hospital;
Ř
Display
a Citizens’ Charter in the Health facility and ensure its compliance through
operationalisation of a Grievance Redressal Mechanism;
Ř
Generate
resources locally through donations, user fees and other means;
Ř
Establish
affiliations with private institutions to upgrade services;
Ř
Undertake
construction and expansion in the hospital building;
Ř
Ensure
optimal use of hospital land as per govt. guidelines;
Ř
Improve
participation of the Society in the running of the hospital;
Ř
Ensure
scientific disposal of hospital waste;
Ř
Ensure
proper training for doctors and staff;
Ř
Ensure
subsidized food, medicines and drinking water and cleanliness to the patients
and their attendants;
Ř
Ensure
proper use, timely maintenance and repair of hospital building equipment and
machinery;
5.2. Functions and Activities
To achieve the above
objectives, the Society shall direct its resources for undertaking the
following activities / initiatives
Ř Identifying the problems
faced by the patients in CHC/PHC;
Ř Acquiring equipment,
furniture, ambulance (through purchase, donation, rental or any other means,
including loans from banks) for the hospital;
Ř Expanding the hospital
building, in consultation with and subject to any Guidelines that may be laid
down by the State Government;
Ř Making arrangements for the
maintenance of hospital building (including residential buildings), vehicles
and equipment available with the hospital;
Ř Improving boarding / lodging
arrangements for the patients and their attendants;
Ř Entering into partnership
arrangement with the private sector (including individuals) for the improvement
of support services such as cleaning services, laundry services, diagnostic
facilities and ambulatory services etc.;
Ř Developing / leasing out
vacant land in the premises of the hospital for commercial purposes with a view
to improve financial position of the Society;
Ř Encouraging community
participation in the maintenance and upkeep of the hospital;
Ř Promoting measures for
resource conservation through adoption of wards by institutions or individuals;
and,
Ř Adopting sustainable and
environmental friendly measures for the day-to-day management of the hospital,
e.g. scientific hospital waste disposal system, solar lighting systems, solar
refrigeration systems, water harvesting and water recharging systems etc.
5.3. Constitution of the RKS / HMS
Governing Body:
Chairperson : District Magistrate
Member-Secretary : Medical Superintendent of the hospital
Members:
§
Chief
Executive Officer, Municipal Corporation
§
Chief
Medical and Health Officer
§
Director,
AYUSH of the District
§
Up
to 2 representatives of PRIs
§
Up
to 3 eminent citizens nominated by the District Collector
§
MNGO
representative
§
Representative
of local Medical College
§
Representative
of corporate sector / NGO hospitals in the city as may be nominated by District
Collector
§
Local
MP/MLA
§
Associate
members : An individual who makes a one time donation of.a specified amount
[e.g. Rs 5,000/- or as may be determined by the District Health Society], may
be made eligible to become a Member of the Governing Body of the Society.
§
Institutional
members: Any institution, which donates a specified amount [e.g. Rs. 50,000/-
or more or as may be determined by the District Health Society] or adopts a
ward of the hospital and bears the cost of its maintenance, may be made
eligible to nominate a person from the institution as a member of the Governing
Body of the society.
5.4 Proceedings of the Governing body
5.4.1 The
meetings of the Governing Body shall be held at least once in every quarter and
at such time and place as the Chairperson shall decide. If the Chair-person receives a requisition
for calling a meeting signed by one-third members of the Governing Body, the
Chair-person shall call such a meeting as soon as may be reasonably possible
and at such place as s/he may deem fit.
5.4.2 Following
minimum business shall be brought forward and disposed off in every meeting of
the Governing Body:
·
Compliance
to Standards and Protocols issued by Government.
·
Review
of the OPD and IPD service performance of the hospital in the last quarter and
service delivery targets for the next quarter.
·
Review
of the outreach work performed during the last quarter and outreach work
schedule for the next quarter.
·
Review
of efforts in mobilizing resources from the community, trade / industry
and local branches of professional
associations like IMA and FOGSI etc.
·
Review
the reports submitted by the Monitoring Committee.
·
Review
the status of utilization of funds, equipment and drugs received under
different programmes of the Government.
·
Review
compliance to Citizens’ Charter displayed in the Hospital and the effectiveness
of the Grievances Redressal Mechanism.
5.4.3 In
addition to the above regular items, the Annual Report of the Society relating
to last financial year shall also be taken up for discussion in the quarterly
meeting falling due after the close of every financial year.
5.4.4 Every
notice calling meeting of the Governing Body shall state the date, time and
place at which such meeting will be held and shall be served upon every member
of the Governing Body not less than twenty one clear days before the date
appointed for the meeting. Such notice
shall be issued by the Member Secretary of the Society and shall be accompanied
by an agenda of the business to be placed before the meeting provided that
accidental omission to give such notice to any member shall not invalidate any
resolution passed at such meeting. In
the event of any urgent business the Chair-person may call the meeting of the
Governing Body at clear ten days notice.
5.4.5 The
Chairperson shall Chair the meetings of the Governing Body. In his/her
absence, the Governing Body shall elect
one from among the members present as Chair-person of the meeting.
5.4.6 One
third of the members of the Governing Body, including the substitutes nominated
under Rule 5.3.8 present in person, shall form a quorum at every meeting of the
Governing Body.
5.4.7 The
membership of an ex-officio member of the Society and of the Governing Body
shall stand terminated when he/she ceases to hold the office by virtue of which
he/she was member and his/her successor to the office shall become such member.
5.4.8 Nominated
members shall hold office for a period of three years from the date of their
nomination. Such members will be eligible for re-nomination for another period
of 3 years.
5.4.9 The
Society shall maintain a roll of members at its registered office and every
member shall sign the roll and state therein his/her rank or occupation and
address. No member shall be entitled to
exercise rights and privileges of a member unless he/she has signed the roll as
aforesaid.
5.4.10 A
member of the Society shall
cease to be members if s/he resigns, becomes of unsound mind, becomes insolvent
or is convicted of a criminal offence involving moral turpitude or removal from
the post by virtue of which s/he was holding the membership.
5.4.11 Resignation of membership shall be tendered to the Governing Body in person to its Member Secretary and shall not take effect until it has been accepted on behalf of the Governing Body by the Chairperson.
5.4.12 If a member of the Society changes his/her
address he/she shall notify his/her new address to the Member Secretary who
shall thereupon enter his/her new address in the roll of member. But if a member fails to notify his/her new
address the address in the roll of members shall be deemed to be his/her
address.
5.4.13 Any
vacancy in the Society or in the Governing Body shall be filled by the
authority entitled to make such appointment.
No act or proceedings of the Society or of the Governing Body shall be
invalid merely by reason of the existence of any vacancy therein or of any
defect in appointment of any of its members.
5.4.14 No
member of the Society or its Governing Body shall be entitled to any
remuneration.
5.5. Powers of the Governing Body
5.5.1 The
Governing Body will have full control of the affairs of the Society and will
have authority to the exercise and perform all the powers, acts and deeds of
the Society consistent with the aims and objects of the Society.
5.5.2
In
particular and without prejudice to the generality of foregoing provision, the
Governing Body may:
·
Make,
amend, or repeal any bye laws relating to administration and management of the
affairs of the Society subject to the observance of the provisions contained in
the Act, provided that:
o proposals for amendments shall be placed before the
Governing Body of the District Health Mission for its consideration and
endorsement;
o proposals for amendment
shall also be sent to the designated authority of the State Government for
endorsement; and
o proposals shall be brought
to the Governing Body after completing
the above endorsement / approval process.
·
Consider
the annual budget and the annual action plan, its subsequent alternations
placed before it and to pass it with such modifications as the Governing Body
may think fit.
·
Monitor
the financial position of the Society in order to ensure smooth income flow and
to review annual audited accounts.
·
Accept
donations and endowments or give grants upon such terms as it thinks fit.
·
Delegate
its powers, other than those of making rules, to the Chair-person,
Vice-Chair-person or other authorities as it may deem fit.
·
Authorize
the Member Secretary to execute such contracts on behalf of the Society as it
may deem fit in the conduct of the business of the Society.
·
Recruit
medical and paramedical staff for the hospital and execute such other contracts
for the improvement of hospital services as it may deem fit.
·
Do
generally all such other acts and things as may be necessary or incidental to
carrying out the objectives of the Society or any of them, provided that
nothing herein contained shall authorize the Governing Body to do any act or to
pass any bye-laws which may be repugnant to the provisions hereof, to the
powers hereby conferred on the Governing Body and other authorities, or which
may be inconsistent with the objectives of the Society.
·
Ensure
compliance to Indian Public Health Standards and to Citizens’ Charter.
·
Establish
a system of public grievance redressal at facility level.
·
Undertake
measures to increase transparency in financial and operational management of
the hospital.
5.6 Powers and functions of the Chairperson of
the Governing Body
5.6.1 The
Chairperson shall have the powers to call for and preside over all meetings of
the Governing Body.
5.6.2 The
Chairperson may himself/herself call, or by a requisition in writing signed by
him/her, may require the Member Secretary to call, a meeting of the Governing
Body at any time and on the receipt of such requisition, the Member Secretary
shall forthwith call such a meeting.
5.6.3 The
Chairperson shall enjoy such powers as may be delegated to him by the Society
and the Governing Body.
5.6.4 The
Chairperson shall have the authority to review periodically the work and
progress of the Society and to order inquiries into the affairs of the Society
and to pass orders on the recommendations of the reviewing or inquiry Committee.
5.6.5 Nothing
in these Rules shall prevent the Chairperson from exercising any or all the
powers of the Governing Body in case of emergencies in furtherance of the
objects of the Society. However, the action taken by the Chairperson on such
occasions shall be reported to the Governing Body subsequently for
ratification.
5.6.6 All
disputed questions at the meeting of the Governing Body shall be determined by
votes. Each member of the Governing Body shall have one vote and in case of a
tie, the Chairperson shall have a casting vote.
5.6.7 Should
any official members be prevented for any reason whatsoever from attending a
meeting of the Governing Body, the
Chairperson of the Society shall be at liberty to nominate a substitute to take
his place at the meeting of the Governing Body. Such substitute shall have all the rights and privileges of a
member of the Governing Body for that meeting only.
5.6.8 Any member desirous of moving any resolution
at a meeting of the Governing Body shall give notice there of in writing to the
Member Secretary of not less than ten clear days before the day of such
meetings
5.6.9 Any
business which it may become necessary for the Governing Body to perform,
except the agenda prescribed for the full meeting as set out as above may be carried out by circulation among all
its members and any resolution so circulated and approved by majority of the
members signing shall be as effectual and binding as if such resolution had
been passed at a meeting of the Governing Body provided that at least one third
members of the Governing Body have recorded their consent of such resolution.
5.6.10 In the
event of any urgent business, the Chairperson of the Society may take a
decision on behalf of the Governing Body.
Such a decision shall be reported to the Governing Body at its next
meeting for ratification.
5.6.11 A
copy of the minutes of the proceedings of each meeting shall be furnished to
the Governing Body members as soon a possible after completion of the meeting.
5.7 Executive Body
Chair-person : Medical Superintendent of the hospital
Member-Secretary
: Senior Medical Officer of the
District Hospital, nominated by Superintendent of the hospital
Members:
§
PRI
representative to the Governing Body
§
District
Collector's nominees to the Governing Body
§
Representatives
of institutional members, if any
§
Additional
members as may be co-opted by the executive Body
5.7.1. Meetings of the Executive Committee shall be
convened by the Member Secretary by giving clear seven days notice in writing
along with the Agenda specifying the business to be transacted, the date, time
and venue of the meeting.
Frequency of meetings: Once
every month
5.8 Regular Agenda
§
Review
of the OPD and IPD service performance of the hospital in the last month and
service delivery targets for the next month.
§
Review
of the outreach work performed during the last month and outreach work
scheduled for the next month.
§
Consider
reports of the Monitoring Committee for remedial action
§
Implementation
of the Citizens’ Charter
The minutes of the Executive
Committee meetings will be placed before the Governing Body at its next
meeting.
5.9
Monitoring Committee
A
Monitoring Committee could be constituted by the Governing Body to visit
hospital wards and collect patient feedback.
The Committee would send a monthly monitoring report to the District
Collector and Chairperson, Zilla Parishad.
5.10 Bodies of the Society for sub-district level hospitals
5.10.1 Governing Body
Chairperson : Sub Divisional Magistrate /
Block Development Officer, Panchayat
Samiti
Co-chair : District programme officer (deputy CMO or equivalent)
in charge
Member-Secretary : A Senior Medical Officer of the Hospital, nominated
by
Officer-incharge of the hospital Superintendent of the
hospital
Members:
§
Officer-in-charge
of the hospital
§
An
AYUSH doctor from a CHC
§
Block
level officers of ICDS, rural development, Panchayati Raj, Water and
sanitation, education and social welfare
§
Representative
of health sector NGO working in the area
§
An
eminent citizen from the town / city, nominated by the District Collector
§
An
eminent citizen from the town / city, nominated by the Chairperson, Panchayat
Samiti, Chief Executive Officer, Nagar Nigam (if applicable)
§
Associate
members/Institutional members: Same as for District Hospital Society
§
PRI
representative
Frequency of meetings and regular agenda: Same as for district hospital
society
Chairperson : Officer in charge of the
hospital
Member secretary : Member Secretary of the
Governing Body (Medical
Officer of
the Hospital, nominated by officer in charge
Superintendent of the Hospital
Members:
§
Two
PRI representatives to the Governing Body
§
District
Collector / SDM's nominee to the Governing Body
§
Block
level officers of ICDS, Water and sanitation and education
§
Representatives
of institutional members, if any
Frequency of meetings and regular agenda: Same as for district hospital
society
5.10.3 Monitoring Committee
Could be on the same pattern as in
District Hospital.
5.11 Provision of enabling rights, vesting assets & authorizing
services
The Govt. may authorize transfer of existing
facilities and assets free of cost and without any liability to the RKS / HMS
of the concerned hospital. In most hospitals, the principle reasons for
malfunctioning and deteriorating services are the inability to spend on new
infrastructure for upgradation & modernization, paucity of funds for
emergencies, gross mismanagement of resources and lack of motivation. Being a
service oriented facility, it needs to permit and grant specific rights to
allow freedom for operations and management. The RKS / HMS should be enabled
with the decision making right to invest in order to meet service requirements.
As mentioned above, user charges should be introduced, as it is believed that
excellent health care on a continuous basis cannot be ensured without adequate
financial provisions. Appropriate relaxations for BPL patients to be ensured,
as per State policy.
5.12 Resource Mobilization
The
funds of the Society shall consist of the following:
·
Grant-in-aid
from the State Government and/or State level society (societies) in the health
sector and/or District Health Society.
·
Grants
and donations from trade, industry and individuals.
·
Receipts
from such user fees as may be introduced for the services rendered by the
hospital.
·
Receipts
from disposal of assets.
5.13 Accounts and Audit
·
The
Society shall cause regular accounts to be kept of all its monies and
properties in respect of the affairs of the Society.
·
The
accounts of the Society shall be audited annually by a Chartered Accountant
firm included in the panel of Chartered Accountants drawn by the designated
authority of the State Government.
·
The
report of such audit shall be communicated by the auditor to the Society, which
shall submit a copy of the Audit Report along with its observation to the
District Collector.
·
Any
expenditure incurred in connection with such audit shall be payable by the
Society to the Auditors.
·
The
Chartered Accountant or any qualified person appointed by the Govt. of
India/State Government in connection with the audit of the accounts of the
Society shall have the same rights, privileges and authority in connection with
such audit as the Auditor General of the State has in connection with the audit
of Government accounts and in particular shall have the right to demand the
production of books, accounts, connected vouchers and other necessary documents
and papers.
5.14 Bank Account
The account of the Society shall be opened in a bank
approved by the Governing Body. All
funds shall be paid into the Society’s account with the appointed bank and
shall not be withdrawn except by a cheque, bill note or other negotiable
instruments signed by the Member-Secretary of the Society and such one more
person from amongst the Executive Committee members as may be decided by the
Governing Body.
5.15 Annual Report
A draft Annual Report and the yearly accounts of the
Society shall be placed before the Governing Body at its ensuing meeting that
may be held in the first quarter of every financial year.
A copy of the annual report and audited statement of
accounts as finally approved by the Governing Body shall be forwarded within
six months of the closure of a financial year to the following:
·
District
Collector.
·
Chair-person,
Governing Body.
·
Chair-person,
Executive Body.
·
Chair-person,
Zilla Parishad.
·
Chair-person,
Urban Local Body [ Nagar Nigam].
5.16 Suits and proceedings
·
The
Society may sue or be sued in the name of Society through its Member Secretary.
·
No
suit or proceedings shall abate by the reason of any vacancy or change in the
holder of the office of the Chair-person or Member Secretary or any office
bearer authorized in this behalf.
·
Every
decree or order against the Society in any suit or proceedings shall be
executable against the property of the Society and not against the person or
the property of the Chair-person, Member Secretary or any office bearer of the
Society.
·
Nothing
in sub-rule as above shall exempt the Chair-person, Member Secretary or office
bearer of the Society from any criminal liability or entitle him/her to claim
any contribution from the property of the Society in respect of any fine to be
paid by him/her on conviction by a criminal court.
5.17 Amendments
The Society may alter or extend the purpose for which it is established and/or the Rules of the Society, provided that such amendment shall only be carried out through the procedure set out in rule as above.
5.18 Dissolution
·
The
Governing Body may resolve to dissolve the Society by bringing a proposal to
that effect in a special meeting to be convened for the purpose, provided that
the proposal for dissolution has been duly approved /endorsed through the
process prescribed for amendment as set out in rule as above.
·
The
dissolution proceedings shall be made in accordance with the provisions of the
Act as amended from time to time in its application in the State.
·
Upon
the dissolution of the Society, all assets of the Society, after the settlement
of all its debts and liabilities, shall stand reverted to the State Government
for such purposes as it may deem fit.
5.19 Contracts
·
All
contracts and other instruments for and on behalf of the Society shall be
subject to the provisions of the Act, be expressed to be made in the name of
the Society and shall be executed by the persons authorized by the Governing
Body.
·
No
contracts for the sale, purchase or supply of any goods and material shall be
made for and on behalf of the Society with any member of the Society or his/her
relative or firm in which such member or his/her relative is a partner or
shareholder or any other partner or shareholder of a firm or a private company
in which the said member is a partner or director.
5.20 Common seal
The Society shall have a common seal of such make
and design as the Governing Body may approve.
5.21
Government power to review
The District Health Society
shall review, monitor and evaluate the performance of the Rogi Kalyan Samities
at the District/Sub District levels.