Architecture of Tertiary Healthcare Delivery Model

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Architecture of Tertiary Healthcare Delivery Modelfor Sub-Urban/Rural India

Sharad Kumar 1, Amrita 2, Bhaskar Bhowmick 3 and Dhrubes Biswas 1,2, 3,4 (Senior Member, IEEE) 1, 2, 3 Rajendra Mishra School of Engineering Entrepreneurship, Indian Institute of Technology Kharagpur, India2Vinod Gupta School of Management, Indian Institute of Technology (IIT), Kharagpur, India

4Electrical & Electronics Communications Engineering, Indian Institute of Technology (IIT), Kharagpur, India

Abstract Healthcare facilities are extremely fragmented andless affordable across much of the developing world. Businessarchitecture for healthcare systems is one of the vitalrequirements to bridge the gap in developing countries. Theresource needed to suffice the insufficiencies of the current healthsystem needs an algorithm driven process. This paper is anattempt to design such an algorithm for resource sharing andutilization. An empirical study has been done to check thesatisfaction determinants of the patients using regressionanalysis.

Keywords- Healthcare, Technology, Framework/Architecture,tertiary care

I. I NTRODUCTION Healthcare is a major component for all which affects

not only the individuals, but families and social networksat large. Health status greatly influences the abilities towork, to adapt, to change, and to relate socially andwithin a family. However, the health perceptions andhealthcare preferences of semi-urban/rural peoplethemselves, does not adequately determined till the status toquote healthy.

In one part of India, we have multi-specialty hospitalswhich satisfies the healthcare needs of urban people withsuper-specialized treatments while on the other hand, a large

part (sub-urban/rural) is lacking for good healthcare facilities.In terms of life expectancy, child survival and maternalmortality rate (MMR), Indias performance has improvedsteadily. Life expectancy is now 63.5 years, infant mortalityrate is now 53 per 1000 live births, maternal mortality ratio isdown to 254 per lakh live births and total fertility rate hasdeclined to 2.6. But the national average of MMR is very highcompared to the international scenario like Sweden (5), USA(24), Brazil (58) and even in neighboring countries like SriLanka (39) and Thailand (48) [1]

Prevalent complex business landscapes in BASIC (Brazil,South Africa, India and China) countries have hindered a freemarket based delivery model, due to inadequate infrastructure,and socio-economic non-inclusiveness. Not only the emergingcountries face the deprivation of emergency care, the OECD(Organization for Economic Co-operation and Development)countries also face similar situations with respect to the

provision of health services despite differences in the culture,social, history and healthcare institutions. Developed countrylike USA has largely succeeded in ensuring universal access to

essential healthcare services [2]. Rapid uncontrolledurbanization and overdependence on conventional business

processes such as revenue generation as service providers coremotive [3] has made the existing health delivery model non-scalable in non-metro and rural areas.

Government/Public health care services in India areorganized at different levels. Primary health care is providedthrough a network of over 146,036 health sub-centre, 23,458

public health centres (PHCs) and 4,276 community health

centres (CHCs) [4]. At the district level on an average there isa 150-bedded civil/district hospital in the main district townand a few smaller hospitals and dispensaries spread over other towns and larger villages. The private sector in India has adominant presence in all the submarketsmedical educationand training, medical technology and diagnostics,

pharmaceutical manufacture and sale, hospital construction andancillary services and, finally, the provisioning of medical care.Over 75 per cent of the human resources and advanced medicaltechnology, 68 per cent of an estimated 15,097 hospitals and 37

per cent of 623,819 total beds in the country are in the privatesector [4]. Of these most are located in urban areas. Of concernis the abysmally poor quality of services being provided at therural periphery by the large number of unqualified persons. Itsrelationship to health outcomes at the population level has

never been established.According to international norms a minimum of about 25

skilled health workers per 10,000 populations (doctors, nursesand midwives) in order to achieve a minimum of 80 per centcoverage rate for deliveries by skilled birth attendants or for measles immunization as seen in cross-country analysis [5].Workforce estimates based on the 2001 Census suggest thatthere are around 2.2 million health workers in India but theseare based on self-reported occupation which is susceptible tounqualified providers being counted as qualified ones.Adjusting for this, the density of health workers falls to a littleover 8 per 10,000 populations of which allopathic physiciansare 3.8 and of nurses and nurse-midwives are 2.4 per 10,000

populations (Source: Annual health report 2010, Government

of India). The majority (70 per cent) of health workers areemployed in the private sector located in urban areas [4].According to the 2001 Census, almost 60 per cent of healthworkers reside in urban areas, which skew their distributionconsiderably. The density of health workers per 10,000

population in urban areas (42) is nearly four times that of rural(11.8) areas. This is the Major factors related to the growth of rural/sub-urban health sector that are responsible for the acuteshortage of health personnel. People in the suburban/rural areas

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do not get enough treatment due to the non-availability of trained human resource and infrastructure in healthcare sector.

The rural and unprivileged both face problems in availingquality wellness benefits. Businesses catering to the rural sector wellness scenario must be encouraged. New methods must bedevised to cater to the wellness sector in India, especially therural sector which accounts to 70 percent living in 641000Indian Villages (Census 2011). Several studies of Indianvillages have also revealed that households descent into

poverty [6,7,8] due to three principal factors i.e., healthexpenses, high-interest private debt, and social and customaryexpenses of which health care expenses figured prominently inmore than half of all cases of decline into poverty [9].Moreover, macroeconomic scenario of healthcare sector is notfeasible for providing health care to all levels of the society.Healthcare delivery model should focus on affordability,accessibility, availability and quality to expand affordablehealthcare to every layer of the society.

The availability of a standard source of health care hasappeared frequently in studies of healthcare access as anindicator of an individual's ability to enter the healthcaresystem [8, 10, 11, 12, 13, 14]. As a factor reflecting "potentialaccess, [13, 15, 16] having an identifiable source of care better enables an individual the opportunity to resolve healthcareissues when they arise

There is an urgent need to bridge the gap for initiatingTertiary Healthcare Services in order to find sustainablesolutions for seventy percent Indian populations residing insemi-urban and rural areas. Society of Social Entrepreneurs(SSE), IIT Kharagpur has already established anentrepreneurship driven tertiary health delivery model. Thiswellness entrepreneurship has partnered Higher EducationInstitution (HEI) i.e., IIT Kharagpur, Insurance Company,Hospitals, new breed of entrepreneurs and most importantly

people at large through a case to case approach and which

adequately explains Global Solutions to Local Problems. TheIndian democratic has different caste, creed, religion andlanguages. Its conservative nature has reasons to face manyhurdles in trust building and create openness for the PPP [17](Amrita et. al., 2009) service delivery models followed by SSE.

II. OBJECTIVE This paper aims to presents the network architecture of

Health Exchange System (HES) developed by SSE, connectingtertiary healthcare needs to technology for suburban/rural

people in Burdwan and Hooghly districts of West Bengal, Indiathrough introducing interventions in technology and in

business model [18, 19] and identify the importantdeterminants (Patient Satisfaction, Trust, Availability and

Accesses ability) of HES that ensures maximum satisfactionfor patients in the existing network model of low cost scalablehealth delivery model. Superior service quality performance incertain dimension ensures maximum customer satisfaction inHES. Outcomes of various determinants will be used tooptimize the existing network architecture of HES at the

patient-micro hospital/Kiosk end. Further aims to check whether network designed and its specifications fulfill theexpectations of patients of semi-urban and rural areas.

Service quality has become the main interest in thehealthcare business. It influences customer assessment andsatisfaction which might result into customer faithfulness.Customer perceptions of service quality have greater potentialto make correct decisions and deliver true value services tocustomers. Among the various public and private sector hospitals and healthcare service providers, network model of

HES system is working for tertiary care services in rural andsuburban people of the Burdwan district through its partnersand alliances with industries. It plays an important role in ruraldevelopment and provides several innovative healthcareservices through technology intervention.

The survival and growth of HES system depends on thequality of services provided to the society and its ability tocompete with private and big hospitals. This leads to variousresearch issues. They are: What are the various services

provided by the HES? How to measure the services quality of HES? What is the impact of service quality dimensions on theoverall service quality? Which service quality dimensionshould banks consider while evaluating the quality of healthcare services? How can these service quality dimensions

be used to optimize the network model of HES? How docustomers see the quality of different aspects of the healthcareservices at HES? Hence, this lead to a methodical andorganized study of these issues.

The paper makes an attempt to study the determinants interms of Patient Satisfaction [20], Trust [21], Availability [22]and Accesses [23] to the Healthcare services at patient-kiosk end of the network model of HES system established inBurdwan district.

III. TERTIARY HEALTH DELIVERY MODEL Healthcare sector constitutes a predominant component of

the healthcare services industry. In the era of ever changingglobal healthcare business environment, a healthy as well as a

well-balanced healthcare system is considered to be quiteessential for any society for growth and prosperity in the world.Customers satisfaction is the lifeblood of healthcare businessand all the business activities revolve around the needs of customers and preferences of the service provider. Thecustomers need for excellent health care services in low cost isessential to changing the society at the BoP level. Society of Social Entrepreneurs (SSE), a not-for-profit organizationaffiliated to Indian Institute of Technology (IIT) Kharagpur founded Health Exchange System (HES) which has putefforts in creating awareness of healthy life style, belief systems, and environmental context of rural/semi urban

people of West Bengal, India. This is made possible by providing the effective, technology based, tertiary healthcarefacilities by its network model.

A. Health Exchange SystemSSE, IIT Kharagpur launched its Kiosk Model for

healthcare run by an entrepreneur trained in health domainthrough Technology Based Entrepreneurship DevelopmentProgram (TEDP) at IIT Kharagpur in 2009. The model isworking with doctors, rural medical practitioners,

pharmaceutical companies, pathological test labs, insurance

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companies and ambulatory services. This case is an example of the Education-Enterprise (EE) association [19, 24, 25, 26] for social enterprise creation, where Higher Education Institutions(HEIs) play a prominent role in filling the tertiary healthcaregap with the local entrepreneurs by using technologyinterventions. This paper highlights a new approach to solvecritical social problems by social enterprise creation involving

motivation and direct support through collaboration of academia and industries.

The Kiosk/micro hospitals are equipped with wirelesscommunication devices and IT infrastructure with basichealthcare facilities, emergency medicines and testingfacilities. These devices are developed by the entrepreneurs of HEIs themselves for providing cost effective solutions. Thetesting equipments are connected to computer system anddirectly transferred to the test data for storage. The systemmonitors and delivers patient's physiological readings to thehospitals and provides an alert mechanism triggered by the

patient's vital signs which is linked to a medical practitioner'smobile device [26]. The architecture aims to provideaffordable, available, efficient and sustainable healthcareservices to society by using higher technology.

Figure 1. Framework Drawing of Tertiary Health Delivery Model

Fig. 1 explains the framework of the tertiary health caredelivery model. The hub and spoke based pervasive andinclusive health delivery system comprises of spokes asKiosk/micro hospitals which penetrate up to the village level.The Kiosk/micro hospitals are owned and run by trainedentrepreneurs of SSE, Science and Technology EntrepreneursPark (STEP), IIT Kharagpur for delivering specialized valueadded services using bottoms-up approach with a technologydriven business model. The model revolves around anadvanced Healthcare Exchange System (HES) consisting of hardware, software and manpower, for putting next generationtechnologies into practice by handholding and motivatinggrass-root entrepreneurs for Fringe Area Service Transport(FAST) designed by SSE [17] to find solutions to abovehealthcare delivery problems.

A real implication of the HES model is done in fringe areasi.e., Burdwan and Hooghly Districts of West Bengal of Eastern

India by SSE, IIT Kharagpur [25, 26]. These Kiosk/microhospitals are one stop shop for rural customers consisting of essential health services such as blood pressure measuring tool,gluco-meter, pulse-oximeter and various other blood samplecollection tools. These Kiosk/micro hospitals are also referral

points for good doctors who are partners of SSE in fringe areasof a tertiary city. The hub and spoke based pervasive and

inclusive health delivery system comprises of spokes asKiosk/micro hospitals which penetrate up to the village level.The Kiosk/micro hospitals are owned and run by trainedentrepreneurs of SSE, STEP, IIT Kharagpur using bottoms-up approach.

1) Network Model Implementation of Health DeliverySystem

Figure 2. Network Structural Design of Tertiary Health Delivery Model [19]

Fig. 2 is a schematic networks design of the said healthdelivery model. It has the network model of the Kiosk/microhospitals and hospitals as nodes. The Kiosk/micro hospitalshave one-to-one and many-to-one relationship among thehospitals, Kiosk/micro hospitals and the diagnostic centers.The communication in the network is established using thetechnical framework of the model. The nodes KA through Knand KB through Kn represent the different versions of theKiosk/micro hospitals. Disruptive dedicated intellectual capital(IC) interventions are introduced at every level of this modelfor empowerment of people and spread out quality healthcare.H1 through Hn represents different kinds of hospitalsconnected to the tertiary health centers through collaborativetechnologies and business model. D1 through Dn are thediagnostic centers which are connected to the Kiosk/microhospitals and sometimes the hospitals too. All these nodeseffectively plan and work together to input the HES model anddeliver the unique business model output i.e., the availability,accessibility and affordable quality healthcare.

The network provides emergency care such as ambulatoryservices and pharmaceuticals to address critical patients.Telemedicine has its own pitfalls in terms of its effectiveness.These Kiosk/micro hospitals also work as vaccination centers,

public health awareness and other related services centers.

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Reis et al. [27] has suggested two groups of variables whichmust be considered to assess access i.e. resources such asincome and utilization of the resources such as wellbeing levelof the patient. Hence, this comprehensive business models

builds community based network to provide networking basedlow cost distributed healthcare delivery.

2) Working of Network Model The working principle of network model for tertiary care is

formulated in a mathematical function as in equation (1). Where, as per the requirement a patient may take primary careat the kiosk and get referred for the intensive care services inthe next higher order Kiosk/micro hospitals and super carehospitals in the existing network.

ijij

iji

iw C S F += (1)

Where i the primary care, degree of sickness is ijS anddegree of care given at the Kiosk/micro hospitals and hospitalsis ijC , where i and j show the different level of sickness andhealthcare services in the health model. Totally healthy andcured, the function is ijij C S equal to one. A patient whoneeds lower order care such as fever can take only primarycare services at any of the Kiosk/micro hospitals and will betreated as cured. The overall wellness function w F at theKiosk/micro hospitals can be seen in the following differentsteps as

Step 1 : Initialization with Kiosk (K 1.0), a patient is visiting

the nearest Kiosk available in network. He can take i

and ijij C S as per as needs, if the ijij C S = 1, will betreated as healthy and cured, else go to Step 2

Step 2 : On the basis of degree of ijS , a health entrepreneur or Doctor will refer to nearest higher order care centre(Kiosk 2.0, Kiosk 3.0 and Hospital) with sudden i services.

Step 3 : At the higher order care centre, if ijij C S = 1 then patent is treated as cured, else referred to the Super specialist care

Step 4 : At super specialist hospitals, ijij C S =1, the patient isconsidered as cured

Step 5: Wellness Index is achieved

In the above steps we have explained the working of network model of HES through simple mathematicalformulation by using the two parameters ijS and ijC . By thismodel we are trying to solve the tertiary health problemswithout harassing the patients and wasting their cure time.However, this research has tried to find out how happy the

patients are with the services of the kiosks.

3) Business Architecture for Micro Hospitals/Kiosks

Business Architecture is necessary for structural design inany area for several organizational processes like enterprise

planning, strategic business planning, business process re-engineering. This is a unifying structure which enables theexecution of the strategy through its initiatives to achieveresults [28, 29].

Healthcare business architecture shown in Fig. 3 at Kiosk-Patient end shows a customer friendly architecturalcommunication in the network. This differs in the complexityof functional relationships and technical needs of our overallnetwork model. This part is specially focused on need of

patients and services provided by micro hospitals/Kiosk inassociation with partners. Architects involved in building acustomer need and possess specialized knowledge support tothe patient of rural/suburban part in Burdwan. A team of fivegraduate research scholars from IIT Kharagpur along withmentors is consistently working in the direction to provide withthe knowledge support to HES. Since 2009, SSE has come along way in healthcare architecture and business architecture toserve many people in Burdwan and Hooghly districts.

Figure 3. Business Architecture at Kiosk/Micro hospital end

Long before patient-centric care and curative architecture atmicro hospitals/Kiosk becomes important end in healthcareform function to results where priority is always accorded to

patient satisfaction and safety. We make every effort to alwaysensure effortlessness, cost-cutting measure and competence for

patients by network model of micro hospitals/Kiosk. Keepingin mind the rising costs of healthcare services our model (HES)focuses on quality of tertiary health care service providing lowcost scalable solution to the people residing Bottom of Pyramid.

Effectiveness of kiosk model has been checked byquestionnaire design and literature review for the identificationof four determinants as of existing literature on healthcare. Thedeterminants are patient satisfaction, trust, availability andaccessibility. These four determinants are very significant atkiosk-patient business end. We have conducted a survey on the

basis of these four determinants. We present the theoreticalframework below to support the above details.

IV. THEORETICAL FRAMEWORK This paper is based on the prior work of the network model

on success determinants of the Technology to Health (T2H)model conducted by Amrita et al., [26] which has analyzed the

primary data from 381 respondents by a structured

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questionnaire from the health service delivery regions of SSE.The study has already revealed the acceptance of the model bysemi-urban and rural people. The quality, affordability, trust,empathy and social acceptance were also the major concerns of the people. The success determination of the HES can beutilized to enhance the services and network of the kiosk tofulfill the customer expectations.

In this paper we are analyzing the network modeldeterminants by conducting a survey of 250 respondents in theBurdwan districts of West Bengal, India. The purpose of themodel is to fill in the tertiary healthcare gaps using anoptimized network. This network re-built on the basis of thesurvey data analysis will lead to the optimization of accessibility, availability and affordability variables.

Fig. 4 is the schematic diagram of the response where wehave measured the determinants of network architecture in theform of four variable i.e., patient satisfaction, trust, access andavailability from the target group.

PatientSatisfaction

AccessHealth Care QualityEntrepreneurs Roleand Behavior Cost Effectiveness

Trust

Medicare ApprovedLocationsRisk DeterminationRisk Management

New Medical Technology

Availability

ExpertsEmergency CareEmergency MedicinesAmbulatory Services

Accesses

Super Specialist DoctorsSuper Specialist HospitalsHealth Insurance ProvidersPre-registration for Super care

Figure 4. The Network Model determinants for Health Exchange System

Managing and allocation of Health Exchange System isseen to involve data collected at every come across of each patient at Kiosk. These data and their analysis are enormous onseveral extents: of patient-come across report; of variables(organizational, problem-solving, and practical) [31, 32, 33]and their resultant indicators for the related medical dataresources; of the clinical and administrative issues to beaddressed; and of the range of the audience for the study.

V. METHODOLOGY This study is based on a survey conducted in Burdwan

during March-April 2011. Primary data was collected in theDurgapur region of the Burdwan district.

We tested this algorithm by two level questionnaire designsfor a population of 280. First level of questionnaire wasdesigned based on the characteristic measures which could helpdefine the satisfaction of the patients. A 5 point Likert scale,ranging from Excellent, Good, Moderate, Bad and Worst wasused. The study is based on the assumption that all the microhospitals/kiosks belong to the same category in the sense of services.

Based on the common factor analysis, we were able toreduce the number of measures into 4 determinants namely,

patient satisfaction, trust, availability and accessibility of Healthcare services from the kiosk. The second questionnairewas designed such as to reflect the rating opinion of therespondents ranging from excellent, good, neutral, bad andworst for these four factors. Each factor had 9 observations.

The strength of the variables of dependence for the satisfactionlevel has also been estimated using regression analysis.

We have used Microsoft Excel. to calculate the dependenceof variables on satisfaction level.

1) Selection of the Study AreaThe implementation of the business model networked

architecture [29, 30] has been done in the Burdwan district of West Bengal and hence is the area selected for the study. Thedistrict being a Non-metro does not have quality healthcare and

proper ratio of health providers to population residing. Peoplewho live far away from the urban areas have little or no accessto the hospitals and wellness delivery systems. Certainemergency medicines are also not available due to the priceand ignorance. Ambulance Services to address the critical

patients to referral hospitals are minimal. Though telemedicineis being cited as an option, have its own pitfalls in terms of itseffectiveness. Some medicines cost much less in India(www.pharmainfo.net), but sometimes due to corrupt business

practices they are not authentic and mere placebos. Healthcaresystems already exist under Government policies but aregenerally poor in quality and have weak supply system of medicines and drug.

The key question is what benefits are achieved from theresources developed using technology interventions inside anetworked model. A key challenge is to achieve an acceptablenetwork of doctors and diagnostic centre cost effectivehealthcare with commensurate quality of healthcare deliveryservices using technology interventions. This is achieved only

when the satisfaction of the patients are determined.2) Sampling Method

It was a sample survey to measure the patient satisfaction,trust, availability and accessibility of the healthcare facilities

by network model of micro hospitals/Kiosk. The 15 microhospitals/ Kiosk are situated in different locations of Burdwandistrict in West Bengal, India. The researchers adopted

purposive sampling method to select the sample response.

3) Collection of DataThe service quality instrument was anchored at a five-point

Likert scale and was used to collect the data from therespondents about their perception regarding the healthcareservices at micro hospital/Kiosk. It was classified into threedifferent parts: Part 3 elucidated seven personal anddemographic variables of the respondents, Part 1 comprisedfour rational variables, and Part 2 comprised 34 servicesquality items included in the four dimensions of servicesquality, viz., Patient Satisfaction (11), Trust (8), Availability(7) and Accessibility (14). We also visited the microhospitals/Kiosk/micro hospitals of the healthcare network model in Burdwan district, to discuss and conduct in-depthinterviews with the health entrepreneurs/Kiosk/micro hospitals

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owners of different branches. The following table shows thestatistics of the return rate.

TABLE I. RESPONSE STATISTICS

First Level Questionnaire Number of questionnaire sent 250.00Response rate 61.20Discarded Data 97.00

Second Level Questionnaire

Number of questionnaire sent 153.00Response Rate 47.71Discarded Data 80.00

The first level of questionnaire was given to a sample of 280 people out of which 247 was received. The returnedquestionnaires were removed and we could analyze 153completed questionnaires. The second level of thequestionnaire was given to these 153 respondents out of whichwe could utilize 73 questionnaires.

The following table shows the socio-economic status of therespondents.

TABLE II. SOCIO ECONOMIC STATUS OF THE RESPONDENTS

Gender: Percentage Family Type PercentageMale 77 Nuclear 23Female 23 Joint 77

Education Family Annual Income (Rs)Matriculation 14 Below 1 Lakh 16HS 23 Below 2 Lakh 21Graduate 48 Below 3 Lakh 36Post Graduate 8 Below 4 Lakh 14Professional Degree 7 Above 4 Lakh or more 14

All the respondents were educated to some level. All of them were adults and majority of the respondents age variedfrom thirty to fifty. Most of the respondents lived in a jointfamily with their parents and siblings. Average population hadincome level of 3 lakhs rupees. Hence, we may clearly statethat we have been able to select a representative population for our research looking at their demographic profile.

The margin of error estimated in the sample is 6.2% with95% confidence interval having 50% margin. The followingequation (2) was used to estimate the margin of error:

* [ *(1 ) / ]oE Z p p n= (2)

where, Z is the critical value of a normal distributiongiven a confidence interval, p is the proportion of response andn is the sample size.

VI. FINDING AND A NALYSIS Research has already established that patients satisfaction

with health care is one of the most important aspects of measuring quality outcome [19, 20]. In the present study

patient satisfaction was the outcome has been measured inhealth exchange system (HES) at kiosk/micro hospitals. We

tried to measure the highest satisfaction responses from therespondents. Since our sample population is 73, we consider the population as large.

The multiple regression analysis of the data received wasconducted keeping the patient satisfaction as the dependentvariable on three independent variables i.e., trust, availabilityand accessibility of the services of the micro-hospitals.

Using the frequency level analysis we obtained thefollowing graphical figures for the satisfaction level in all themeasuredvariables.

05

1015202530354045505560657075

Excellent Good Moderate Bad Worst

Respondent's Satisfaction Level

A v e r a g

e S a

t i s f a c

t i o n

L e v e

lPatient Satisfaction

Trust

Availability

Accessibility

Figure 5. Average Satisfaction Level of the Respondents

The above Fig. 5 shows that the satisfaction levels of the patients are fairly good comparatively to the other levels. Thecurve for accessibility shows the rating little towards rightrating showing that respondents are either unaware of the

parameter or do not care about them. Though the level of

excellent raters are not more the distribution is skewed towards positive side showing a favorable result.

Figure 6. Frequency distribution for Patient Satisfaction Observations.

The above Fig. 6 shows the observed values of the patientssatisfaction which shows that the respondents are moderatelyand fairly happy with the factors we asked them for

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satisfaction. However the observation for role of entrepreneurs,facilities and behavior of entrepreneurs does not show strongresponse.

Figure 7. Frequency distribution for Trust Observations.

The above Fig. 7 shows that recognition of the micro-hospital and belief of getting healthy have high scores.However, risk management and new medical technologies arenot much highly rated. However, they are ready to refer their friends and kins for this facility at kiosks.

Figure 8. Frequency distribution of the Availability of facilities atkiosk/micro-hospitals

The above Fig. 8 shows diverse curves with healthcareexpert having the better response. Though the quality of emergency services and super-specialty doctors do not showgood satisfaction response, mother and child has the highestsatisfaction response.

Figure 9. Frequency distribution of the Accessibility

The above Fig. 9 does have much rating except the referralhospitals. However, encouragement by insurance providers hasalso shown a good positive response.

The four determinants for success of micro-hospitals have been taken as variables for multiple regressions. Patientsatisfaction has been considered as the dependant variable onthe independent variables trust, availability and accessibility.

Our Null hypothesis for the determination of the regressionis has been taken such that the three variables of satisfactioni.e., trust, availability and accessibility do not depend on thedependant variable satisfaction. The hypothesis has been takenas follows:

0 : H Patient satisfaction is not dependant on trust,availability and accessibility variables and are notrelated

:a H Patient satisfaction dependant on trust, availability andaccessibility variablesAs we precede the analysis we have put down the

maximum satisfaction level responses together to check thehypothesis.

TABLE III. TABLE 3: OBSERVATION OF VARIABLES FOR RESPONSE ON MAXIMUM SATISFACTION

Observation(i)

PatientSatisfaction

(Y)Trust(X 1)

Availability(X2)

Accessibility(X 3)

1 22 10 15 102 27 7 10 23 9 4 3 94 3 2 10 7

5 3 7 5 12

6 7 12 1 57 7 12 5 58 7 5 5 139 3 10 6 4

Calculating the mean for all the variables Y, X1, X2, andX3 using the formulas for mean we got the values as 9.78,

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7.67, 6.67 and 7.44. The values of means show that they arealmost near to each other except the variable X2.

The correlations between dependent variable with eachindependent variable have been checked. We assumed 95%confidence interval for the sample population.

TABLE IV. CORRELATION BETWEEN Y AND X1Patient Satisfaction

(Y) Trust (X 1)

Patient Satisfaction (Y) 1

Trust (X 1) 0.1281 1

The correlation value between patient satisfaction and trustshows that they are slightly and linearly related to each other.

TABLE V. CORRELATION BETWEEN Y AND X2

PatientSatisfaction (Y) Availability (X 2)


Availability (X2) 0.6055 1

Unlike the correlation between patient satisfaction andavailability of medical services at the kiosk we can see that thevariables are strongly and linearly related to each other.

TABLE VI. TABLE 6: CORRELATION BETWEEN Y AND X3

PatientSatisfaction

(Y) Accessibility (X 3)


Accessibility (X3) -0.2662 1

The correlation between patient satisfaction andaccessibility has shown that they are negatively related to eachother.

However, when we run the correlation between theindependent variables we did not get any relation betweenthem.

TABLE VII. TABLE 7: CORRELATION BETWEEN X1, X2 AND X3

Trust (X 1)Availability

(X2)Accessibility

(X3)

Trust (X1) 1

Availability (X2) -0.1311 1Accessibility

(X3) -0.3768 -0.0052 1

Later we run the observations on the multiple regressionanalysis using the formula for multiple regression as follows:

0 1 1 2 2 3 3Y b b b b= + + + (3)

The multiple regressions on the four data response on themaximum satisfaction side were conducted as shown belowtable.

TABLE VIII. REGRESSION STATISTICS

Multiple R 0.67

R Square 0.45

Adjusted R Square 0.12

Standard Error 8.19

The value of R-Square which is the Coefficient of

determination shows we have explained 45% of the originalvariability and is explained by this relationship. However, thevalue of adjusted R-Square is very small compared to R-Squarewhich shows that 12% variance in the outcome that thevariable patient satisfaction explains in the sample population.

TABLE IX. ANOVA CALCULATION

df SS MS F Significance F

Regression 3.00 272.29 90.76 1.35 0.36

Residual 5.00 335.27 67.05

Total 8.00 607.56

The ANOVA calculation in table 9 shows that thesignificance of F-Test is acceptable in the normal distribution.The given value for the above degrees of freedom in F-Table is9.01 which is more than that of the observed value of 0.36.Hence we accept the alternate hypothesis, that the variable

patient satisfaction is dependent on other three variables.However, from the obtained result of multiple regressions isthe following equation (4).

2.80 0.30( ) 1.27( ) 0.50( ) Estimated Patient

Satisfaction

Trust Availability Accessibility= + + (4)

The coefficients obtained shows that patient satisfaction isdependent on the independent variables trust and availability

but not dependant on the accessibility.

Looking at the socio-economic status from therepresentative population residing in the districts of Burdwan,we may conclude on the non-dependence of accessibility on

patient satisfaction. Half of the population have completedgraduation and have income level less than 3 lakhs rupees. Thismay mean that they are more worried about availability of good doctors are their trust on them. However, due to the lack

of doctors they have no other choice than to select from the fewexisting doctors even if they are not cured fully from them.

We may also interpret that our algorithm of micro-hospitalsis based on the factors of trust and availability of facilities for

patient satisfaction. Based on the frequency observations, it isevident that the micro-hospitals need to improve the quality of super-specialty facilities. The referral system shows a goodresponse which is obvious from our result of regression that the

patients need to have trust for being satisfied.

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Based on this observation we go back to the function of well ness

w F which is defined by the primary care and the

patient sickness level after the cure from it. We had mentionedthat total healthy and cured function needs satisfaction of thecomponent of level of sicken i.e., ijij C S . Based on the

requirement of healthcare services and random interview, inthe region, we assumed that the population residing in theselected area of study was not satisfied with the primary caresystems in the districts. Our regression analysis has tried to findout the level of satisfaction on the sickness level therespondents have faced.

However, we tried to find out the patient satisfactiondeterminants of the current business architecture of the kiosks.The variables availability and trust might play a key role in

building this architecture of the kiosk models.

VII. CONCLUSIONAn optimized healthcare network is important to maintain

the resources available in the developing countries especially inIndia. On the basis of our current research, the existinghealthcare network might be appropriate for semi-urban andrural India keeping the inefficiencies of primary healthcare inmind. The technology and business intervention in the network affects considerably the quality of human life in these regions.The forthcoming optimization will help the proper utilizationof resources and patient care system. Healthcare managementwill be more formalized and regularized by strengthening thetechnology based patient care management.

Patient satisfaction with services provided should beconsidered as an outcome measure of the care provided atkiosks/micro hospitals which might help to improve the qualityof the healthcare service in our business architecture. Our finding emphasises to improve trust and availability of

healthcare facilities in the kiosks. Accessibility does not holdgood for those who do not have strong education backgroundour income level. The lower cost model also might help theimprovement of the satisfaction level.

VIII. FUTURE WORK Although the satisfaction index is acceptable, it is useful for establishing the required improvements, it is also important toidentify the reasons for dissatisfaction to complement thisinformation. The structural and human resources optimizationwould also help improve the requirements of population. Co-incubation network architecture may also suit well to them. Anempirical study of the parameters necessary for resourcesharing in hospitals and other partners for creating the network architecture might help us to understand the over all function of wellness.

ACKNOWLEDGMENT

We acknowledge the participation and support of themembers of Science and Technology Entrepreneurs Park, IITKharagpur especially Mr. Ashok Ghosh and Mr. ArunangshuBhunia in this research. We are also thankful to Department of

Science and Technology, Government of India to providesupport through Technology Business Incubation (TBI)

project.

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