Chapter 8

Place Parameter inHospital Sector

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Chapter - 8Place Parameter in Hospital Sector

Place factor is considered more important for goods marketing rather than service marketing. In fact, in case of services distribution, channel management is even more critical than goods. Location is the key to successful marketing of service. In a classic marketing sense, place refers to the timely distribution of goods and services through channels, wholesale outlets, and sales agents, so that product are efficiently delivered to the market place.

8.1 Access to Service

The term used for place in health care is access to services. Access refers to the hours the hospital admitting office is open, the 24 hour emergency and pharmacy service, the surgery schedule, the appointment policy of the x-ray department, the hours the food service is open, the signs (not always easy to find) that direct people to various locations in the hospital, the distance and travel time from the physician's office to the hospital, and the proximity of one department to another.

8.2 Right Access Strategy

Accordingly, in planning its service mix for a target market, a hospital needs to consider the following questions in order to determine the right access strategy : How far is the hospital from major physician concentrations ? Is the service scheduled at times convenient for physician and patients? How long does it take for patients to get to the service location ? Do patients know how to find the service location ? Should variations of the service be made available ? Is parking adequate? Are admitting and scheduling procedures adequate? Is information about the service or hospital readily available?

Access is the critical linkage of the hospital and relationships through which service are efficiently delivered to consumers desiring or needing an exchange relationship with the hospital. A carefully planned access strategy formulated on reliable market information can significantly improve service utilization by providing needed healthcare services at a place most accessible to the consumer.

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Home healthcare programs, multi-speciality clinics, mobile health vans, "ICU on wheels", the physicians' office annex, visiting nurse programs, emergency helicopter services, community-based health education programs, telemetry, phone access to health information, and industrial medical clinics are all good examples of decisions to offer better access to much needed services. Unfortunately, many access decisions are not based on good marketing research. They should be! If they were, there would be fewer failures.

8.3 Importance of Location

In healthcare sector, the patient or the customer physically has to be present to avail the service. Some hospitals have started providing services of nurse, physiotherapists, doctor etc. after the discharge of the patient @ home services. Mobile clinics, mobile blood donation vans, fully equipped ambulances, satellite clinics, telemedicine etc. are some of the known examples.

The success or failure of a marketing strategy is often dependent upon where the product is available. The healthcare terms of "access" and "availability" are more in line with the true marketing concept. In that they represent more of a consumer orientation than does the traditional marketing term of "Place" or "distribution". Consideration must be made for such variables as referral mechanisms, location of facilities, and the hours in which services will be available. These considerations will determine the extent and mode of access to the product.

The proximity of a service to a customer often affects both the demand for the service and the degree of satisfaction with it. Many older hospitals are found in the deteriorating sections of the city, away from potential middle income patients. The use of marketing strategies to improve accessibility through primary care clinics, better parking and access to the hospital facility, or shuttle bus may increase utilization of the hospital by the target group.

In the marketing process, distribution of medicare services is playing a pivotal role. Many experts say that location is the key to successful marketing of services. In the hospital service, the customer i.e. patient has to be present to avail the service. This focuses on the instrumentality of almost all who are found involved in making available the services to the ultimate users. So the medical personnel needs a fair blending of two

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important properties e.g. professionally sound and in-depth knowledge of psychology. This would make the services in tune with the expectations of users.

Customers try to locate conveniently located service provider. Customers may be more loyal or be willing to pay slightly more for nearby service provider. One of the reasons is that in India transportation is not exactly cheap. At the same time parking places are difficult to find. Now-a-days hospitals try to give single location services, i.e. in-house laboratory, blood bank, catering services, radiology, travel desk, library etc.

8.4 The effect of IT on locational issue

Information Technology has revolutionized the service concept. Patient through internet can contact for away doctors. He can send his physical reports to anywhere in the world. Doctors sitting in different corners of the world can discuss the case through Video Conferencing. Apollo Health and Lifestyle Limited (AHLL), a wholly owned subsidiary of the Apollo group of Hospitals announced its plans to expand the network of its franchisee. Day to day healthcare centres “ "The Apollo Clinic" are opened in the states of Gujarat, Maharashtra and Madhya Pradesh. AHLL already has three successfully operational clinics in the western region (two in Ahmedabad and one in Surat). Ratan Jalan, CEO, AHLL says that as a leading healthcare service provider, they believe that the only way to ensure a healthier population is to make quality day to day healthcare services accessible to everyone. Apollo Clinics provide complete solution for the day-to-day healthcare needs. Besides offering speediest consultation services, diagnostic facilities and preventive health check-up packages, all the clinics have well stocked 24 hours pharmacy. In next five years they are planning to set up 250 Apollo Clinics including 30 to 40 clinics abroad. It is also setting up "health Spas" in strategic locations across the country.

They believe in holistic medicine and integration of both complementary and alternative medicine to the treatment protocol. In Ahmedabad AHLL has launched the novel teller ECG through wire. It is a unique concept by which heart specialists sitting at the hospital control room could read the ECG charts sent by General Practitioners (GPs) from across the state and advise them back. Their plan is to connect 150 GPs.

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8.5 Recent Trends - Medical Tourism

The recent trend being seen in the healthcare services in India is to complement it with tourism. This has seen a fairly large number of foreigners flocking to India for treatment. Corporate hospitals are providing full package with accommodation, transportation etc. to patients & relatives. Offices are opened in U.K., U.S.A. for outsourcing of patients. These offices through internet and the teleconferencing are bringing together doctors and patients. They work as intermediaries. Indian private hospitals are of good standard, expenses are relatively less, highly skilled medical care is provided. Patients and relatives can feel at home, relatives can have sight seeing due to tie-ups with operators. Indian hospitals can capitalize on the opportunity by having a co­ordinated strategy and upgrading facilities to global standards to attract lucrative US market. This is being cashed in by leading travel agents such as Thomas Cook, Cox & Kings and Kuoni which have drawn up a slew of healthcare packages. Thomas Cook has roped in leading surgeon Dr. Padam Sanghvi as its medical tourism project advisor and is also looking at having a tie-up with a leading hospital chain in India. Cox & Kings has partnered with Vedic India and Omkar Trust, two leading medical bodies that promote medical tourism in India. Dr. Batra's positive Health Clinic has a tie-up with Cox & Kings, Brightland Holidays and Sterling Resorts that offers discounts to members. Similarly Apollo Hospitals has tied up with Sita, a part of Kuoni Group to form the Sita care project.

8.6 Medical Transcription

Medical transcription refers to conversion of notes of healthcare producers into accurate readable records. This includes patient history, reports, clinical notes, lab reports, X-ray reports, and other investigations. The records can be sent to concerned hospitals in the US. The global market for IT enabled services is estimated to US $200 billion by 2010. Medical transcription is a permanent legal document which gives the results of a medical investigation. It facilitates communication and helps in insurance claims.

The main processes involved in a medical transcription are as follows :

i) Hospitals get signed up, doctors are trained in the process and they dictate to a pre-set toll-free number. This is stored in the server at the other end of that number.

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ii) The sound is converted to digits and sent to the offshore, outsourcing centre as a 'wave file' via Satellite. The digitized data gets converted back to sound where the trained transcriptionist listens to the dictation and transcribes.

iii) Quality control persons listen to the transcribed file for checking and making corrections. The transcribed reports are transmitted back as a 'doc-file'.

8.7 Telemedicine

SATCOM BASED TELEMEDICINE CONNECTIVITY

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In an attempt to bring urban medical expertise to backward rural areas, the Indian Space Research Organisaiton (ISRO) is setting up 100 more telemedicine centres across the country with the help of the Central Government. ISRO has a separate budget for application for space technology for civilian purposes. The proposed network of telemedicine centres using INSAT Satellites would be a big leap for the nation in mitigating the problems faced by almost 60 crore people in the rural region. Technology of telemedicine was successfully put to use by ISRO during Bhuj earthquake, Kumbhamela and Sarbarimala pilgrimages. ISRO is also developing a separate satellite 'Health-Sat' exclusively for meeting the healthcare and medical education needs of the country. ISRO in association with Central Government Departments sponsored the largest international telemedicine conference "INTELE MEDINDIA" IN March 2005 at Bangalore. The theme was 'Telemedicine for global healthcare'.

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8.8 A clinic on Wheels

Mobile clinics are a unique way to bring better healthcare to villages. The Uttaranchal Mobile Clinic and Research Centre is a unique initiative that seeks to bring healthcare to villages. First Mobile Hospital and Research Centre was flagged off by Dr.A.P.J Abdul Kalam, in October 2002. It has been found to be an extremely popular and practical healthcare model for Uttaranchal. The project is a joint effort of Technology Information Forecasting and Assessment Council (TIFAC) and the Uttaranchal Government. The project has been conceived keeping in mind the specific needs of the remote hilly terrain of Uttaranchal where negligible modern healthcare is available to the needy who stay in far-flung areas.

This is probably the first time anywhere in the country that a comprehensive healthcare model comprising of on the spot diagnosis and treatment has been developed to cater to the rural population. Because of this healthcare model it has been possible to provide state-of-the-art comprehensive healthcare to the poor in remote areas of Uttaranchal.

Dr. C.S.Pant, a New Delhi based radiologist was instrumental in setting up the centre. He is originally from Uttaranchal. During his visits to Kumaon, he was appealed to see the poor healthcare facilities available at district hospitals. So deciding to do something, he set up the first mobile clinic. People had no choice other than to be at the mercy of quacks. Even reasonably well off, people have no place to go for diagnosis.

The main objective of having a mobile hospital is to provide diagnostic facilities like ultrasound, x-ray, ECG, laboratory and basic instruments for eye, ENT and gynaecological check ups. Curative healthcare provided includes prescription and on-the-spot dispensing of medicines for common ailments and referral to hospitals, for other cases. The research functions consist of developing a health profile and analysis of health issues in rural areas. This health profile includes age, gender, caste, class and location specific data besides creating a general profile of the health status to start education programmes in order to raise awareness about preventive healthcare issues like family planning and communicable diseases. With the help of audio visual equipm ent and a large screen fitted in the van, educational films can be shown in villages.

The mobile clinic has on board state-of-the-art facilities like ultrasound, an x-ray machine, computerized pathology laboratory and an ECG machine. The X-ray equipm ent is capable of examining almost all parts of

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the body. The provision of an automatic x-ray film processor is a boon. The pathology laboratory, besides doing routine blood and urine tests is provided with a semi-automatic analyzer capable of doing almost all the blood biochemistry, including sugar, cholesterol, urea and lipid profile. All medical data including the patient's registration is fully computerized so as to generate a medical profile of previously inaccessible terrain, thus providing a great input to planners for future projections. The mobile medical team comprises of one lady medical orderly, one physician and one radiologist besides which it has a full team of paramedics including x-ray, lab and ECG technicians and a pharmacist.

There are also mobile clinics that cater to specific ailments of the eye and heart, dental disorders and for diseases like cancer. However, this model addresses the daily needs of people living in places that are far from cities. In the hills transporting patients from one place to another is both expensive and time consuming. Because of the topography, a patient often, requires two or three escorts who add to the expenses. This was an additional reason prompting them to take modern diagnostic facilities and treatment to patient's doorsteps, so that diagnosis and treatment is possible at a minimum costr Every month 15 camps are held on predetermined dates. The van visits a village once a month. Patients who wish to avail of this facility are required to register by paying a nominal fee of Rs.10, which is valid for two visits. People who have been issued below poverty line ration cards are treated free.

There has been an overwhelming response to the mobile hospital and research centre in the short span of 16 months. Tibetan Hill Council at Darjeeling has already replicated it and very soon a similar van is going to be introduced in the Garhwal region. Three such mobile vans have been introduced in Mizoram too. Instead of having permanent infrastructure with adequate facilities, one can go for mobile facilities, which are not only practical but also cost effective. Even in cities like Delhi, it can be replicated to provide high end diagnostic facilities like CT scan. The mobiles can be shared between five or six government hospitals on a weekly basis or so. They are the most practical and convenient option to reach out to the masses and can be extremely useful in disaster management.

8.9 Life Brigades on Wheels - Ambulances

Though in an enormously pathetic condition, ambulances today are gradually getting well equipped, with paramedics operating towards the

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golden hour concept. The Indian healthcare industry is on par with the western world in providing healthcare services; nevertheless it has gallingly failed to focus on the ambulance services. Despite the alarmingly high road-accident rates in the Indian metropolises and the frequent occurrences of natural calamities like floods and earthquakes, the country has almost negligible Emergency Medical Services to treat victims in the vital first hour. The Indian hospitals must be technically well equipped to handle emergency and trauma cases, but unknowingly they have missed to consider the ambulances, which are the backbone of emergency.

However, the scenario Is changing since four to five years. Corporate hospitals, private organizations and quite a few NGOs have commenced high-end ambulance services. Also, the incoming of international ambulance associations has been cordially accepted by the Indian Healthcare Industry.These players have meticulously thought about incorporating the vehicle with basic equipments, accompanying the vehicle with well-trained people and most importantly following the golden hour concept. In true sense, they are life brigades moving on wheels.

The moment an emergency call is received, the respective ambulance service should reach the site within 10 minutes. Thereon the immediate first aid to be provided along with proper transportation of the patient to the nearest hospital is imperative. AH this decides the survival of the patient. In short, major morbidity and mortality could be reduced if they receive treatment in first one hour, which is the golden hour.

Most of the present ambulances in India are only transportation vehicles. We don't have a central ambulance service, no uniform national emergency number like 999 in England or 911 USA. Our ambulances lack in standardization. They are not spacious, void of any equipments, paramedics are not well trained and with no management protocols of seriously ill patient. The patient is sometimes being sent without oxygen, IV or monitoring. So by the time the ambulance reaches the tertiary hospital, the patient is beyond salvage. Ambulance services across the nation still need an alteration. The government and trust hospitals are slightly reluctant to incorporate a high end ambulance service. Lack of funds could be a demerit behind the disinterest among the government and trust hospitals in such a vehicle as running an ambulance is a full time service and involves a lot of investment. Operating such an

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expensive service and sustaining it, needs to be feasible. There is a critical need of well-trained paramedics.

8.10 EMS - Emergency Medical Services

Emergency Medical Services (EMS) is now available in India - certainly a ray of hope well planned ambulance services for immediacy and as a first step in emergency and trauma care have made their entry in India. Many of these services have tied up with international organizations. Ruby Halls, for instance, works on project called "saving lives". This project was launched in 1999, is a joint venture of West Midlands Ambulance service, U.K., Ruby Hall Clinic, Royal Life Saving Society, Birmingham and Rotary Club of Poona and Birmingham.

Topsline Emergency service commenced by Topsgroup in 2004, are in the business of responding to any life threatening emergency call. Their international partner is Emergency Response Training Inc, USA. Topsline has a set of 100 life brigades and life patrols scattered in Mumbai, Thane and Navi Mumbai. Each brigade is a combination of mini ICCU ambulance and a mini fire brigade that is accompanied by a pilot, paramedics, doctor, combat officer, armed officer and a commander. Considering the heavy traffic in metropolises, the paramedic/doctor travels on a bike so that they can reach the accident site and provide the necessary first aid.

Indraprastha Apollo, Delhi has a fully equipped ambulance with advanced Cardiac life support, trained doctors and basic life support, trained nurse / paramedic. The hospital has also introduced the concept of two wheeler ambulance that function as emergency ambulances. Considering the congestion on the roads, it was felt that a big van as an ambulance meant loss of crucial time in saving a patient, especially in accident or cardiac cases. Most of the ambulance services following EMS and having international tie ups have a toll free number.

Hygiene and sanitation care is not neglected. Bed sheets are changed before any new patient is moved on the ambulance. Vaccum cleaning is frequently done along with defumigation at least once a week. The ideal ambulance should be with adequate amenities like jumbo oxygen cylinder, triple channel monitor, defibrillator with external pacing facility, portable ventilator and trolley cum stretcher with minimum of three people. It should have rescue equipments like cutting saw for extrication from motor vehicle. Appropriate air conditioning and trauma

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equipment like spinal board and neck support should be there. If the ambulance has a telemedicine set up for certain sectors, then it will help in much faster emergency solutions. Ideally, any well equipped ambulance should consist of cardiac monitor SP02, ECG machine, AED/defibrillator, NIDP/blood pressure, ventilator, suction machine, immobilizers, scoop stretchers/foldable trolleys, emergency medicines, combitubes, syringe infusion pump, glucometer, life saving drugs, oxygen, disposables, all kinds of splints and an IV stand.

Ambulance access for all Mumbai is an organization working towards saving lives by increasing the awareness and education about the importance of EMS to people. It provides a network of well-equipped, advanced and basic life support ambulances in Mumbai. It has a tie-up with London Ambulance Service and ambulances are equipped with their standards.

All efforts considered for the future to be bright, all hospitals should have fully equipped ambulances and moreover, the service should be centralized and nationalized. This can help to brighten the prospects of safe patient transport. Apollo Hospital has introduced Apollo Air Ambulance for emergency facilities across Gujarat, (source : Gujarat Healthline June 2006)

8.11 Phelophepa Health Care Train

Bringing Good health to the Masses

It has been said that a nation without health is a nation without hope. Inspired by this philosophy, and the belief that health care should be accessible to all, two organizations have put their resources together to provide rural South Africans with sixteen coaches of good health.

The Transnet Foundation's Phelophepa train, which means good health in Sotho and Tswana, started on 10th January 1994 as the first and the only primary health care train in the world, operating as a health and educational facilitator reaching thousands of rural communities in South Africa.

The original agreement, between Transnet's corporate social investment department and the optometry department of the University of Johannesburg, was to provide rural South Africa with primary eye care. Today this 16-coach train provides optometry, nursing, dentistry,

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psychology, and pharmaceutical services. The train is run by 17 permanent staff members living on the train during the entire run, supported by 27 final year and post-graduate students from tertiary institutions in South Africa, who rotate on a fortnightly basis. Apart from providing health-related training, students from the Tourism and Hospitality School at the Border Technikon also assist the catering manager on board, while at the same time, they gain experience in catering and hospitality services.

The train boasts a modern communications network, an industrial kitchen that serves more than 40,000 meals during the 36 week period, a unique power car generating enough electricity to supply a small town for two weeks, and comfortable clinic offices and consulting rooms.

The services rendered on the train enhance existing health services, or provide services where these currently do not exist in communities. The major objective of the Phelophepa train is that of screening and education, making people aware of looking after their own health.

Screening services are also taken to local schools in the area. If there is a child who needs further help, a letter is written to the parents informing them of the problem and offering a solution.

Lynette Coetzee, strategic manager and the main force behind the project, says she was stumped by the disparities when she started travelling to the rural areas. None of us knew what the backlog really was. At this point one of most important facets of the project is the marketing. We have to ensure that the train is well promoted in the rural areas months before the time so that people have enough time to organize transport to get to the train.

A team of interpreters is used at each stage to drive home their message. This coupled with close contacts with local politicians, teachers, farmers' associations and mineworkers' bodies. The average amount that each patient pays for his or her care is a subsidised R35. Since the train's inception more than 222,792 prescriptions have been dispensed and about 1.5 million people are helped per year.

The train tries to support the local economy as far as possible and residents are recruited as cleaners, interpreters and security. About R14,000 is spent on food per week, which is bought at the various destinations.

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The train costs about R(Rand) 25 million per year to run. Transnet provides 60% of the funds and private donors provide the rest. The programme requires a lot of feedback so they can keep on improving the system. It is a continuous learning experience to try figure out the best way in which they can help. They need to do a lot of educating about things like diabetes and hypertension. Some people in the rural areas don't know they have the disease or even what it is and how to stay healthy. They have now brought in an education coach to train key members in the community about basic hygiene, STD's, Aids and home based care, so they can teach and help others in the community. They are even teaching them to grow their own vegetable gardens so they receive adequate nutrition.

The train is not just about physical healing, it is also about the psychological healing that the country needs. (Source : Indwe May 2006)

8.12 LIFE LINE EXPRESS

India does not have large no. of airborne hospitals but it is a matter of pride that we have a hospital (Life Line Express) running on the rails. It was started on 16th July 1991 from Mumbai railway yard. At that time George Fernandes was our Railway Minister. It is a three coach donated train by Indian Railways and Health Ministry. All the three compartments are white in colour with blue stripe. Air conditioned O.T. is in the middle compartments out of other two compartments, one is for doctors and the staff and other for store, pantry and two generators. At present it has gone to Uttar Pradesh via Manmad and Hyderabad. This mobile has conducted many medical camps to various places like Ahmedabad, Chainpur, Mathura, Gauriganj, Manmad etc. This hospital provides free of cost services in the rural areas. This train can cover more area than the mobile van.

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