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.
2.1. 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
Chairperson : District Magistrate
Member-Secretary : Medical Superintendent of the hospital
§ 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
§ 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)
Member-Secretary : A Senior Medical Officer of the Hospital, nominated by
Officer-incharge of the hospital Superintendent of the
§ 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
§ 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.
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.
· 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.
· 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.