Functions of hospitals:
The technical discussion
of the Tenth World Health Assembly was held in 1957, the subject of which was
"The Role of the Hospital in the Public Health Programme". Some two
hundred participants attended the sessions under the general chairmanship of
Dr. A. J. Metcalfe, Director‐General of Health of
Australia. Participants were split into nine groups, and the nine group reports
were consolidated to make a general statement. From the start of the
discussions the cards were stacked in favour of an extension of hospital
functions for it is recorded that the groups were all but unanimous accepting
the definition of a hospital put out in the first report of the Expert
Committee on Organization of Medical Care of the World Health Organization: "The
hospital is an integral part of a social and medicalorganization, the function
of which is to provide the population complete healthcare, both curative and
preventive, and whose out-patient services reach out to the family in its home
environment; the hospital is also a centre for the training of health workers
and for bio-social research."
The main function of a
hospital is to provide the population with complete health care; it also
functions as the centre for the training of health workers. A hospital is generally
a vital part of a social and medical organization.
Following are some of
the broad categories of Hospital functions:
Medical care ‐ which involves the treatment and management of
patients through the staff of physicians.
Patient Support ‐ which relates directly to patient care and includes
nursing, dietary diagnostic, therapy, pharmacy and laboratory services.
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 other maintenance. Besides these the
following are some major responsibilities coming under administrative service:
·
To plan, direct
and coordinate financial operations of the hospital.
·
To prepare work
and financial plan and provide fund estimates for programs and projects.
·
To manage the
receipt and disbursement of cash/ collections.
·
To administer
personnel development programs, policies and standards;
·
To give advice
on matters affecting policies, enforcement and administration of laws, rules
and regulations.
·
To procure,
store, manage and issue the inventory and disposal of unserviceable hospital
equipment and materials; and
·
To provide
general services such as repairs and maintenance, housekeeping, laundry,
transport and security.
Teaching ‐ Vocational, Undergraduate, Postgraduate, Continuing
education.
Research ‐ Basic research, Clinical research, Health services
research, Educational research.
Employment ‐ Inside hospital : Health professionals, other
health care workers Outside hospital: Suppliers, Transport services.
Medical sociologists
assert that the delivery of health services is much more than simply the
application of scientific and technical knowledge. Health care services are
delivered by people to people within various social environments, which can
influence the way medical technology is delivered or received and, perhaps most
important, the clinical outcomes for people seeking help.
More over the rising
costs and inconsistent quality of health care have raised significant questions
among professionals, policy makers, and the public about the way health
services are being delivered. For the past 50 years, medical sociologists have
made significant contributions in improving our understanding of the nature and
impact of the organizations (hospitals) that constitute our health care system.
In this section, three central issues in the sociology of health services have
been discussed:
·
Health services
unequally distributed, contributing to health inequalities across status
groups;
·
social
institutions reproduce health care inequalities by constraining and enabling
the actions of health service organizations, health care providers, and
consumers;
·
the structure
and dynamics of health care organizations shape the quality, effectiveness, and
outcomes of health services for different groups and communities;
·
the policy
implications for future health care reform efforts.
One of the fundamental
concerns of medical sociologists over the past 50 years has been to document
and explain gender, socioeconomic, and racial‐ethnic
differentials in health outcomes. Among the early explanations for these
patterns were disparities in the distribution of health services among social
groups, and substantial attention was devoted to documenting systematic
differences in access to health care. More recently, evidence has emerged
suggesting that the adverse impact of health care disparities on population
health is increasing, highlighting the need for additional research (Lesser and
Cunningham 1997). As a result, sociologists have taken a renewed interest and
adopted a more complex and comprehensive approach to health services research,
examining the nature, quality, and timeliness of care received under a variety
of illness conditions.
Sociological research
has documented significant gender differences in help‐seeking. Women are more likely than men to visit a
doctor for an array of both physical and mental health problems (Courtenay
2000; Green and Pope 1999; Kessler, Brown, and Broman 1981). They are also more
apt to have a regular physician and to obtain preventative screenings (Bostick
et al. 1993; Centers for Disease Control 1998; Powell‐Griner, Anderson, and Murphy 1997). However, men who
do consult a health professional may receive better treatment than women for
the same condition. The evidence is particularly strong in the case of heart
disease. Women who present with symptoms of cardiac disease are less likely to
be referred for diagnostic tests, given cardiac drugs, or instructed to make
lifestyle changes. Conversely, they are three to five times more likely to be
sent home without any treatment (Lockyer and Bury 2002; McKinlay 1996). These
patterns delay diagnosis and contribute to higher mortality rates among women
with heart disease relative to men.
Decades of research by
sociologists suggests that people with less income and education face greater
obstacles accessing health services than their more well‐off counterparts, despite having higher health care
needs (Dutton 1978; Katz and Hofer 1994). Disparities are particularly marked
in the area of primary care (Rundall and Wheeler 1979). For example, adults and
children of lower socioeconomic status (SES) are less likely to have routine
physical examinations and screening procedures, such as prenatal care,
immunizations, mammograms, and colonoscopies (Goldman and Smith 2002; Lantz,
Weigers, and House 1997; McDonald and Coburn 1988). Moreover, they are less
likely to receive medical intervention in a timely manner, and they often
receive less intensive and lower quality treatments (Williams 1990). Together,
these patterns result in poorer long‐term
outcomes and higher emergency room and hospitalization rates for conditions
that would not normally require them (Padgett and Brodsky 1992; Pappas et al.
1997).
Because income and
educational attainment are so closely linked to race and ethnicity in America,
patterns of health care inequality observed in racial‐ethnic minority groups are similar to those found in
low‐SES populations (Williams and Collins 1995). That
is, racial‐ethnic minorities generally have less access to
health services, in particular primary and preventative care, and they also
tend to receive delayed treatment and lower quality acute and long‐term care than whites (Blendon et al. 1989; Smedley,
Stith, and Nelson 2003; Williams 1990). Though these patterns are better
established in African American populations, studies suggest they also extend
to Latinos, Asian Americans, and Native Americans (Angel and Angel 2006;
Collins, Hall, and Neuhaus 1999; Fiscella et al. 2002). While much of the
disparity in health services use can be explained by SES differentials, race‐ethnicity tends to exhibit a modest, independent
effect on health services use. These effects have been attributed to racial
discrimination by health services providers and racial segregation of
minorities into communities with less access to high‐ quality health services (Polednak 1993; Williams
and Collins 1995).
A unique strength of
the sociological perspective is the focus on underlying social structural
mechanisms of phenomena that ostensibly occur at the individual level (McKinlay
1996). Sociologists have long conceptualized medicine as a social institution,
highlighting the influence of macro factors on help‐seeking and the practice of health care in everyday
life (Freidson 1970; Mechanic 1975; Parsons 1951). The institution of medicine
is characterized by a powerful set of social norms, rules, values, and
practices that provides a blueprint for the behavior of individuals and
organizations (e.g., physicians, patients, hospitals, HMOs, etc.), and
systematically structures the relationships between them. Sociologists have
contributed much to our understanding of the ways that culturally and
historically shaped institutional forces constrain the behavior of health care
providers and consumers, reproducing health care inequalities across social
groups (Light 2004). Sociologists have been instrumental in documenting changes
in the institution of medicine over the twentieth century. In what Scott and
colleagues (2000) call the era of professional dominance (1945–1965), the
motivating ideology in medicine was commitment to quality care. Additionally,
there was a strong sense of obligation to provide health care to all,
regardless of a person’s ability to pay for it (Klarman 1963). Accordingly, the
poor received free care from physicians and hospitals, and the population at
large paid on a sliding scale according to their means. In the era of federal
involvement (1966–1982), concern with equitable access prevailed, but the
government increasingly took over responsibility for funding and regulating the
fair distribution of health care (Scott et al. 2000). At the same time, health
services expenditures began to increase rapidly, and concerns about cost
containment began to overshadow the long‐standing
commitment to quality care and equity that had characterized the institution of
medicine since its inception (Brown 1979). In the current era of managerial
control and market mechanisms (Scott et al. 2000), the health care sector is
conceptualized as an industry, or economic system, and efficiency and profit
are central motivating values. Changes in health policy (and ultimately
practice) enacted by the Reagan administration began as part of a broader
political movement characterized by welfare state retrenchment and by the
shifting of government control to competitive market forces (O’Connor 1998).
These events, described in greater detail by Mechanic and McAlpine (2010, in
this issue), culminated in the corporatization of health care and the managed
care ethos that pervades the institution of medicine today.
There
is a Separate and Unequal distribution of health service in the Public and
Private Health Care Sectors. This
trend has important implications for the types and quality of care received by
lower statusgroups. For instance, managed care organizations minimize risk by
denying coverage to sicker, less profitable patients and spreading the risk out
among a large consumer group that contains both healthy and sick individuals.
These practices shift much of the financial responsibility for indigent care
(i.e., those who are unable to pay for services) to physician groups and
hospitals, pressuring them to balance their budgets by cutting costs associated
with uninsured or publicly insured patients. At the same time, professional
resources and government funds are increasingly being diverted to the
profitable private sector (Waitzkin 2000). This has forced many public health
facilities to close their doors, shrinking the public sector and widening the
health gap between the rich and the poor. Sociologists have demonstrated that
the result of this profit driven funding environment is essentially two
divergent health care systems, public and private, characterized by radically
different experiences and outcomes (Dutton 1978; Lutfey and Freese 2005;
Smedley et al. 2003). Supporters of the for‐profit
sector have argued that those without private insurance can still access
private health services through Medicare and Medicaid reimbursements. On the
contrary, sociologists have identified numerous barriers that minimize use of
the private sector by the publicly insured: (1) Medicare and Medicaid often pay less thanprivate market value for a
given service, forcing the patient to pay the difference in cost; (2) Medicare
and Medicaid policies are notoriously complex, prompting confusion and fear of
incurring fees in the private sector; (3) Community and geographic barriers may
restrict access to private facilities and providers, even when patients are
publicly insured (Macintyre, MacIver, and Sooman 1993; Williams and Collins
2001); (4) Finally, private facilities and providers may overtly or subtly
discourage publicly-insured (and uninsured) patients from using their services.
At even greater risk for slipping through the cracks ofour health care system
are the working poor and lower middle class—those whose incomes neither qualify
them for public insurance nor allow them to afford private coverage (Seccombe
and Amey 1995).
Seeking to understand
the implications of organizational structure and dynamics in health services
settings, a number of medical sociologists have focused more narrowly on
organizations. Indeed, much of the classical work in medical sociology during
the 1960s and 1970s explored various aspects of health care organizations,
especially the general, acute‐care hospitals (Coe
1978; Goss1963; Wilson 1963), as well as medical schools, physician offices,
and psychiatric hospitals (Coe 1978; Freidson 1970; Strauss et al. 1963). With
advances in technology and economic opportunities in the health care sector, and
with the epidemiological shift from acute to more chronic and long‐term health conditions, the types and varieties of
health care organizations expanded dramatically from the 1960s onward.
Nevertheless, these early studies had enormous descriptive value and
contributed to a fundamental understanding of our emerging health system. They
also highlighted a myriad of organizational challenges in delivering health
services, including the depersonalization and devaluing of patients (Coe 1978);
the interpersonal dynamics between doctors and patients (Freidson 1970; Glaser
and Strauss 1965; Goffman 1961) the power relationships and conflicts among
health professional groups (Goss 1963); and the tendency toward bureaucratic
medical decision making and treatment (Freidson 1970; Goss 1963; Strauss et al.
1963). Most importantly, this body of work sensitized a generation of medical
sociologists to the nature of medical work and established a reference point
that continues to inform the field. In more recent years, medical sociologists
have examined critical organizational changes that have had implications for
how and what types of care are delivered, as well as how effective the care is
for various social groups.
·
Expanding
government’s regulatory role in the delivery of health services must
necessarily be accompanied by a better
marriage of research and policy. In recent years, policy makers have called
for more “comparative effectiveness” research, specialized research that
compares the cost and clinical efficacy of treatments for particular
conditions. Recent efforts to improve care have gravitated toward performance
measurement and linking payment to concrete outcomes. While a focus on outcomes
is undoubtedly valuable, existing research has barely scratched the surface of
the broad and complex social and organizational factors that shape efficiency
and effectiveness. In this regard, sociological research is important because
it underscores that quality care is determined not only by what services are
provided, but also how they are
delivered, by whom, and to whom.
·
Policy makers
should identify locations for building facilities, increasing funding, and
augmenting services and providers that are optimally useful and attractive to
those in underserved communities.
·
It is necessary
to consider how the uninsured and underinsured currently utilize those services
that are available, and how to bring people at the margins into the health care
system. For instance, incentivizing the use of primary, preventative, and
follow‐up health care among those currently relying on
emergency room services may be an effective strategy.
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