Topic Seven:
Health Care Organization and Policy
The Hospital in Society
• The most prevalent feature of modern medicine is the emergence of
the hospital as the centre of most health care interventions.
• Since many health problems require a level of medical treatment and
personal care that extends beyond the range of services normally
available in the patient's home or in the physician's office, modern
society has developed formal institutions for patient care intended to
help meet the more complex health needs of its members.
• The hospital, the major social institution for the delivery of health
care, offers considerable advantages to both patient and society.
The Hospital in Society
• (i) From the standpoint of the individual, the sick or injured person has access
to centralized medical knowledge and the greatest array of technology in
hospitals.
• (ii)From the standpoint of society, as Talcott Parsons and Renee Fox (1952)
suggest, hospitalization both protects the family from many of the disruptive
effects of caring for the ill in the home and operates as a means of guiding the
sick and injured into medically supervised institutions where their problems
are less disruptive for society as a whole.
• The development of hospitals as institutions providing medical services for the
general public proceeded in pace with prevailing needs, beliefs, values, and
attitudes of the societies they served. This is seen in the evolution of the
hospital's role in society over time.
The Hospital in Society
• Historically, hospitals have passed through four distinct phases of development: (1) as
centers of religious practice; (2) as poorhouses; (3) as deathhouses; and (4) as centers of
medical technology
Hospitals as Centers of Religious Practice
• Although the Romans were the first to establish separate medical facilities (for economic
and military reasons) that have been described as hospitals, the origin of the institution
we know today as the hospital has usually been associated with the rise of Christianity.
• Christian theology emphasized that human beings were duty bound to provide
assistance to the sick and needy. This belief was reinforced by the notion that spiritual
salvation could be obtained by whoever provided such a service.
• Consequently, the Roman Catholic Church encouraged its clergy to found hospitals,
located near churches as an integral feature of Christian religious endeavor.
The Hospital in Society
• The primary functions of the medieval hospital were the exercise of religious practices and the
extension of charity and welfare services to the poor, including both the able-bodied and the sick.
These early hospitals, therefore, provided a wide spectrum of social tasks for the benefit of the
lower classes, especially the provision of food, shelter, sanctuary, and prayer as well as nursing.
Hospitals as Poorhouses
• During the Renaissance and the Reformation, the religious character of the hospital began to
disappear, as increasing numbers of hospitals were placed under the jurisdiction of secular
authorities.
• The secular control of hospitals marked a period of decline for the development of Europe's
hospital system. Even though monks and nuns continued to work in hospitals, the removal of the
centralized authority of the Church left hospitals under many separate administrations, usually
those of municipal governments.
The Hospital in Society
• While this policy relegated the poor, both the incurably ill and the able-bodied, to poorhouses or
to the streets for their support, it marked the beginning of a new definition of hospitals as
institutions active in treating the sick and injured so that they could return to society.
• However, by the end of the sixteenth century, the economic and social conditions of the poor
worsened to a considerable degree. Unemployment, higher prices, and the loss of land created a
serious problem of vagrancy throughout Europe.
• Many vagrants claimed to be sick or crippled, and they crowded whatever hospital facilities were
available.
• In accordance with the new definition of social welfare as a community rather than a church
responsibility, measures were eventually taken by city and national authorities to provide public
assistance.
• Many hospitals were reopened, but they soon acquired the characteristics of boarding houses,
because they offered food and shelter to the poor, regardless of whether they were sick or
healthy.
The Hospital in Society
Hospitals as Deathhouses
• Although medical treatment was recognized as the primary function
of the hospital in the eighteenth century, the primitive level of that
treatment produced few cures.
• Trained physicians were unable to achieve consistent results with
their techniques, and accordingly, neither they nor hospitals were
held in high esteem by the general population.
• Because so few patients survived treatment, despite occasional heroic
efforts, hospitals acquired an image as places where the poor went to
die.
The Hospital in Society
Hospitals as Centers of Medical Technology
• Since the end of the nineteenth century, a new image of hospitals evolved as institutions
where patients of all social classes could generally expect to find the highest quality
medical care and could reasonably expect to be cured of their disorders.
• Three major factors were responsible for this change:
• (i) First was the fact that medicine had indeed become a science in terms of
employing the scientific method to seek out accurate medical knowledge and to develop
successful techniques that could be employed in a consistent manner. Because the new
medical technology required extensive and often expensive facilities, the facilities were
centralized in hospitals so that they could be available to most physicians. Hospitals
eventually became places where physicians also referred their upper- and middle-class
patients, since the most advanced medical technology was located there.
The Hospital in Society
• (ii) A second important factor, concomitant with the development of medical
technology, was the discovery and use of antiseptic measures in the hospital
to help curtail infection. Hospitals were not only properly cleaned and
ventilated but also patients with infectious diseases were isolated in special
areas of the hospital, and hospital staffs were required to wash their hands
and change their clothing after working with these patients. The use of such
items as surgical masks, rubber gloves, and sterilized surgical instruments
became commonplace.
• (iii)Third, there was a significant improvement in the quality of hospital
personnel. Especially important was the entry on to the scene of the trained
nurse and the laboratory technician, whose specialized skills were able to
support the physician in his or her primary role of diagnostician and
practitioner.
The Hospital in Society
• In the twentieth century, the hospital has become the major institutional
resource available to society for coping with problems of health and illness.
• Such hospitals have been described as "multipurpose institutions," in that
they provide a variety of health-related functions such as: (1) treating
patients; (2) providing laboratories and other medical facilities to the
community; (3) training health practitioners; (4) conducting medical research;
and (5) sponsoring health education and preventive medicine programs for
the general public.
• The primary goal of the hospital, however, is that of providing medical
treatment to its patients within the limits of contemporary medical knowledge
and technology and the hospital's available resources.
• To accomplish its tasks and coordinate its various activities, the hospital relies
on a prescribed hierarchy of authority, which is operationalized through
formal rules, regulations, and administrative procedures.
The Hospital in Society
• The key to hospital efficiency and overall effectiveness is coordination of the
various departments and individuals. They represent a complex and highly
specialized division of labor that is both interlocking and interdependent.
• In summary, the hospital's organization consists of a varied group of
professionals and allied health workers with different functions, training, and
occupational values. To make this social organization function effectively, it
has been necessary to construct a decentralized system of authority organized
around the central objective of service to the patient.
• While the administrator directs and supervises hospital policy, the medical
staff retains control over medical decisions. Yet, hospitals can be held legally
responsible for what happens within its premises. Thus, hospitals have a
responsibility for the care of their patient separate from that of physicians.
The Hospital-Patient Role
• While hospital services are oriented toward a supportive notion of patient
welfare, hospital rules and regulations are generally designed for the benefit
of hospital personnel, so that the work of treating large numbers of patients
can be more efficient and easier to perform.
• Consequently, the sick and the injured are organized into various patient
categories (e.g., maternity-obstetrics, neurology, orthopedics, urology,
pediatrics, psychiatry) that reflect the medical staff's definition of their
problem and are then usually subject to standardized, staff-approved medical
treatment and administrative procedures.
• While it can be argued that standardizing patient care results in increased
organizational efficiency-and ultimately serves the best interest of the patient-
a prominent theme of the hospitalization experience noted by medical
sociologists has been that of depersonalization.
The Hospital-Patient Role
• Coe (1978), for example believes that patients in general tend to be
devalued by hospital personnel because they are sick and dependent.
• He argues that patients are alienated from their usual lives and
reduced to a largely impersonal status in the hospital through three
basic mechanisms of hospital processing: (1) stripping; (2) control of
resources; and (3) restriction of mobility.
• Coe explains that when patients present themselves for treatment in
a hospital, they bring with them a particular social identity, what
Goffman refers to as a "face" ; this represents their attitudes, beliefs,
values, concept of self, and social status, all of which form the basis
for their manner of presenting themselves to the world.
The Hospital-Patient Role
• Stripping occurs when the hospital systematically divests the person of these past
representations of self. The patient's clothes are taken away and replaced with a set of
pajamas. This is regardless of whether the pajamas are the property of the hospital or
the patient. The simple fact of wearing pajamas serves as a uniform that identifies that
person as sick and restricts movement to those areas of the hospital in which pajamas
(patient dress) are authorized.
• Personal belongings of value are taken away and locked up for safekeeping by the staff.
Visiting regulations control not only when patients are allowed to have visitors but also
who is allowed to visit (children under age 14 are typically excluded).
• In addition, the staff supervises the patient's diet, decides when the patient should be
asleep or awake, and in essence controls the general conduct of the patient's social life in
the hospital. The hospital routine for one patient is very similar to the routine of others
who have the same or similar health problems.
The Hospital-Patient Role
• Another important feature of hospitalization is the control of resources by the staff. Coe includes
under the control of resources not only physical items, such as bedclothes and toilet paper, but
also the control of information about the patient's medical condition. Patients are normally not
aware of their prognosis or the results of laboratory tests and X-rays, unless the physician decides
to inform them.
• The third aspect of depersonalization outlined by Coe is the restriction of mobility. In most
hospitals, patients are not allowed to leave their wards without the permission of the head nurse,
who is usually required to know the location of all patients at all times. When patients do leave
the ward to travel to another area of the hospital, they are generally accompanied by a nurse,
nurse's aide, or orderly.
• When patients are admitted to the hospital and also when discharged, they are taken in a
wheelchair between the ward and the hospital entrance, regardless of their ability to walk,
because the hospital is "responsible" for them whenever they are inside its walls. The result is
that even the ability of patients to move about is supervised and controlled.
Reform and Policy
• The major issues in the public debate about health care delivery in most societies, both
more developed and less developed ones, are those of (1) cost, (2) equity, and (3) the
geographic distribution of services.
Cost
• The issue attracting the greatest amount of public attention is the rising cost of health
care that diminishes the ability of some people in society to obtain adequate health
services because they cannot afford health insurance.
• The budget required to meet the health care of people keeps increasing as populations
expand and the health issues multiply and get more [Link] is, therefore,
competition for scarce resources pitting health against other sectors.
• Questions begin to emerge on the proportion of national and local budgets that can
feasibly be devoted to health without compromising other equally important services.
Reform and Policy
Equity in Health Services
• The problem of equity with respect to health services has been lessened with
health care reform in some societies but still remains a major problem in
many societies.
• In a free-market system lacking national health insurance, those persons who
are economically disadvantaged are also medically disadvantaged when it
comes to obtaining quality services.
• The urban poor have historically been dependent on public hospitals and
clinics rather than private hospitals and practitioners for providing patient
care. That is still the case today for many of the poor and near poor.
• The rural poor likewise have problems of access to health care, as medical
facilities and health practitioners may not be available locally.
Reform and Policy
Geographic Distribution of Services
• Besides problems with rising costs and equity, systems of health care delivery are often not
evenly distributed geographically.
• A major factor in obtaining adequate medical care for some people is the numerical shortage of
physicians serving patients in rural areas and urban slums.
• Physicians generally prefer to practice medicine in urbanized settings, where they are close to
cultural, educational, and recreational facilities.
• Another advantage of an urban practice is its proximity to extensive technological resources in
the form of well-equipped hospitals, clinics, and laboratories staffed by well-trained personnel.
• Also important are the relationships with colleagues, which tend to enhance professional life.
These relationships are more readily available in urban areas where there are greater
opportunities for professional recognition. Finally, it should be recognized that the more
financially rewarding medical practices are those in large cities.