2011 IEEE Global Humanitarian Technology Conference

Architecture of Tertiary Healthcare Delivery Model for Sub-Urban/Rural India

1, 2, 3

Rajendra Mishra School of Engineering Entrepreneurship, Indian Institute of Technology Kharagpur, India 2 Vinod Gupta School of Management, Indian Institute of Technology (IIT), Kharagpur, India 4 Electrical & Electronics Communications Engineering, Indian Institute of Technology (IIT), Kharagpur, India essential healthcare services [2]. Rapid uncontrolled urbanization and overdependence on conventional business processes such as revenue generation as service providers core motive [3] has made the existing health delivery model nonscalable in non-metro and rural areas. Government/Public health care services in India are organized at different levels. Primary health care is provided through 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 is a 150-bedded civil/district hospital in the main district town and a few smaller hospitals and dispensaries spread over other towns and larger villages. The private sector in India has a dominant presence in all the submarketsmedical education and training, medical technology and diagnostics, pharmaceutical manufacture and sale, hospital construction and ancillary services and, finally, the provisioning of medical care. Over 75 per cent of the human resources and advanced medical technology, 68 per cent of an estimated 15,097 hospitals and 37 per cent of 623,819 total beds in the country are in the private sector [4]. Of these most are located in urban areas. Of concern is the abysmally poor quality of services being provided at the rural periphery by the large number of unqualified persons. Its relationship 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, nurses and midwives) in order to achieve a minimum of 80 per cent coverage 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 that there are around 2.2 million health workers in India but these are based on self-reported occupation which is susceptible to unqualified providers being counted as qualified ones. Adjusting for this, the density of health workers falls to a little over 8 per 10,000 populations of which allopathic physicians are 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 are employed in the private sector located in urban areas [4]. According to the 2001 Census, almost 60 per cent of health workers reside in urban areas, which skew their distribution considerably. 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 acute shortage of health personnel. People in the suburban/rural areas

Sharad Kumar1, Amrita2, Bhaskar Bhowmick3 and Dhrubes Biswas1,2, 3,4 (Senior Member, IEEE)

Abstract Healthcare facilities are extremely fragmented and

less affordable across much of the developing world. Business architecture for healthcare systems is one of the vital requirements to bridge the gap in developing countries. The resource needed to suffice the insufficiencies of the current health system needs an algorithm driven process. This paper is an attempt to design such an algorithm for resource sharing and utilization. An empirical study has been done to check the satisfaction determinants of the patients using regression analysis. Keywords- Healthcare, Technology, Framework/Architecture, tertiary care

I.

INTRODUCTION

Healthcare is a major component for all which affects not only the individuals, but families and social networks at large. Health status greatly influences the abilities to work, to adapt, to change, and to relate socially and within a family. However, the health perceptions and healthcare preferences of semi-urban/rural people themselves, does not adequately determined till the status to quote healthy. In one part of India, we have multi-specialty hospitals which satisfies the healthcare needs of urban people with super-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 maternal mortality rate (MMR), Indias performance has improved steadily. Life expectancy is now 63.5 years, infant mortality rate is now 53 per 1000 live births, maternal mortality ratio is down to 254 per lakh live births and total fertility rate has declined to 2.6. But the national average of MMR is very high compared to the international scenario like Sweden (5), USA (24), Brazil (58) and even in neighboring countries like Sri Lanka (39) and Thailand (48) [1] Prevalent complex business landscapes in BASIC (Brazil, South Africa, India and China) countries have hindered a free market based delivery model, due to inadequate infrastructure, and socio-economic non-inclusiveness. Not only the emerging countries 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 country like USA has largely succeeded in ensuring universal access to

978-0-7695-4595-0/11 $26.00 2011 IEEE DOI 10.1109/GHTC.2011.32

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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 availing quality wellness benefits. Businesses catering to the rural sector wellness scenario must be encouraged. New methods must be devised to cater to the wellness sector in India, especially the rural sector which accounts to 70 percent living in 641000 Indian Villages (Census 2011). Several studies of Indian villages have also revealed that households descent into poverty [6,7,8] due to three principal factors i.e., health expenses, high-interest private debt, and social and customary expenses of which health care expenses figured prominently in more than half of all cases of decline into poverty [9]. Moreover, macroeconomic scenario of healthcare sector is not feasible for providing health care to all levels of the society. Healthcare delivery model should focus on affordability, accessibility, availability and quality to expand affordable healthcare to every layer of the society. The availability of a standard source of health care has appeared frequently in studies of healthcare access as an indicator of an individual's ability to enter the healthcare system [8, 10, 11, 12, 13, 14]. As a factor reflecting "potential access, [13, 15, 16] having an identifiable source of care better enables an individual the opportunity to resolve healthcare issues when they arise There is an urgent need to bridge the gap for initiating Tertiary Healthcare Services in order to find sustainable solutions for seventy percent Indian populations residing in semi-urban and rural areas. Society of Social Entrepreneurs (SSE), IIT Kharagpur has already established an entrepreneurship driven tertiary health delivery model. This wellness entrepreneurship has partnered Higher Education Institution (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. The Indian democratic has different caste, creed, religion and languages. Its conservative nature has reasons to face many hurdles in trust building and create openness for the PPP [17] (Amrita et. al., 2009) service delivery models followed by SSE. II. OBJECTIVE

Service quality has become the main interest in the healthcare business. It influences customer assessment and satisfaction which might result into customer faithfulness. Customer perceptions of service quality have greater potential to make correct decisions and deliver true value services to customers. 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 and suburban people of the Burdwan district through its partners and alliances with industries. It plays an important role in rural development and provides several innovative healthcare services through technology intervention. The survival and growth of HES system depends on the quality of services provided to the society and its ability to compete with private and big hospitals. This leads to various research 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 the overall service quality? Which service quality dimension should 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 do customers see the quality of different aspects of the healthcare services at HES? Hence, this lead to a methodical and organized study of these issues. The paper makes an attempt to study the determinants in terms 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 in Burdwan district. III. TERTIARY HEALTH DELIVERY MODEL

This paper aims to presents the network architecture of Health Exchange System (HES) developed by SSE, connecting tertiary healthcare needs to technology for suburban/rural people in Burdwan and Hooghly districts of West Bengal, India through introducing interventions in technology and in business model [18, 19] and identify the important determinants (Patient Satisfaction, Trust, Availability and Accesses ability) of HES that ensures maximum satisfaction for patients in the existing network model of low cost scalable health delivery model. Superior service quality performance in certain dimension ensures maximum customer satisfaction in HES. Outcomes of various determinants will be used to optimize the existing network architecture of HES at the patient-micro hospital/Kiosk end. Further aims to check whether network designed and its specifications fulfill the expectations of patients of semi-urban and rural areas.

Healthcare sector constitutes a predominant component of the healthcare services industry. In the era of ever changing global healthcare business environment, a healthy as well as a well-balanced healthcare system is considered to be quite essential for any society for growth and prosperity in the world. Customers satisfaction is the lifeblood of healthcare business and all the business activities revolve around the needs of customers and preferences of the service provider. The customers need for excellent health care services in low cost is essential to changing the society at the BoP level. Society of Social Entrepreneurs (SSE), a not-for-profit organization affiliated to Indian Institute of Technology (IIT) Kharagpur founded Health Exchange System (HES) which has put efforts 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 healthcare facilities by its network model. A. Health Exchange System SSE, IIT Kharagpur launched its Kiosk Model for healthcare run by an entrepreneur trained in health domain through Technology Based Entrepreneurship Development Program (TEDP) at IIT Kharagpur in 2009. The model is working 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 healthcare gap with the local entrepreneurs by using technology interventions. This paper highlights a new approach to solve critical social problems by social enterprise creation involving motivation and direct support through collaboration of academia and industries. The Kiosk/micro hospitals are equipped with wireless communication devices and IT infrastructure with basic healthcare facilities, emergency medicines and testing facilities. These devices are developed by the entrepreneurs of HEIs themselves for providing cost effective solutions. The testing equipments are connected to computer system and directly transferred to the test data for storage. The system monitors and delivers patient's physiological readings to the hospitals and provides an alert mechanism triggered by the patient's vital signs which is linked to a medical practitioner's mobile device [26]. The architecture aims to provide affordable, available, efficient and sustainable healthcare services to society by using higher technology.

India by SSE, IIT Kharagpur [25, 26]. These Kiosk/micro hospitals 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 sample collection tools. These Kiosk/micro hospitals are also referral points for good doctors who are partners of SSE in fringe areas of a tertiary city. The hub and spoke based pervasive and inclusive health delivery system comprises of spokes as Kiosk/micro hospitals which penetrate up to the village level. The Kiosk/micro hospitals are owned and run by trained entrepreneurs of SSE, STEP, IIT Kharagpur using bottomsup approach. 1) Network Model Implementation of Health Delivery System

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

Figure 1. Framework Drawing of Tertiary Health Delivery Model

Fig. 1 explains the framework of the tertiary health care delivery model. The hub and spoke based pervasive and inclusive health delivery system comprises of spokes as Kiosk/micro hospitals which penetrate up to the village level. The Kiosk/micro hospitals are owned and run by trained entrepreneurs of SSE, Science and Technology Entrepreneurs Park (STEP), IIT Kharagpur for delivering specialized value added services using bottoms-up approach with a technology driven business model. The model revolves around an advanced Healthcare Exchange System (HES) consisting of hardware, software and manpower, for putting next generation technologies into practice by handholding and motivating grass-root entrepreneurs for Fringe Area Service Transport (FAST) designed by SSE [17] to find solutions to above healthcare delivery problems. A real implication of the HES model is done in fringe areas i.e., Burdwan and Hooghly Districts of West Bengal of Eastern

Fig. 2 is a schematic networks design of the said health delivery model. It has the network model of the Kiosk/micro hospitals and hospitals as nodes. The Kiosk/micro hospitals have one-to-one and many-to-one relationship among the hospitals, Kiosk/micro hospitals and the diagnostic centers. The communication in the network is established using the technical framework of the model. The nodes KA through Kn and KB through Kn represent the different versions of the Kiosk/micro hospitals. Disruptive dedicated intellectual capital (IC) interventions are introduced at every level of this model for empowerment of people and spread out quality healthcare. H1 through Hn represents different kinds of hospitals connected to the tertiary health centers through collaborative technologies and business model. D1 through Dn are the diagnostic centers which are connected to the Kiosk/micro hospitals and sometimes the hospitals too. All these nodes effectively plan and work together to input the HES model and deliver the unique business model output i.e., the availability, accessibility and affordable quality healthcare. The network provides emergency care such as ambulatory services 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 which must be considered to assess access i.e. resources such as income and utilization of the resources such as wellbeing level of the patient. Hence, this comprehensive business models builds community based network to provide networking based low 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 care at the kiosk and get referred for the intensive care services in the next higher order Kiosk/micro hospitals and super care hospitals in the existing network.

Business Architecture is necessary for structural design in any area for several organizational processes like enterprise planning, strategic business planning, business process reengineering. This is a unifying structure which enables the execution of the strategy through its initiatives to achieve results [28, 29]. Healthcare business architecture shown in Fig. 3 at KioskPatient end shows a customer friendly architectural communication in the network. This differs in the complexity of functional relationships and technical needs of our overall network model. This part is specially focused on need of patients and services provided by micro hospitals/Kiosk in association with partners. Architects involved in building a customer need and possess specialized knowledge support to the patient of rural/suburban part in Burdwan. A team of five graduate research scholars from IIT Kharagpur along with mentors is consistently working in the direction to provide with the knowledge support to HES. Since 2009, SSE has come a long way in healthcare architecture and business architecture to serve many people in Burdwan and Hooghly districts.

Fw = i + S ij C ij
i ij

(1)

Where i the primary care, degree of sickness is S ij and degree of care given at the Kiosk/micro hospitals and hospitals is C ij , where i and j show the different level of sickness and healthcare services in the health model. Totally healthy and cured, the function is S ij C ij equal to one. A patient who needs lower order care such as fever can take only primary care services at any of the Kiosk/micro hospitals and will be treated as cured. The overall wellness function Fw at the Kiosk/micro hospitals can be seen in the following different steps as Step 1: Initialization with Kiosk (K 1.0), a patient is visiting the nearest Kiosk available in network. He can take i and S ij C ij as per as needs, if the S ij C ij = 1, will be treated as healthy and cured, else go to Step 2 Step 2: On the basis of degree of S ij , 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 S ij C ij = 1 then patent is treated as cured, else referred to the Super specialist care Step 4: At super specialist hospitals, S ij C ij =1, the patient is considered as cured Step 5: Wellness Index is achieved In the above steps we have explained the working of network model of HES through simple mathematical formulation by using the two parameters S ij and C ij . By this model we are trying to solve the tertiary health problems without 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

Figure 3. Business Architecture at Kiosk/Micro hospital end

Long before patient-centric care and curative architecture at micro hospitals/Kiosk becomes important end in healthcare form function to results where priority is always accorded to patient satisfaction and safety. We make every effort to always ensure effortlessness, cost-cutting measure and competence for patients by network model of micro hospitals/Kiosk. Keeping in mind the rising costs of healthcare services our model (HES) focuses on quality of tertiary health care service providing low cost scalable solution to the people residing Bottom of Pyramid. Effectiveness of kiosk model has been checked by questionnaire design and literature review for the identification of four determinants as of existing literature on healthcare. The determinants are patient satisfaction, trust, availability and accessibility. These four determinants are very significant at kiosk-patient business end. We have conducted a survey on the basis of these four determinants. We present the theoretical framework 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 by semi-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 be utilized to enhance the services and network of the kiosk to fulfill the customer expectations. In this paper we are analyzing the network model determinants by conducting a survey of 250 respondents in the Burdwan districts of West Bengal, India. The purpose of the model is to fill in the tertiary healthcare gaps using an optimized network. This network re-built on the basis of the survey data analysis will lead to the optimization of accessibility, availability and affordability variables. Fig. 4 is the schematic diagram of the response where we have measured the determinants of network architecture in the form of four variable i.e., patient satisfaction, trust, access and availability from the target group.
Access Health Care Quality Entrepreneurs Role and Behavior Cost Effectiveness Patient Satisfaction Medicare Approved Locations Risk Determination Risk Management New Medical Technology Trust

Based on the common factor analysis, we were able to reduce the number of measures into 4 determinants namely, patient satisfaction, trust, availability and accessibility of Healthcare services from the kiosk. The second questionnaire was designed such as to reflect the rating opinion of the respondents ranging from excellent, good, neutral, bad and worst for these four factors. Each factor had 9 observations. The strength of the variables of dependence for the satisfaction level has also been estimated using regression analysis. We have used Microsoft Excel. to calculate the dependence of variables on satisfaction level. 1) Selection of the Study Area The 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. The district being a Non-metro does not have quality healthcare and proper ratio of health providers to population residing. People who live far away from the urban areas have little or no access to the hospitals and wellness delivery systems. Certain emergency medicines are also not available due to the price and ignorance. Ambulance Services to address the critical patients to referral hospitals are minimal. Though telemedicine is being cited as an option, have its own pitfalls in terms of its effectiveness. Some medicines cost much less in India (www.pharmainfo.net), but sometimes due to corrupt business practices they are not authentic and mere placebos. Healthcare systems already exist under Government policies but are generally poor in quality and have weak supply system of medicines and drug. The key question is what benefits are achieved from the resources developed using technology interventions inside a networked model. A key challenge is to achieve an acceptable network of doctors and diagnostic centre cost effective healthcare with commensurate quality of healthcare delivery services 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 micro hospitals/ Kiosk are situated in different locations of Burdwan district in West Bengal, India. The researchers adopted purposive sampling method to select the sample response. 3) Collection of Data The service quality instrument was anchored at a five-point Likert scale and was used to collect the data from the respondents about their perception regarding the healthcare services at micro hospital/Kiosk. It was classified into three different parts: Part 3 elucidated seven personal and demographic variables of the respondents, Part 1 comprised four rational variables, and Part 2 comprised 34 services quality items included in the four dimensions of services quality, viz., Patient Satisfaction (11), Trust (8), Availability (7) and Accessibility (14). We also visited the micro hospitals/Kiosk/micro hospitals of the healthcare network model in Burdwan district, to discuss and conduct in-depth interviews with the health entrepreneurs/Kiosk/micro hospitals

Accesses Super Specialist Doctors Super Specialist Hospitals Health Insurance Providers Pre-registration for Super care

Availability Experts Emergency Care Emergency Medicines Ambulatory Services

Figure 4. The Network Model determinants for Health Exchange System

Managing and allocation of Health Exchange System is seen to involve data collected at every come across of each patient at Kiosk. These data and their analysis are enormous on several extents: of patient-come across report; of variables (organizational, problem-solving, and practical) [31, 32, 33] and their resultant indicators for the related medical data resources; of the clinical and administrative issues to be addressed; 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 the Durgapur region of the Burdwan district. We tested this algorithm by two level questionnaire designs for a population of 280. First level of questionnaire was designed based on the characteristic measures which could help define the satisfaction of the patients. A 5 point Likert scale, ranging from Excellent, Good, Moderate, Bad and Worst was used. The study is based on the assumption that all the micro hospitals/kiosks belong to the same category in the sense of services.

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owners of different branches. The following table shows the statistics of the return rate.
TABLE I. RESPONSE STATISTICS

tried to measure the highest satisfaction responses from the respondents. Since our sample population is 73, we consider the population as large. The multiple regression analysis of the data received was conducted keeping the patient satisfaction as the dependent variable on three independent variables i.e., trust, availability and accessibility of the services of the micro-hospitals. Using the frequency level analysis we obtained the following graphical figures for the satisfaction level in all the measured variables.
75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 Excellent Good

First Level Questionnaire Number of questionnaire sent Response rate Discarded Data Second Level Questionnaire Number of questionnaire sent Response Rate Discarded Data

250.00 61.20 97.00 153.00 47.71 80.00

Average Satisfaction Level

The first level of questionnaire was given to a sample of 280 people out of which 247 was received. The returned questionnaires were removed and we could analyze 153 completed questionnaires. The second level of the questionnaire was given to these 153 respondents out of which we could utilize 73 questionnaires. The following table shows the socio-economic status of the respondents.
TABLE II. SOCIO ECONOMIC STATUS OF THE RESPONDENTS

Patient Satisfaction Trust Availability Accessibility

Gender: Percentage Family Type Percentage Male 77 Nuclear 23 Female 23 Joint 77 Education Family Annual Income (Rs) Matriculation 14 Below 1 Lakh 16 HS 23 Below 2 Lakh 21 Graduate 48 Below 3 Lakh 36 Post Graduate 8 Below 4 Lakh 14 Professional Degree 7 Above 4 Lakh or more 14

Moderate

Bad

Worst

Respondent's Satisfaction Level

Figure 5. Average Satisfaction Level of the Respondents

All the respondents were educated to some level. All of them were adults and majority of the respondents age varied from thirty to fifty. Most of the respondents lived in a joint family with their parents and siblings. Average population had income level of 3 lakhs rupees. Hence, we may clearly state that 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% with 95% confidence interval having 50% margin. The following equation (2) was used to estimate the margin of error:

The above Fig. 5 shows that the satisfaction levels of the patients are fairly good comparatively to the other levels. The curve for accessibility shows the rating little towards right rating 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.

MoE = Z * [ p *(1 p ) / n]

(2)

where, Z is the critical value of a normal distribution given a confidence interval, p is the proportion of response and n is the sample size. VI. FINDING AND ANALYSIS
Figure 6. Frequency distribution for Patient Satisfaction Observations.

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 in health exchange system (HES) at kiosk/micro hospitals. We

The above Fig. 6 shows the observed values of the patients satisfaction which shows that the respondents are moderately and 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 strong response.

Figure 9. Frequency distribution of the Accessibility

Figure 7. Frequency distribution for Trust Observations.

The above Fig. 9 does have much rating except the referral hospitals. However, encouragement by insurance providers has also shown a good positive response. The four determinants for success of micro-hospitals have been taken as variables for multiple regressions. Patient satisfaction has been considered as the dependant variable on the independent variables trust, availability and accessibility. Our Null hypothesis for the determination of the regression is has been taken such that the three variables of satisfaction i.e., trust, availability and accessibility do not depend on the dependant variable satisfaction. The hypothesis has been taken as follows:

The above Fig. 7 shows that recognition of the microhospital and belief of getting healthy have high scores. However, risk management and new medical technologies are not much highly rated. However, they are ready to refer their friends and kins for this facility at kiosks.

H 0 : Patient satisfaction is not dependant on trust,

availability and accessibility variables and are not related H a : Patient satisfaction dependant on trust, availability and accessibility variables As we precede the analysis we have put down the maximum satisfaction level responses together to check the hypothesis.
TABLE III. TABLE 3: OBSERVATION OF VARIABLES FOR RESPONSE ON MAXIMUM SATISFACTION Figure 8. Frequency distribution of the Availability of facilities at kiosk/micro-hospitals Observation ( i) 1 2 3 4 5 6 7 8 9 Patient Satisfaction (Y) 22 27 9 3 3 7 7 7 3 Trust (X1) 10 7 4 2 7 12 12 5 10 Availability (X2) 15 10 3 10 5 1 5 5 6 Accessibility (X3) 10 2 9 7 12 5 5 13 4

The above Fig. 8 shows diverse curves with healthcare expert having the better response. Though the quality of emergency services and super-specialty doctors do not show good satisfaction response, mother and child has the highest satisfaction response.

Calculating the mean for all the variables Y, X1, X2, and X3 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 are almost near to each other except the variable X2. The correlations between dependent variable with each independent variable have been checked. We assumed 95% confidence interval for the sample population.
TABLE IV. CORRELATION BETWEEN Y AND X1 Patient Satisfaction (Y) Patient Satisfaction (Y) Trust (X1) 1 0.1281 1 Trust (X1)

The multiple regressions on the four data response on the maximum satisfaction side were conducted as shown below table.
TABLE VIII. REGRESSION STATISTICS 0.67 0.45 0.12 8.19

Multiple R R Square Adjusted R Square Standard Error

The correlation value between patient satisfaction and trust shows that they are slightly and linearly related to each other.
TABLE V. CORRELATION BETWEEN Y AND X2 Patient Satisfaction (Y) Availability (X2) Patient Satisfaction (Y) Availability (X2) 1 0.6055 1

The value of R-Square which is the Coefficient of determination shows we have explained 45% of the original variability and is explained by this relationship. However, the value of adjusted R-Square is very small compared to R-Square which shows that 12% variance in the outcome that the variable patient satisfaction explains in the sample population.
TABLE IX. df Regression Residual Total 3.00 5.00 8.00 SS 272.29 335.27 607.56 ANOVA CALCULATION MS 90.76 67.05 F 1.35 Significance F 0.36

Unlike the correlation between patient satisfaction and availability of medical services at the kiosk we can see that the variables are strongly and linearly related to each other.
TABLE VI. TABLE 6: CORRELATION BETWEEN Y AND X3 Patient Satisfaction (Y) Patient Satisfaction (Y) Accessibility (X3) 1 -0.2662 1

Accessibility (X3)

The ANOVA calculation in table 9 shows that the significance of F-Test is acceptable in the normal distribution. The given value for the above degrees of freedom in F-Table is 9.01 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 is the following equation (4).
Estimated Patient = 2.80 + 0.30(Trust ) + 1.27( Availability ) 0.50( Accessibility ) Satisfaction

The correlation between patient satisfaction and accessibility has shown that they are negatively related to each other. However, when we run the correlation between the independent variables we did not get any relation between them.
TABLE VII. TABLE 7: CORRELATION BETWEEN X1, X2 AND X3

(4)

The coefficients obtained shows that patient satisfaction is dependent on the independent variables trust and availability but not dependant on the accessibility. Looking at the socio-economic status from the representative population residing in the districts of Burdwan, we may conclude on the non-dependence of accessibility on patient satisfaction. Half of the population have completed graduation and have income level less than 3 lakhs rupees. This may 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 few existing doctors even if they are not cured fully from them. We may also interpret that our algorithm of micro-hospitals is based on the factors of trust and availability of facilities for patient satisfaction. Based on the frequency observations, it is evident that the micro-hospitals need to improve the quality of super-specialty facilities. The referral system shows a good response which is obvious from our result of regression that the patients need to have trust for being satisfied.

Trust (X1) Trust (X1) 1 Availability (X2) -0.1311 Accessibility (X3) -0.3768

Availability Accessibility (X2) (X3) 1 -0.0052 1

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

Y = b0 + b11 + b2 2 + b3 3

(3)

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Based on this observation we go back to the function of well ness F which is defined by the primary care and the
w

Science and Technology, Government of India to provide support through Technology Business Incubation (TBI) project. REFERENCES
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patient sickness level after the cure from it. We had mentioned that total healthy and cured function needs satisfaction of the component of level of sicken i.e., S ij C ij . Based on the requirement of healthcare services and random interview, in the region, we assumed that the population residing in the selected area of study was not satisfied with the primary care systems in the districts. Our regression analysis has tried to find out the level of satisfaction on the sickness level the respondents have faced. However, we tried to find out the patient satisfaction determinants 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. CONCLUSION An optimized healthcare network is important to maintain the resources available in the developing countries especially in India. On the basis of our current research, the existing healthcare network might be appropriate for semi-urban and rural India keeping the inefficiencies of primary healthcare in mind. 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 utilization of resources and patient care system. Healthcare management will be more formalized and regularized by strengthening the technology based patient care management. Patient satisfaction with services provided should be considered as an outcome measure of the care provided at kiosks/micro hospitals which might help to improve the quality of the healthcare service in our business architecture. Our finding emphasises to improve trust and availability of healthcare facilities in the kiosks. Accessibility does not hold good for those who do not have strong education background our income level. The lower cost model also might help the improvement 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 to identify the reasons for dissatisfaction to complement this information. The structural and human resources optimization would also help improve the requirements of population. Coincubation network architecture may also suit well to them. An empirical study of the parameters necessary for resource sharing 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 the members of Science and Technology Entrepreneurs Park, IIT Kharagpur especially Mr. Ashok Ghosh and Mr. Arunangshu Bhunia in this research. We are also thankful to Department of

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