1. A Psychosocial Study of Selected Health Problems in Low Income Urban Colonies of South Delhi
Author/s:Desai Kalpana N
Publication source: Unpublished Ph.D. Thesis Submitted to Jawaharlal Nehru University, 1997.
Year of publication: 1997
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Individual Private Practitioners, Alternate Systems of Medicine
Issues addressed: Utilization of Private Sector, Government Hospitals.
Objectives: This study primarily focusses on problems faced by people from low income families, their relationship with the family environment and its influence on health perception and behaviour. This study was conducted in a resettlement colony in South Delhi.To study the psycho-social aspects of selected health problems across three urban colonies in Khanpur area of Delhi. To assess the family environment in households across these colonies and study its relationship to health problems.
Methodology: This study was done in three types of urban slums which included a resettlement colony, an unauthorized colony and an urban village all seen as part of a continuum. Forty households were chosen on a random basis from each of the categories mentioned above. These were essentially in-depth case studies and focussed on selected health problems. These included fever, diarrhoea, alcoholism, mental retardation, epilepsy, skin infections, tuberculosis, psychoses, gynecological problems, Sexually Transmitted Diseases and AIDS.
Findings and conclusions: The physical and socio-economic conditions were the poorest in the unauthorized colony, followed by the resettlement colony and then the urban village. The extent of family support networks also varied across the three types of settlements. When asked about satisfaction with different providers viz. private clinic or nursing home, government hospital and alternate systems of medicine, a very high percentage of the study households (95-97 percent) expressed satisfaction with private clinics. The high satisfaction levels were expressed with government hospitals by the households in the unauthorized colony while only 70 percent of the households in resettlement and 75% in urban village were satisfied with the government hospital. The proportion of households which found alternate systems of medicine satisfying, was high in all three settlements. Across all three settlements there was a difference in type of services sought for various types of ailments. For a number of acute conditions like fevers and diarrhoea and skin infections the majority of the households resorted to the private practitioner. For chronic ailments like tuberculosis, and STDs there was less reliance on the private practitioner; around 40-60 percent of the households relied on the public hospital . For conditions like mental retardation, epilepsy and psychoses a large proportion used the public sector hospitals. This study points to the selective use of private practitioners for treatment of illnesses in the three settlements where the poor predominantly reside. For acute conditions they resort to private practitioners but for several chronic ailments there is greater reliance on the public hospitals. This kind of resort pattern requires the importance of strengthening the public sector and working out referral systems from the private to public sectors in case of all diseases. There is also a need to develop management and reporting systems for specific diseases for which people resort for treatment to the private sector.
2. A Review of the Rules & Regulations Concerning Private Sector Participation in Health Care in India & An Assessment of the Functioning of ESI, GIC & Hospital Insurance Schemes
Author/s: Operations Research Group
Publication source: Operations Research Group, Baroda
Year of publication: 1989
States covered: Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh, West Bengal, Tamil Nadu
Social geography: Urban
Data source: Primary & Secondary
Type of study: Policy review
Type of private sector: Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed:Regulation, Organisation, Financing, Incentives, Partnerships, Payment mechanismms, Insurance
Objectives: The study reviews the rules and regulations of private sector participation in health care, and assesses the functioning of the ESIC, GIC, and hospital health insurance schemes.
Methodology: The methodology includes (1) discussions with officials of the concerned ministries or insurance agencies, and their State branches, obtaining documents on regulations and published data on current coverage and financial viability of insurance schemes, (2) discussions with hospital superintendents of Apollo and Birla Heart hospitals, and obtaining published data, (3) interviews with a sample of beneficiaries, (100 insured persons belonging to each scheme in the four state capitals, and 34 1 ps of Apollo scheme) and providers (40 ESIC doctors from 4 State capitals), for their perceptions of the schemes. The data for State-level operations of GIC was problematic.
Findings and conclusions: The study reveals that the GIC scheme operates in towns with population above 5,000. The policy holders are government employees and professionals, with incomes above Rs.3, 000/- except in Bihar where the cited income was Rs.1,500-3,000. Private nursing homes and practitioners are the main providers of health care, except for government hospitals in Rajasthan and monthly health care expenditure per family is cited as Rs.100-200, but below Rs.100 in Uttar Pradesh. The beneficiaries expressed dissatisfaction with cumbersome claims processes, delays in settlement, and lack of coverage for minor ailments like flu, malaria, etc. The financial viability of the scheme is not a concern because the claim ratio is low. The state-level coverage and infrastructure of ESIC scheme is reviewed. All four states incurred lower per capita expenditure than the national ESIC average. The respondents identified the following problems: low quality and quantity of drugs: delays in claims settlement: malpractice and corruption: poor services, especially OPD for TB, skin diseases, etc. A brief review of the Apollo Health Association's intermediary role between patients and Apollo hospital is presented, and the nature of benefits listed. The Apollo Health Association is proposed as a model for other specialist private hospitals, and a future project of medical insurance for rural areas is listed. The findings are in the form of observations, and a large scale evaluation, based on sound sample design, is suggested especially for the ESIC scheme.
3. A study on Capital Investment Decisions in Private Hospitals in Madras City
Author/s: Sukanya S
Publication source: M.S.Dissertation, Department of Humanities and Social Sciences, I.I.T (Madras) Chennai
Year of publication: 1994
States covered: Tamil Nadu
Social geography: Urban
Data source: Primary
Type of study: Cross sectional survey, primary data.
Type of private sector: For profit, sole proprietorship, partnership and corporate hospitals.
Issues addressed: Investment in medical equipment, government policy, competition strategy, regulation.
Objectives: a) To understand the pattern of investment in medical equipment in private hospitals in the city of Madras (now knows as Chennai). b) To determine the influence of financial and non-financial factors on investment decisions. c) To understand the role of the stakeholders in the decision- making process for investment in medical equipment ,and d) To assess the extent to which private hospitals use capital budgeting techniques in investment evaluations and to find the reasons therefore.
Methodology: This study was confined to "for-profit" hospitals, offering multi specialties in allopathic medicine. These hospitals offered both inpatient and outpatient services. The study excluded all non-profit (sometimes called voluntary) and government hospitals. Purposive sampling method was used in selecting hospitals for survey since there were no reliable data on their size and distribution in the city. Also very few hospitals were expected to participate in this survey. Hence purposive sampling was adopted. Yet the study chose 50 hospitals from different parts of the city. Out of these 50 hospitals, 25 were sole-proprietary, 10 were partnership and the remaining 15 were corporate hospitals. Three of these were public limited and twelve were private limited companies. A structured questionnaire was used to collect data from hospitals. Information was collected regarding the following: Nature, size and form of organization, range of services/ specialties offered, medical and paramedical and other personnel employed, total value (cost) of capital equipment (including imaging, laboratory equipment, surgical equipment, medical and intensive care equipment etc) volume of inpatients and outpatients. Besides, a number of questions seeking insights into decision- making process within hospitals were asked.
Findings and conclusions: Hospitals with a high bed capacity (more than 90) and corporate hospitals invest more on intensive care and therapy equipment and less on laboratory equipment, while the reverse is the case with smaller hospitals. Investment in imaging equipment is the highest and that in laboratory is the lowest. Investment in imaging equipment accounts for 50% of the total investment. All hospitals strongly perceived that non-financial factors significantly influenced their investment decisions. The extent and the order of influence do not vary with ownership pattern and bed-capacity. But the perception of the decision makers on the role of financial factors varied with ownership. Bed capacity did not influence the perception of the decision makers. Corporate hospitals aim at wealth maximization in the long run. Capital budgeting techniques were not used by most hospitals in investment evaluations. It is necessary to introduce medical audit and technology assessment in private hospitals. It is necessary to make a more detailed study of private hospitals investment pattern in capital equipment. This will help policy makers to think of appropriate regulatory mechanisms. Under the existing payment mechanisms, such heavy capital investments are likely to make providers both over-utilize and charge high for the services.
4. A Study on Contracting out of Dietary Services by Public Hospitals in Bombay
Author/s: Bhatia M.R
Publication source:Department Of Health Services Studies, TISS, Bombay
Year of publication:1997
States covered: Maharashtra
Social geography:Urban
Data source:Primary
Type of study: Cross Sectional
Type of private sector:Hospitals
Issues addressed: Contracting, Costs, Organisation, Quality
Objectives: To review the contracting arrangements in the public hospitals of Bombay. To study the existing contracting arrangements of dietary services in the study hospitals. To compare the costs of direct provision of services with the price of contracted services. To examine and assess patient satisfaction, quality of the dietary services and attempt to develop appropriate quality indicators for the dietary services in public hospitals under consideration.
Methodology: The study was undertaken in one teaching and two peripheral public hospitals where dietary services were contracted (contract hospitals) and in the same teaching hospital and three other peripheral hospitals where dietary services were managed by hospital staff was taken for the control group (in house). In the teaching hospital studied, 40% of dietary workload was on contract the rest of the workload was in house. The study utilised a mix of methodologies. Original contract documents were analyzed with respect to duration, nature of contract, reasons for contracting out, monitoring of contract, penalty clauses etc. To assess the costs to the public hospitals for direct provisions of dietary services and price of the contracted services, costs were identified and measured under heads-salary, raw material, gas, water, electricity, space and capital costs of equipment. The patient satisfaction was assessed through a survey of 1100 patients through structured interview schedules. An attempt was made to assess the quality of the dietary services by using the Input-Process-Output model for quality assessment. In addition, the expert opinion of a dietician was considered with regards to nutritional and caloric content of the diets. In addition semi structured interviews were undertaken with the contractor, hospital administrators, BMC diet committee members and other experts.
Findings and conclusions: It is observed that there are hardly any private contractors bidding for tenders to realize the benefits of competitive tendering. The study reveals that formal competitive tendering does not exist in the true sense. Contractors continue year after year in most instances. Although the contract document specifies the contents of the diet, it does not specify any quality guidelines. In the absence of any specific quality standards, the hospital administrators are unable to monitor the quality of food supplied by the contractor effectively. Although all the hospitals studied, where diet is contracted out are under one authority, i.e. Bombay Municipal Corporation, the terms and conditions of the contract document vary. It is interesting to note that the criterion for selection of the contractor was mainly on the basis of Rate / meal quoted by the contractor at the teaching hospital, whereas in the peripheral hospitals, the criterion for selection was on the basis of maximum royalty the contractor was willing to pay to the hospital, as the price per meal is fixed. There is no formal mechanism for supervising contractor performance. No records are maintained by the hospital in this regard. It is observed that only those municipal hospitals which have either recently started or have undergone recent expansions have dietary services on contract and hence the question of retrenchment of staff does not arise. Also, because of the strong union that operates in municipal hospitals, this is not be feasible.
The price per meal is less in contract hospitals (Rs. 5.75, Rs.4.00 & Rs. 3.70) as compared to the cost per meal in the in-house hospitals (Rs. 7.47, Rs.7.48, Rs.9.32 & Rs. 11.99). This could be attributed mainly to salary costs, which are lower in Contract Hospitals. Comparing the In-house Dietary services, it is observed that the cost per meal is less in teaching medical college hospitals (Rs.7.47, Rs. 7.48) as compared to the peripheral hospitals (Rs. 9.32 & Rs. 11.99). This could be attributed to the increased efficiency in teaching hospitals, economics of scale, high bed occupancy and availability of trained professionals. Among the peripheral hospitals, significantly more number of patients receive food on time. In In-house hospitals it is (99.1%) as compared to Contract hospitals (86.%). This difference is not observed in teaching hospitals. Among peripheral hospitals significantly more number of patients are satisfied with quantity of food served in In-house hospitals as compared to Contract hospitals. A similar trend is observed with regards to certain quality indicators like taste, flavour, appearance etc. There is no significant difference with regard to patients' satisfaction to the quantity and quality of food served in teaching hospitals. Overall patient opinion regarding dietary services in peripheral hospital shows that significantly more patients are satisfied with In-house dietary services (92.4%) as compared to contract hospitals, Kandivili and Centenary where the overall satisfaction was only 65.1%. Although a higher percentage of patients were overall satisfied with dietary services in teaching hospitals (79.4%), this difference was not significant. Overall diets provided by In-house services were much better than the contract diets (both in terms of quality and quantity).
The Diet Committee of the BMC should be entrusted with the job of centralized drawing of contracts for all its hospitals. This would lead to uniformity in diets in all its hospitals. This would also reduce transactional costs and increase possibility of negotiation for contracts. The monitoring and implementation of the contracts would be the total responsibility of the local hospital administration. Administration should be trained to draft, monitor, implement and evaluate contracts. There is a need to develop quality indicators with respect to dietary services in public hospitals. Periodic evaluations of contracted services is necessary with regards to levels and standards of services, satisfaction of users and the quality of services. The hospital should develop a system for formal evaluations. Penalty clauses for performance failures as laid down in the contract document should be used as and when necessary. The selection criteria for the contractors need modifications. New entrants should be encouraged. In the absence of true competition and absence of inadequate system for monitoring the performance of contractor, BMC may consider partial contracting in which only the labour is on contract. Therefore, the hospital is free from day to day labour problems and at the same time management has total control over the quantity and quality of diets served to patients. To set in motion an effective method of self-checking of the performance of diet services, patients should be made aware of their food entitlement.
5. A Study of Growth in Health Services Provided by Private Health Care Institutions in Jaipur
Author/s: Kabra S.G, Malti Patni
Publication source: Rajasthan Voluntary Health Association and Voluntary Health Association of India
Year of publication: Unstated
States covered: Rajasthan
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Utilisation, Quality, Financing
Objectives: To collect, collate and analyse a representative sample of baseline data of private health care facilities in Jaipur as an indicator of the rate and extent of privatisation. To document the private health care facilities developed in Jaipur in the period 1960 to 1991. To study the use of the private facilities by both the inpatients and outpatients in the hospitals.
Methodology: The study was conducted in the city of Jaipur. A list of all private nursing homes was compiled from various sources such as institutions, doctors, pharmacists, etc. A questionnaire was mailed to the hospitals & nursing homes. The researchers had to revise the sample keeping in mind the time constraint under which they were working. Thus they decided to limit the sample only to 50 private health institutions. Initially, the hospitals were hesitant to reveal the information but when the purpose and utility was properly explained to them, they showed their willingness to cooperate. The researchers were able to generate a response rate of 70%. The only difficulty, which the researchers faced, was the authenticity of the data. Since the hospitals did not maintain proper records of their In and Out patients, the researchers had to rely upon the oral information given to them.
Findings and conclusions: The number of patients who visited the Out Patient Departments per annum was 6 lacs as of 1991. The IPD figure per annum was approximately 60 thousand. The total bed strength of all the hospitals was 1283 beds. The cumulative growth rate of the bed strength over the period between 1960 to 1992 was 951.64%. It grew 9.5 times over this period. The cumulative growth rate in bed strength over this period was 1229.69% (12.30 times). The cumulative growth rate in IPD was 1689.91% i.e. 16.90 times growth. The number of beds grew from 122 beds between 1960-1969 to 1283 beds between 1990-1992.The number of OPD and IPD patients rose to 611659 and 60857 respectively in the above-mentioned period. However, the increase in the number of beds varied every five years. The highest number of beds was added between the period of 1980-1985. This also meant the highest patient handling capacity by both OPD and IPD in that time span. An average of 400 beds were added per decade. The health care services provided by the nursing homes grew at a decreasing rate. The study states that the sharp increase in the private health care facilities in the last decade indicates the new trend of privatisation, which began in 1991. The study also indicates that the capacity of the people to pay for the health services is increasing. At the same time they are not satisfied with the government services. The growth of small private speciality hospitals is due to their financial viability. Lastly, the study has emphasized the need of carrying out more such studies. This kind of database would be useful for determining areas for government intervention. This is necessary to maintain standards in the private health sector and check it from becoming exploitative.
6. A Study of Household Health Expenditure in Madhya Pradesh
Author/s: George Alex, Ila Shah, Sunil Nandraj
Publication source: Foundation for Research in Community Health (FRCH), Bombay
Year of publication: 1993
States covered: Madhya Pradesh
Social geography: Urban & Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Utilisation, Financing, Costs, Expenditure
Objectives: To estimate the expenditure of households on health as a proportion of total consumption expenditure. To estimate the household level expenditures on health care and to document the components of health expenditure and its differentials by variables such as class, social geography, etc.
Methodology: The study was conducted in two districts of Madhya Pradesh i.e. in Sagar and Morena. These districts were selected as they were representative of developed and underdeveloped districts. Multi-stage sampling was employed to select 770 households covering a population of 5202, (62.08% from rural areas and 37.92% from urban areas) from these districts.
Findings and conclusions: It was found that the acute prevalence rate was 162.16/ 1000, and the chronic prevalence rate 128.33 / 1000. Acute morbidity was found to be high in the urban areas, whereas chronic and handicapped morbidity was high in the rural areas. It seemed to indicate that the definition of morbidity was influenced by the seriousness of illness and the accessibility to health facilities. The annual per capita health expenditure was Rs.299.16, which formed 8.44% of overall consumption expenditure. There was a steady increase in the annual per capita health expenditure between the classes. It was Rs.28.16 in the lowest class, which went as high as Rs. 563.94 in the highest class. The difference between the lowest and the highest class was as high as 339.79%. The per episode cost for health care was much higher than the per capita figures. It was as high as Rs.134.23 for a one-month recall period for the whole sample. The corresponding figures for the lowest class was Rs.71.91, and for the highest class was Rs.243.60. The intra-rural and intra-urban difference in per capita and per episode expenditures was wide. Within the rural areas, the annual per capita expenditure was the highest (Rs.314.16) in the PHC villages, but monthly per episode expenditure was the lowest, as against remote villages, where it was the opposite (viz. Rs. 219.96 and Rs. 145.63). Within urban areas, the annual per capita and monthly per episode costs were higher in district headquarters (Rs.322.448, Rs. 134.7) than in small towns (Rs.280.92 and Rs. 116.86). The utilization of the private sector for health care was found to be as high as 69.05%. Only 15.52% of the episodes sought public health care, out of which 6.14% utilized government /civil hospitals, and 6.88% utilized the PHC / government dispensaries, while Sub Centers were used only by 1.73%. In 85.39% of the episodes, the patient received medicines, or medicines with injections alone.
7. A Study of Supply and use of Pharmaceuticals in Satara district. (Part1)
Author/s: Phadke Anant, Audrey Fernandes, L. Sharda, Pratibha Mane, Amar Jesani
Publication source: Foundation for Research in Community Health (FRCH), Pune
Year of publication: 1995
States covered: Maharashtra
Social geography: Rural & Urban
Data source: Primary & Secondary
Type of study: Cross Sectional, Prospective
Type of private sector: Hospitals, Practitioners, Pharmaceuticals, Unqualified practitioners
Issues addressed: Utilisation, Financing, Prices, Quality, Regulation, Costs, Cost effectiveness
Objectives: This study had various components and various objectives: The present abstract concerns itself only those related to the private sector. To study the amount and the pattern of drug supply to the public and private health sector in Satara district and the shortages of drugs faced by the public health sector. To study the role of pharmaceuticals in Satara district.
Methodology: The location of the study was Satara district and the study was conducted between 1992 - 1993. This district was chosen for the study since it fulfilled the study conditions such as socio-economic development, size of the civil hospital {number & beds}, existence of cottage hospital, expenditure on drugs and logistical convenience. For the study of the private sector, doctors from each of the following educational backgrounds were chosen from each of the three zones. Post graduate, MBBS, non-allopathic degree holders (Ayurvedic or Homeopathic - both types as a rule prescribe allopathic medicines) and Registered Medical Practitioners (who do not have any recognized degree as such).
To estimate the cost of drug supply in the private sector, discussions with the medical representatives, medical storeowners, distributors and others were held. But it was impossible to get information since companies wee reluctant to reveal their sales figure for reasons of competition and income tax. Access to the audited figures for 17 of the largest drug distributors who were operating in Satara, Karad, Phaltan towns of Satara district were obtained along with information from the Medical Representatives (MR) and the medical storeowners
Findings and conclusions: By taking into account only the audited sales figures of the major 17 drug distributors and the estimated sales figures of the other distributors it was estimate that there was a minimum sale of Rs.26.6 crores of drugs in Satara. If the estimate of the drug store owners were to be taken into account then the minimum estimate would be Rs.30 crores. If unbilled and unaccounted sales are taken into account then the MR estimate would be Rs.50 crores. It was also found that there was a 20% growth in drug sales per year. The sale of drugs in the private sector in the Satara district in 1991 - 92, was atleast Rs.21.28 crores, which is 38 times the drug supply to the public sector.
8. A Study of Supply and use of Pharmaceuticals in Satara District. (Part 2)
Author/s: Phadke Anant, Audrey Fernandes, L. Sharda, Pratibha Mane, Amar Jesani
Publication source: Foundation for Research in Community Health (FRCH), Pune
Year of publication: 1995
States covered: Maharashtra
Social geography: Rural & Urban
Data source: Primary & Secondary
Type of study: Cross Sectional, Prospective
Type of private sector: Hospitals, Practitioners, Pharmaceuticals, Unqualified practitioners
Issues addressed: Utilisation, Financing, Prices, Quality, Regulation, Costs, Cost effectiveness
Objectives: This study has various components and objectives: The present abstract concerns itself only those related to the private sector. (Also refer part1). The overall aim of this second phase was to study the use of pharmaceuticals in Satara district. To study the prescriptions of doctors in public and private sector in order to assess their rationality, the extent of the use of unnecessary injections. To correlate these aspects of prescriptions with the educational status of doctors, and the relevant socio-economic factors. To study the factors affecting prescription behavior of doctors, viz. the Continuing Medical Education of doctors, the extent of competition amongst doctors; the marketing practices of the drug - companies and drug stores etc. To study the extent and nature of sale of prescription-drugs (schedule - drugs) which are sold over the counter (OTC) without prescription. To estimate the wastage in both public and private sector on account of use of irrational drugs by doctors. To study the extent of expenses incurred by patients on account of "private - prescriptions" given by doctors in the Public Health Facilities (PHFs)
Methodology: The location of the study was Satara district and the study was conducted between 1992 - 1993. This district was chosen for the study since it fulfilled the study conditions such as socio-economic development, size of the civil hospital {number & beds}, existence of cottage hospital, expenditure on drugs and logistical convenience. For the study of private sector, doctors from each of the following educational backgrounds were chosen from each of the three zones. Post graduate, MBBS, non-allopathic degree (Ayurvedic or Homeopathic - both types as a rule prescribe allopathic medicines) and Registered Medical Practitioner (who do not have any recognized degree as such. To record all the drugs given to the patient, data was collected prospectively by posting pharmacist-investigation for a day in each of the clinics to record both types of drugs - those given in the dispensary and those prescribed for buying from a medical shop for first 30-35 cases.
Prescription analysis: It is widely believed by critics that doctors' prescriptions in India are irrational to a large extent, leading to a lot of financial wastage. The current study has conducted such an analysis of 1944 prescriptions collected in 59 visits to Out Patients Clinics of 30 public health facilities and of 1638 prescriptions from 62 visits to 19 private clinics from different parts of Satara district.
Factors Influencing Prescription - Behaviour Of Doctors: A pretested structured questionnaire was administered to seek information regarding qualifications of the doctor, his/her sources of continuing medical education the number of medical representatives that visited him in a week, his/her views on patient's expectations, his/her opinions on drugs available in the open market.
Focussed interviews were conducted with those doctors who were willing to give information beyond the questionnaire.
Financial Wastage Due To Irrational Prescriptions: Out of the 1080 and 810 prescriptions collected in summer 1993 from public and private sector respectively, 10% sub-sample was picked up by systematic random sampling. This sub-sample was subjected to cost analysis. The per day cost of drug treatment according to prescriptions by doctors, minus the per day cost according to Standard Drug Treatment Regimens (SDTRs) gave, the financial loss to the patients due to irrational prescriptions per day of drug treatment.
Proportion Of Private Prescriptions In Public Health Facilities: Out of the 561 prescriptions copied from PHFs during winter 1993, a 20% sub sample was selected by systematic random sampling. In the case of the 145 prescriptions thus selected, the drugs prescribed through the "outside - prescriptions" and the "dispensed drugs" were listed separately. The cost of both types of drugs (prescribed and dispensed) was calculated as per retail prices as given in the 1992-93 edition of Indian Pharmaceutical Guide (IPG)
Findings and conclusions: Prescription – Analysis: The average score per prescription was very low. The proportion of rational prescriptions was low and of irrational prescriptions high in all types of doctors. The proportion of rational prescriptions and the average score per prescription directly proportionate with the educational qualification of the doctor. Though the overall score of consultants (post graduate doctors) was slightly better, they tend to use more unnecessary drugs. A very high proportion of prescriptions of all types of doctors contained irrational or unnecessary hazardous drugs or unnecessary injections or more than 3 drugs. Public sector prescriptions were more rational than the private sector prescriptions. However, the proportion of irrational injections in the public sector was slightly higher than in the private sector. All types of doctors from Registered Medical Practitioner (RMPs) in a small village to post graduates in large town were found to be writing grossly irrational prescriptions.
Factors Influencing Prescription - Behaviour of Doctors: CME in the private sector is almost entirely left to the discretion of the individual doctors and only 12.6% actually subscribed to periodicals other than those published by drug companies. In the public sector, the department of health services conducted trainings at frequent intervals for Medical Officers, though these mainly stressed the implementation of National Programmes. The drug company propaganda, through its printed literature (i.e. pamphlets and periodicals), Medical Representatives form the most important source of "Continuing Medical Education for doctors. Though this is promotional literature and therefore biased, it receives the sanction of more than 68.1% of private and 50% of public doctors as being a source of education. Cost of drugs influenced prescribing patterns in a significant way. The rising costs of drugs made it difficult for a doctor to dispense drug as well as charge a fee. Some doctors therefore resorted to dispensing less and prescribing more. Increased crowding of doctors led to private doctors seeking ways to draw and keep patients leading to a change in prescribing habits. Administration of placebos, in the form of unnecessary injections, drugs, prescribing of more expensive drugs to appease the patients' notion that 'the more expensive the medicine the better it is' were all strategies to keep the clientele with them.
Illegal Sale of Over The Counter(OTC) Drugs: It was found that all types of drugs were available OTC without doctor's prescription. OTC sales in a day (Rs.497.99) accounted for 11.23% of the total drug sales (Rs.4436) in a day in that shop.
Financial Wastage due to Irrational Prescriptions: Due to irrational prescription of medicines, a whopping 63.6% of money spent on drugs was wasted. The proportion was much higher in case of private sector (69.2%) as compared to that in the public sector (55.4%). Based on available estimates of the rate of morbidity in India, in the community, and the 1991-92 OPD attendance data in PHFs in Satara district, this wastage was Rs. 4.76 and Rs. 2.08 in private and public sector respectively per day, per prescription. If this data was projected at Satara district population, (1991) the wastage amounts to Rs. 17.70 crores.
Proportion of Private Prescriptions in Public Health Facilities: In the case of 145 randomly selected O.P.D. cases the cost of 'private prescriptions' in Public Health Facilities, was 15.43 % of the cost of drugs. In absolute terms, the cost of these privately prescribed drugs if distributed over all these 145 patients, came to only Rs. 0.82 per patient (It may be noted that out of these 145 patients, many were not given any private prescription). In the bigger and small towns also, the cost of privately purchased drugs as a proportion of cost of dispensed drugs on an average was 15.64%. It ranged from zero to 221.5%. The average cost of privately purchased drug, per prescription in these 7 PHFs was found to be Rs.7.97, which was much higher than that found for all centers. (Urban and rural together). It appeared that the overall proportion of privately prescribed drugs in PHFs was not high but was sizeable. In some Public Health facilities in big and small towns, it ranged considerably, from zero to a very high of 22.5%
The overall conclusions of the study are: The drug supply to the public sector in Satara District was a mere Rs. 5.6 million, as compared to the most minimum, reliable estimate of a drug sale of Rs. 212.8 m in the private sector during 1991-92. The drug supply especially to PHCs and RHs suffers from chronic gross shortages and haphazardness. The overall quality of prescriptions of doctors both in public and private sector was low. There was a very high proportion of use of unnecessary, irrational, hazardous drugs and injections especially in the private sector. Public Sector prescriptions were more rational than private sector prescriptions. The proportion of rational prescriptions increased with educational qualification. There was very little of proper Continuing Medical Education of doctors. This along with the influence of the medical Representatives, increasing prices of drugs and competition amongst doctors influenced the prescription of doctors in the private sector, whereas in the public sector, the chronic shortage of drugs affected prescriptions, apart from lack of proper CME. Due to irrational prescriptions, 69% and 55% of the money spent on prescriptions in the private and public sector, respectively, was wasted, with an average of 63%. Projected to the Satara-district level, this wastage amounted to Rs. 17.7 crores out of the total drug supply of Rs. 22 crores. Patients visiting government clinics in Satara district had to buy 15% of the drugs prescribed to them, instead of getting all drugs free. If all the patients coming to the six PHC under study were to be adequately and rationally treated, there would be a drug short fall of Rs. 30284 per PHC. The shortfall could be met by a mere 8.34% increase in the annual recurring expenditure of Rs. 0.363 million per PHC. If all the patients in Satara district were to be adequately and rationally treated and if all children and women were to be fully covered in the MCH Programme in 1991-92, the drug-expenditure would be Rs. 20.61 crores, compared to the total drug expenditure of Rs. 21.84 crores in Satara district. It was thus, not lack of resources, but its irrational waste which was responsible for the unmet drug needs of the Satara district.
9. A Study of the State of Medicare Facilities in Agra
(with special reference to Nursing Homes of Agra), Project Report
Author/s: Bharti Ramkishan
Publication source: Unpublished Masters Dis-sertation, M.S.W. Agra University, 1992-93.
Year of publication:1993
States covered: Uttar Pradesh
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Nursing Homes, Indian Systems of Medicine.
Issue addressed: Characteristics of Private; Staffing, Costs and Prices of Services, Quality of Care
Objectives: The study focuses on the infrastructural facilities available at nursing homes. It also studies the qualifications and experiences of service providing professionals in the nursing homes.
Methodology: A survey of a few nursing homes in Agra city was conducted for this study.
Findings and conclusions: he study shows that the average academic qualifications of the service providersin the nursing homesare varied. Fifty percent have passed the intermediate; forty percent are graduates and another ten percent are post graduates. The post graduate doctors are either BAMS or BHMS qualified and eighty percent of these practitioners practise allopathic medicine.
About 30% of the professionals have 15 to 20 years practice, followed by another 25% with 10-15 years, 25% of them have 5-15 years and 20% of them have only 0-5 years of experience. A majority of them (90%) act as consultants to various nursing homes on a casual basis and the remaining 10% are employed temporarily in these nursing homes. Most of the nursing homes i.e. 85% have employed paraprofessionals who are intermediate (12th standard) or Matric pass. Not a single pharmacist was found during the study in these nursing homes. About 25% of nursing homes have employed technicians who are intermediate (12th standard pass). A large number of nursing homes i.e. 90% refer their patients to other hospitals (both government and private) due to inadequate infrastructural facilities at these nursing homes.
The consultancy charges range between Rs. 25/- to Rs. 50/- per patient and the bed charges range from Rs. 50/- to 150/- per bed. The private room charges lie between Rs. 100/- to Rs. 200/- per day excluding the additional nursing charges. The average number of patients admitted to these nursing homes are 171 in private rooms as compared to 240 patients in general wards. The average income of nursing homes in Agra city around is Rs. 53,000/- per month. In a small town in Uttar Pradesh the study shows that fifty percent of the promoters were unqualified. This is different from the trends observed by studies of private institutions, in large cities, which are mainly promoted by practitioners atleast with an MBBS degree. This kind of a trend has implications for quality of care and raises the need for ensuring some minimum regulations. From study it is also evident that nursing homes are earning quite a substantial amount per month. This raises questions regarding over-charging of patients, and the quality of services being provided by these nursing homes.
10. A Study of the State of Medicare Facilities in Agra City (With Special Reference to Medical Practitioners),
Author/s: Pandey, Baidya Nath Kumar
Publication source: Masters in Social Work. Agra University, 1992-93.
Year of publication: 1993
States covered: Uttar Pradesh
Social geography: Urban
Data source: Primary
Type of study: Case Study/Descriptive
Type of private sector: Qualified Private Practitioners
Issues addressed: Personnel in Private Sector; Prices and Costs of Medical Care;
Objectives: This study aims at the nature and standard of health care delivery by qualified private practitioners. It also explores the nature of private practice and the cost effectiveness of their services provided.
Methodology: It is a case study of selected private clinics in Agra. It is an exploratory study, which looks into the condition of these clinics.
Findings and conclusions: The study revealed that a majority of these practitioners belong to the 30-40 year group and are engaged mainly in private practice. A majority of these doctors who had joined for M.B.B.S.after intermediate want to acquire specializations. A majority of them have five years of experience and prefer to practice privately. Their practice is mostly specialty-based rather than general practice. They have trained technicians as their supporting staff. Routine first aid is the primary service provided by these clinics. Other preventive services such as immunization, anti rabies, and anti toxic services are secondary in nature. Many doctors are found to charge additionally for these facilities and the consultation charges of these practitioners range between Rs. 30- 35 for each alternate visit and their daily earnings are between RS- 300-500. Most of them refer their patients to specialist doctors due to inadequate facilities available in their clinic. Most of the patients who use these services are from the upper middle class. A majority of the practitioners interviewed are of the opinion that services have become commercial as a result of increased competition. This, in turn, has led to a number of undesirable, unfair practices. This study shows that there is a trend towards specializations rather than general care. Here, the emphasis is solely on curative services with minimal preventive inputs. The earnings by these doctors' ranges from Rs. 10,000 to 15,000 a month. This trend requires regulation of medical practice in both government and private institutions. Some process needs to be initiated at the state level, which at the moment is lacking.
11. A Study of the State of Medicare Facilities in Agra City (with special reference to Ayurved and Unani)
Author/s: Singh Pratap
Publication source: MSW, Project Report Agra university, 1993.
Year of publication: 1993
States covered: Uttar Pradesh
Social geography: Urban
Data source: Primary
Type of study: Case Study/ Descriptive
Type of private sector: Indigenous Systems
Issues addressed: Practices and Characteristics of Indigenous Private
Objectives: The study aimed to understand the present conditions of Medicare facilities and elicit the preferences of the patients towards various medical system/agencies. It sought to study the extent of use of allopathic methods of practice by Ayurvedic and Unani practitioners.
Methodology: It is a case study of a few selected Ayurvedic and Unani practitioners. It is an exploratory study which tries to study the conditions under which these practitioners operate and the trends of preferences of patients for utilization of available Medicare facilities.
Findings and conclusions: The average age of these indigenous practitioners is 70 years and above and the average duration of their practice is around 20 years. With regard to the qualification of the practitioner about 50% of them have studied up to intermediate (12th standard) level, about 10% of them have studied up to graduation level, 15% of them are of middle to high school level and about 25% of them have done qualifications called Ayurved Ratna. It has been found that 75% of them have general practice and none of them provides any specialized practice. About 65% of them agreed that their profession is based on training, 35% it was a family profession. 35% of them belong to the third generation of family practice, 25% are the second generation of practitioners and the remaining are first generation practitioners. It is found that these practitioners do use allopathic methods of treatment along with ayurvedic and unani medicines. This study provides some insights into the social background and nature of practice of the practitioners of indigenous systems of medicine.
12. A Study of the State of Medicare Facilities in Agra City (with special reference to Pathology Labs)
Author/s: Tomar Vishal Singh
Publication source: MSW, (Project Report) Agra University, 1993.
Year of publication: 1993
States covered: Uttar Pradesh
Social geography: Urban
Data source: Primary
Type of study: Case Study
Type of private sector: Pathology Labs
Issues addressed:Organization of Private Care (Pathology Labs), Subsides form Government, Referrals to Labs Cost of Services.
Objectives: The objective of the study was to find out the nature of sources provided by pathology labs towards medical care and to list all the health services provided in all the wards of Agra city.
Methodology: It is a case study of 12 selected pathology labs of the city. It is an exploratory study, which sought to look at the conditions of the pathology labs and the kind of services they provide.
Findings and conclusions: The study identified forty-eight pathology labs in the city and of these twelve were studied in depth. The study revealed that no government incentives or subsidies were given to run these labs. On an average the cost of the services provided by these labs is very high. As a result, the poor do not have much access to it. It has been found that the services provided by the labs are generally below average. In almost all laboratories there is a lack of advanced technology. The average income of the lab ranges between Rs 12,500 to Rs 50,000 per month. There has been an increase in the number of patient referrals to these pathology labs in recent times and allopathic doctors refer most of their patients to these labs for routine lab testing. The summary of findings are no subsidy has been offered for setting up pathology labs. There is variation in size, quality and cost of services provided by there labs. These labs do not conduct high technology testing. They are confined to routine tests and X-rays. The average income of the lab ranges from Rs. 12,500 to Rs. 50,000 per month. There has been an increase in the number of patient referrals to these labs.
13. An Epidemiological Study on the Outbreak of Malaria in Valiyathura:
A coastal area of Kerala
Author/s: Ramesh Harihara Iyer
Publication source: M D dissertation, Dept of Community Medicine, Medical College, Thiruvananthapuram, Kerala, 1997
Year of publication: 1997
States covered: Kerala
Social geography: Rural
Data source: Primary
Type of study: Prospective survey.
Type of private sector: Private practitioners (allopathic and other systems of medicine)
Issues addressed: utilization of private services
Objectives: (a) To determine the prevalence of malaria, (b) To examine the relationship between demographic, socio-economic, cultural factors and prevalence of malaria, and relationship between certain vector factors favouring prevalence of
Methodology: A sample of 1475 individuals from about 2000 households were studied. A survey was conducted in March - June 1996 in Valiyathura, ward of the Thiruvananthapuram city. The locality is known to be poor and has very few private General Practitioners. There is one voluntary scheme sponsored by Valiyathur Church.
Findings and conclusions: The study estimated a point prevalence rate of 1.98% for June 96 and a period prevalence rate of 13% for 1995-96, with a case fatality of 1.74%. Malaria was prevalent among the most illiterate. Malaria was more prevalent among fishermen than among students and housewives. It was also more prevalent among those living in thatched / sheet houses. Malaria was more prevalent among those with inadequate light and ventilation and was higher among large families. It was lower among families with domestic animals and birds. Sixty percent of the families used chemicals to control malaria, while 30% used larvicides. Eighty eight percent of the patients used government facilities for treatment, while only 4.5% used private facilities. Close to 95% of the patients used allopathy, the remaining used other systems of medicine.
14. An Examination of Public and Private Sector Sources of Inpatient Care in Trivandrum District, Kerala (India), 1999
Author/s: Rick K Homan and K R Thankappan
Publication source: Achuta Menon Centre for Health Services, Thiruvananthapuram, Kerala
Year of publication: 1999
States covered: Kerala
Social geography: Urban & Rural
Data source: Primary
Type of study: Cross-sectional study
Type of private sector: For profit, corporate hospitals, and public sector hospitals.
Issues addressed:Performance of private and public hospitals, personnel issues, government policy, partnerships with public sector,
Objectives: The purpose of this study is (a) to provide a description of the structure of the health care sector in Trivandrum district of Kerala state, (b) to examine patients' perception of quality, factors affecting choice of provider, (c) to evaluate the financial burden of care, and (d) to analyze the inputs and performance of both private and public hospitals in the district. The study concludes with a description of the challenges facing the public sector health delivery system and identify some potential responses to these challenges.
Methodology: The study collected relevant data from 29 public hospitals and 9 private hospitals in the district. Public sector hospitals included one super specialty, two tertiary hospitals, five secondary levels hospitals, three Community Health Centres, four Block Primary Health Centres (one from each taluk), four mini primary health centres and four sub-centres. Out of 9 private hospitals, three were within the city boundary, and six from three taluks in the periphery. Structured interviews were conducted with hospital superintendents or the medical officer in-charge of each institution. Information was collected to describe the following issues: waiting time for various services, areas of shortages or surpluses, perceived patient preferences for the facility, referral patterns to and from other providers and patient billing information. In addition, data was collected on the volume and mix of services provided by the facility, the inputs to the provision of care, the capacity of selected areas of facility and operating expenditure.
Findings and conclusions:Based on a 5 point Likert type scale of self-reported satisfaction, patients from the public sector reported lower levels of satisfaction with the care received than the level of satisfaction of the patients from the private sector facilities. The poor and somewhat poor tended to be more neutral about the care received, and the better off were more likely to be at one extreme or another. The reported behaviour of clinical staff appeared to improve with the socio-economic status of the patient. The key perceived problems with government hospitals were : they are too far away (57% agreed), lack of attention from caregivers (54%), bad behaviour of staff (405) and lack of hygiene (30%). Geographic accessibility was not a cause for concern while choosing a private facility. The study suggests that the demand for hospital care among private sector patients may be fairly inelastic. The hidden cost of care associated with care in public hospitals was greater for the poor. This was indicative of the longer lengths of stay or more chronic nature of diseases faced by them in public hospitals. Both at secondary and tertiary level care, inpatient charges as fraction of total out of pocket expenditure was predominant. It was about 75% at the tertiary level; at the secondary level, it was 42% in public sector and 71% in private sector.
Hospital and Laboratory performance: Private hospitals at Trivandrum Taluk operated at a high level of occupancy rate while those in other taluks had a surplus of beds, staff and an occupancy rate of less than 50%. This is attributed to the fact that these hospitals were recently established and the general perception that better quality care was available only in large cities. The shortest average length of stay tended to be in private hospitals. Most doctors in public hospitals believed that "quantity kills quality of care" delivered by them. On the average private hospitals performed three times the number of caesarean deliveries in the public hospitals; but it is not known whether these women in private hospitals are older than those in public sector. 25% of lab tests in public sector were referred to private laboratories. Private sector hospitals tended to order more x-rays per patient (on average 55% more) than the public sector; For private hospitals, a larger share of personnel expenditures went to physicians than in the public hospitals. The higher personnel costs in the private secondary and tertiary level hospitals was due to the use of many more physicians than in the public sector, and a lower use of qualified nurses and paramedical personnel.
Over crowding in large public hospitals needs to addressed. This can be done by extending the consultation hours and capacity of the outpatient area and by use of more qualified nurses, physicians assistants, etc. There is a need to have co-operative arrangements with private hospitals: For example, the government could use private hospitals for government employees at lower negotiated rates. Given the history of ineffectual regulation of private enterprises by the public sector, one should not hold out too much hope for regulatory approaches. Recruitment and retention of physicians particularly in rural (out-lying) areas pose another major challenge. Increasing the intake of students in medical colleges is not likely to solve this problem. The study suggests that the issue of geographic preference needs to be addressed. This will see a noticeable increase in the number of physicians in the outlying areas . The private sector in out-lying areas also faces the problem of recruiting and retaining physicians. The study is unable to assess the relative efficiency of hospitals since there is no control for the variation in quality of care produced. But the study makes an attempt to draw some inferences based on the scale of operations within the hospitals: The public sector hospitals are experiencing "x-efficiencies" in that they are producing services beyond their intended capacity. For private sector hospitals, the low occupancy levels create the opposite problem (of under-utilization). The authors suggest that the root cause for most problems seems to be the misallocation of resources. It is feared that the momentum of the system overwhelms the ability to focus on long-term goals and the result is a series of short-term crises. The government must improve documentation of the medical records and additional control to monitor performance of providers.
15. An Exploratory Study of Social Dynamics of Women's Health in Adityapur Village of Birbhum District
Author/s: Soman Krishna
Publication source: M.Phil Dissertation, Jawaharlal Nehru University, New Delhi, 1992.
Year of publication: 1992
States coverd: West Bengal
Social geography: Rural, Gender, Family.
Data source: Primary
Type of study: Cross Sectional and Case Reports
Type of private sector: Individual private practitioners
Issues addressed: Utilization of Private Sector
Objectives: The study was conducted in Adityapur village of Birbhum district in West Bengal. The purpose of the study was to understand the family dynamics of women's health and illness and their interaction with the larger social processes.
Methodology: A complete census of the socio-economic status of households was conducted. Simultaneously, information was elicited on the health problems of the population in the age group of15 years and above. This was supplemented by qualitative information on social, economic and political life of people, their health care practices and in-depth exploration and case reports on specific illnesses across various socio-economic strata. The study included 272 households. There were 971 individuals in the specified age group of them, 456 were women.
Findings and conclusions: Despite significant transformation in different aspects of life in the village, the life of women was the least affected. They continued to stay within the boundaries of households, performed labour without actively participating in decision making process. Estimates of annual reported illness of women showed direct differentials in socio-economic categories. Moreover, they were more ill than their men folk in corresponding socio-economic categories and the gap was maximum among the poor. While seeking health care, women were in a much more disadvantageous position compared to their men folk in corresponding socio-economic categories. For illness, they were dependent upon the private practitioners in the village who did not have any medical qualification-and mostly received training as compounders or were self-trained. For a few in the socio-economically 'better-off' sections, even if the initial consultation was with qualified private practitioners in town, follow-up was inadequate. Women in the poorer section were mostly using government services for immunization and iron supplementation . The reasons for women's restraint in seeking medical treatment were their perceptions of severity, sense of responsibility towards family, relationships within family, its economic conditions and priorities of men. Men's illness was an added factor in the delay in seeking treatment by women. While similar factors were active at the family level too, the more visible among them were the economic status of the family and men's attitude towards women's illness. At the larger level, it was the balance of power within the patrilineal structure of the society that kept women away from quality health care.
16. An Integrated View of Developmental Programmes in Kutanad: Implications for Health and Well-being of Agricultural Labourers
Author/s: Divakar Sindhu
Publication source: Unpublished M.Phil dissertation submitted to Jawaharlal Nehru University, New Delhi, 1994.
Year of publication: 1994
States covered: Kerala
Social geography: Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Qualified private practitioners
Issues addressed: Utilization of Private Services -Qualified Practitioners in
Government and Private Institutions
Objectives: The larger objective of this study was to take an integrated view of developmental programmes and their implications for the health and well being of agricultural labourers in Kuttanad district of Kerala. The study also includes some observations on the state of health care services in the area.
Methodology: A review of secondary literature reveals that the health care infrastructure is not equipped to cope with the kind of demand for services particularly, during harvest season, when agricultural labourers migrate from other places. Although the primary healthcare network exists, and there is a mobile outreach service, it cannot reach areas where the services required.
Findings and conclusions: The survey reveals that people often visit private practitioners largely due to poor communication and transport facilities to develop management and reporting systems for specific diseases for which people resort for treatment to the private government hospitals. Further,health staff do not prefer to be placed here. This causes understaffing, leading to a negative sector impact on access and utilization of government health institutions in the area.
17. Bangalore Hospitals and the Urban Poor: A Report Card
Author/s: Suresh Balakrishnan and Anjana Iyer
Publication source: Public Affairs Centre, Bangalore
Year of publication: 1997
States covered: Karnataka
Social geography: Urban
Data source: Primary
Type of study: Cross sectional survey study.
Type of private sector: For profit, mission and charity hospitals. Also government hospitals.
Issues addressed: Cost of care, patients' perception of quality of care, consumer issues, regulation.
Objectives: To generate feedback from the urban poor on the quality of hospital services they receive.
Methodology: The field survey covered a sample of 361 citizens drawn from 12,896 economically weaker households scattered across 65 locations in and around Bangalore city. Households with incomes below Rs.3500/- per month were considered for the study. The inpatient sample covered 108 users of government hospitals, 46 users of Municipal Corporation Hospitals, 63 users of Mission and Charity Hospitals, and 63 users of Private Hospitals. The study covered 81 out-patients, of which 47 were from government hospitals, and 34 from Mission and Charity hospitals. The study used a purposive selection of three government and three private hospitals. The following information was collected by the study: Usage profile of different types of heath care facilities, quality of medical care and facilities, cost of services, behaviour of doctors and services, dynamics of speed money, overall satisfaction of patients.
Findings and conclusions: 31% of patients from government hospitals gave clear positive ratings, while only 20% from Corporation hospitals did so. In contrast 57% of the users in Mission and private hospitals gave positive ratings. Only 30% of the users of government and corporation hospitals made the choice primarily for inexpensive treatment. But only 10% of the users of government hospitals reported satisfaction with free treatment. Around 50% of users in government hospitals and 80% of those in corporation hospitals reported spending amounts from Rs.100/- to Rs.800/- for treatment. Costs of treatment in Mission and Private hospitals were much higher. But a significant portion of what the poor spent was on speed money (un-billed charges). Around 51% of users in government hospitals and 87% of users in corporation hospitals reported paying speed money. In contrast, this figure was 29% in Mission hospitals and 22% in private hospitals. This study observes that this difference in the practice of accepting speed money existed though there was no major difference in the staff salaries across private and public hospitals. About 60% of the patients (from all sectors) reported a waiting time of more than 10 minutes for emergency care. The cleanliness of hospitals was reported to be lowest in the government sector (40%), while it was 73% for mission hospitals and 81% for private hospitals. More than 70% of the patients from Mission hospitals felt that the nursing staff was helpful, while it was only 30% in government and corporation hospitals.
The public hospitals may be cheap but the poor have to pay extra in terms of speed money and still cope with poor quality of services. Such problems are not because of lack of facilities. There is a problem of poor quality of management in tackling grievances of the users, particularly when they are poor. The public hospitals, which are supposed to play this crucial role, have little capacity development support in this vital area. There are no publicly stated standards of performance that public or private hospitals will have to adhere to. A wider awareness of procedures and standards, and mechanisms to make individuals publicly accountable for adherence to procedures and standards, would make a strong impression on the performance of the hospitals.
18. Behavior of The Private Sector in the Health Services Market of Bombay
Author/s: Yesudian C.A.K
Publication source: Department of Health Services Studies, TISS, Bombay
Year of publication:
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Quality, Regulation
Objectives: To study the complex behavior of health services providers in the private sector in terms of different forms of operation., delivery of services, and to assess the existing control mechanisms and policy options available for their regulation.
Methodology: Fifteen key informants were interviewed to obtain the necessary information. The informants held key positions in the health sector. These included hospital administrators, senior clinicians and members of social action groups interested in health sector. Information regarding various aspects such as physical location, disposal of waste, equipment, manpower, medical malpractices, etc was sought from the informants.
Findings and conclusions: The private facilities in Bombay range from sophisticated hospitals to small clinics run in the slum areas by semi-qualified doctors. The types of nursing homes and clinics vary widely in terms of services offered. However, the sector faced sharp criticism from the people and the media. Litigations were filed in the court and a committee was appointed by the court to look in to the matter. The salient features of the committee's report found that the condition of private hospitals was poor. A majority of the respondents said that majority of the hospitals were situated away from the residential locality. However nursing homes and clinics situated in the poor areas were near the residential locality causing nuisance and posing health hazards to the people in the vicinity. According to the respondents waste such as surgical material, bandages, dressing material, placenta, were usually thrown in the public dustbins. Even amputed toes and limbs were found in the bins occasionally. Three major reasons were given justifying the use of modern equipment in the private sector. Firstly there was a lack of improvement of technology in the public sector hospitals and thus modern technology should be encouraged in the private sector. Secondly, if the modern technology is available to the rich people the poor will get the benefits of the public health system. Thirdly since the private sector is highly competitive, modern technology is necessary to improve its' performance. The people opposing the modern technology were raising questions about the overuse of the diagnosis, high costs of treatment and unethical medical practices and commercialization of the sector. Less than half of the respondents felt that the private facilities had skilled manpower to operate the modern equipment. Almost all the respondents felt that the nursing homes did not have a properly trained staff. Some hospitals and some nursing homes appointed non-allopathic doctors. These doctors did not have the necessary expertise in modern medicine nor were they able to handle emergency situations. There was a shortage of the qualified nurses in the hospitals and nursing homes. All the respondents agreed that the patient care would suffer badly if qualified nurses were not employed. The respondents also emphasized the dangers of the administration of wrong drugs by the nurses. They were highly critical of the private clinics and nursing homes because they employed uneducated staff.
Consultants working for public hospitals admitted their patients to these hospitals. If they did not have particular equipment at his private nursing home or clinic, they used the facility of the public hospital to treat their own patients. In addition, the public hospitals were used by these consultants as means of getting clients who could afford private treatment. Most of the respondents agreed that private practitioners were involved in large-scale malpractices. There was a prevalence of 'cut' practice among the doctors in the city. The cuts were received by the doctors for the referrals to the laboratories made by them. The percentage of such cuts went even to 40% of the fees received by the laboratories or by the specialists. Unnecessary investigations and even surgeries were carried out by the doctors. The other area of the malpractices was false bills and certificates issued by the doctors to their patients. Poor sterilization led to diseases such as Hepatitis-B or even the HIV infection. Many respondents complained about the negligence in the post-operative care. Often intravenous drug administration was carelessly done. The specialists often neglected patients in the general ward. The practitioners in the slum areas did not follow any guidelines regarding the treatment. In recent years, there has been growing pressure to regulate the private sector both from the public and from various organizations. However, the provisions of the BNHRA (1949) have not been implemented properly and there are many loop hole in the act, which need to be checked. Even the high court took notice of bad implementation of the act and directed the formation of an apex committee and three zonal committees to review the act and to suggest changes. The study has concluded that private sector has become a major provider of the health care services. It makes all levels of curative care available to the people across all economic strata. However the services provided by the private sector have not been up to the standard. Medical negligence and medical malpractices have proliferated in the private health sector.
Policy related to the private sector in Bombay should be directed towards two main issues 1) Development of the municipal health services 2) regulation and monitoring of the private health services. Private sector should be given incentives such as tax benefits to start more secondary and tertiary level facilities. Private participation in some of the municipal facilities in the non-poor areas should be encouraged. Strengthening the public facilities would force the private sector to improve its services in the poor areas. Regulatory norms for various aspects such as physical standards, qualified manpower, etc. should be evolved and be made compulsory. A holistic approach to direct and regulate the growth of the private sector in Bombay is much needed.
19. Changes in the Health Status of Kerala : 1987, 1995
Author/s: Kunhikannan K T and K P.Aravindan
Publication source: KSSP, Kerala, 1999
Year of publication: 1999
States covered: Kerala
Social geography: Rural
Data source: Primary
Type of study: Cross sectional survey
Type of private sector: For profit hospitals.
Issues addressed:Utilization of private and primary health services, costs of care, household expenditure, place of delivery, morbidity,
Objectives: The primary objective of this study was to link the socio-economic and health status of the Kerala State. The study followed up a sample of households surveyed in 1987 and conducted a repeat survey of their health and socio-economic status in 1996. The study was undertaken by the Kerala Sastra Sahitya Parishad (KSSP). (Refer Kannan et al (1987) for findings of the original study).
Methodology: A sample of 8.53% (about 5000 households) of the original households (of 1987) were resurveyed in 1996. The study design was identical to the 1987 study, because the chief objective of this study was to make a comparison of morbidity and health expenditure between these two study periods. Thus the data constitutes a panel and was close to a sequential cohort database. A structured questionnaire was used to collect household information. Volunteers were trained in seven centers (one center for two districts) in one-day training camps. The study also accounted for inflation in prices over the 10 year period, at a compound rate of 10% per year. The cut-off levels for categorizing income into four groups in 1996 were Rs.236, Rs.448, and Rs.590, compared to Rs.100, Rs.190 and Rs.250, respectively, in 1987. All the districts in the state were represented in proportion to the population.
Findings and conclusions: The proportion of the poor declined from 63% to 49.5% of the population. The poorest class decreased from 15% to 7% during the 10-year period. Significant improvement in housing and sanitation were also seen: Thatched houses decreased from 32% to 14% with concomitant increase in the tile and concrete roofing. The practice of open defecation declined from 51% to 28%, and 70% of the houses had latrines in 1996 compared to 48% in 1987. Access to safe drinking water: Families with their own well and house pipe rose from 57% to 70% during 1987-1996. Access to public taps fell from 8.5% to 7.5%.
Cardiovascular events, cancer, accidents, and suicides continue to be the leading causes of death (as in 1987). The overall morbidity rate for acute disease was 121.9 per 1000 population. The rate for chronic diseases was 115 per 1000. A two-week recall period was used for this survey. Though both acute and chronic diseases registered a reduction of 41% and 17%, respectively, the proportion of non-communicable diseases increased in 1996. But the acute morbidity pattern across socio-economic classes was the same in 1996 as in 1987. About 58% of the total acute morbidity was contributed by communicable diseases and 42% by non-communicable diseases. Among the disabled, the number of people with mental retardation increased from 210 (1987) to 244 (1996) per 100, 000 population. Blindness declined from 208 to About 80% of the people seek care from the modern medical system. The study did not look into the reasons for this continuing pattern. About 63% of the people seek care from the private health sector, 30% seek care from the government sector. Nearly 10% depend on self-care first before going to either private or public hospitals.
Institutional deliveries accounted for 97% all deliveries. In 1987, it was 78%. The proportion of deliveries made in private hospitals increased from 42% in 1987 to 58% in 1997, whereas, government hospitals accounted for only 39% (in 1996), just 2% more than its coverage in 1987. Caesarean deliveries went up from 12% in 1987 to 21.4% in 1996. This was a rural sample. If the urban sample was included, the figure would be higher. The average expenses for a delivery in a government hospital were Rs.2025. It was Rs.2870 in a private hospital. In private hospitals, the average expense for a normal delivery was Rs.2456, while for a caesarean delivery it was Rs.4944. In the case of a government hospital, it was Rs1670 and Rs.2864, respectively. Surprisingly, c-sections form a greater proportion of total deliveries in government hospitals (30%) than in private hospitals (17%). The major shift to c-section has taken place in the government sector. More than 80% of people know about the existence of PHCs, but only about 40% of rural population attends them. Lack of medicine and long distances were the two main reasons for the low utilization of PHCs. About 75% of the people reported that health workers from PHCs had not visited their house in the preceding one month.
The survey collected information about medical expenditure incurred during the fortnight prior to the study. The medical expenditure per morbid person per episode increased from Rs.16.5 to R.165.2 during the decade, an increase of nearly 900%. The per capita medical expenditure rose from Rs.88.92 to R.548.8 during the period, an increase of about 520%. After accounting for inflation (at 10% per year), the per capita medical expenditure still showed an increase of nearly 400% over the decade. This explosive increase was not confined to medicine alone. The period witnessed a big increase in doctors' fees, laboratory charges, etc. This phenomenon, (called mediflation) also affected other systems of medicine, although not to the same extent. It is important to note that the difference in expenditure in private and government sectors was not significant.
The most important "disturbing fact" arising from this study, according to the authors, is that the impact of mediflation was most severe in the lower socio-economic groups: While the rise in per capita medical expenditure in the study period is 326% in socio-economic groups (3 and 4, these are better off groups), it is 768% in SES I (the poorest group) and a whopping 1002% in SES 2. Similarly, the ratio of annual per capita medical expenditure to the per capita income shows a very uneven distribution across the social groups. In the richest segment, this ratio as percentage was 2.18 in 1987 and 2.44 in 1966, whereas in the poorest it rose from 7.18% to an almost unbelievable figure of 39.63%. In SES 2, the medical expenditure is 16.11% of the income. This has led many people to indebtedness in rural and urban areas. In absolute terms, the poor are spending as much as the richest on medical care. This has occurred in a period of remarkable decline in morbidity.
20. Characteristics and Structure of Private Hospital Sector in Urban India: a study of Madras city
Author/s: Muraleedharan V R
Publication source: Small Applied Area Research Paper 5, Bethesda, MD: Partnership for Health Reform Project, Abt Associates Inc.
Year of publication: 1999
States covered: Tamil Nadu
Social geography: Urban
Data source: Primary
Type of study: Cross sectional primary survey and policy paper.
Type of private sector: For profit, small and medium private hospitals, private consultants.
Issues addressed:Prices of private care, provider payment mechanisms, personnel issues, incentives and disincentives, government policy
Objectives: The objectives of the study were to analyze the size and geographical distribution of private hospitals in Madras city. Study the extent of infrastructural facilities provided in these hospitals. Study the range of specialty services offered, their organizational features, personnel employed, their work- load, utilization and pricing of selected services. Assess the various payment/incentive schemes prevalent in various private hospitals and identify strategies for improving the performance and accessibility of the private hospital market.
Methodology: The study covered a sample of 73 private hospitals from various zones of Madras city (now known as Chennai City, capital of Tamil Nadu state). The number of beds in all except a few hospitals was between 10 and 50. The study also involved in-depth discussions with 30 physicians from various private hospitals. This study excludes both corporate public limited hospitals and Trust (not-for-profit) hospitals. The study focused primarily on maternity care services, although details of other services were also collected. Two specific survey instruments were used for data collection: One was a structured questionnaire used by a field investigators to collect original data directly from hospitals. The other instrument was a set of questions used for conducting personal interviews with physicians on payment methods prevailing in various hospitals. The details of these two questionnaires are summarized below.
Survey Instrument I collected the following information from private hospitals. This was a structured questionnaire consisting of 50 questions divided into 4 parts. Part I concerned background information on hospitals (such as nature of organization, range of specialties offered). Part II concerned information on infrastructural facilities (such as water supply, power supply, drainage connection etc). Part III concerned hospital personnel (including physicians' profile, their consulting hours, strength of other personnel). Part IV concerned information specific to maternity services, in addition to information on charges for a number of diagnostic and minor procedures (many of which relate to maternity care).
Survey Instrument 2 (to collect information from physicians on fee payment method and nature of relationship with hospitals). Physicians were asked to describe the method of fee payment they adopted and whether they had any agreed basis for sharing their fees with hospitals they visit as consultants. During interviews, data on physicians' professional qualifications, years of service, names of hospitals where they do consulting etc. was also collected.
Findings and conclusions: The city of Madras (recently renamed as "Chennai") has close to 400 private hospitals, for a population of nearly 8 million people including the suburban areas. Individual physicians own most private hospitals. There are only 6 Corporate Public Limited Hospitals (which are listed in the stock markets). The average size of private hospitals in the city is around 30, and there are many with fewer than 10 beds located in various parts of the city. Broadly, one can say that the private/public ratio of beds in the city is about 48 percent / 52 percent. The private hospitals sector in India has grown passively over the years, without any kind of state policy directing its growth and development. As a result, the private hospitals have had no incentive to follow any norms either with regard to physical infrastructures (space per bed, provision of certain utilities such as drinking water, drainage facilities, elevators, back-up power etc) and staffing pattern. For example, there are no common norms for setting up an Intensive Care Unit, as a result there is a vast variation in provision of ICU facilities across private hospitals. The study has shown that on a number of accounts there is prima facie evidence for policy makers to worry about the quality and quantum of physical infrastructure available for good patient care in private hospitals.
In Tamil Nadu, as in many other states in India, it is common for government doctors to work as consultants in private hospitals. This is more common in large urban areas. Also, there is a complex network of arrangements between these private hospitals and physicians, and with local diagnostic centers. These diagnostics centers may be independent (stand-alone type) or may be attached to larger private hospitals. It would be worthwhile to conduct a separate study on the nature of relationship between them, as they are likely to influence their financial performance for mutual benefits since most payments are made out of pocket on a fee-for-services basis. While it is difficult to provide an accurate analysis of the competition and market strategies amongst private hospitals in Madras city, it is not altogether impossible to say anything in this respect. Out study indicates a strong presence of non-price competition among private hospitals in Madras City.
The study concludes with a number of issues of policy concern and also suggests certain policy options. One of them concerns the issue of regulation. Who should regulate the private hospitals, what should be regulated and to what extent, and by what process should governing be carried out? These three questions are constantly raised by the private hospitals whenever the issues of regulation and standards are discussed with them. The study has provided some basic data showing the prevailing practice on a number of physical facilities and staffing pattern in private hospitals for policy makers to make a beginning. Given that public sector physicians are in demand in many private hospitals, it is necessary to think of policies that would be beneficial to both private and public health sectors. One possible policy could be to identify specialties in high demand from private sector and develop specific measures to moderate their practice. Additional components of this policy could include: (a) public sector physicians may be asked to share his/her fees with government since he/she is allowed to practice in private hospitals and (b) limit the number of public sector physicians that could be allowed to practice in a private hospitals based on some mutually agreed criteria. Another possible but less realistic policy option is to ban private practice of public sector physicians, which will be met with intense resistance from the medical community and perhaps some other influential groups close to policy makers. The latter policy option would achieve, if it could be enforced, one definite result: The government doctors during office hours will not practise in private premises. But, whether or not that would ensure substantial improvement in the provision of care within government premises during those hours is a moot question.
The study has shown that the current payment system has an incentive for physicians to over-provide care depending upon patients' ability to pay. The relevant policy issue would be to address how far such over-provision could be contained. The study argues that while it is difficult to implement such policies, it cannot be allowed to persist and therefore policy makers must give adequate legal protection to the indigent and medically needy patients who could otherwise be a victim of over-or under- treatment. Several policy options can be put forward to promote a health growth of private hospitals market in urban India, but they must be acceptable by those who represent it. Much of what can be done depends on how providers perceive the current scenario in the market. Most physicians and hospitals expressed concern over the 'intense competition' in the market, and how as a result they are not doing well financially. Although it is difficult to prove such impressions one way or another with 'hard data', they cannot be brushed aside as mere concoctions to fool the analysts or policy makers. It is difficult to regulate and moderate the private hospital sector given their past reckless unbridled growth in the past, but some positive initiatives can be made by the Government. The first step in that direction should be in building their own credibility. As a part of this exercise, the state could perhaps create a separate body - which may be called the State Private Health Sector Development Agency - concerned with developmental needs of the private hospitals in the state. The primary aim policies should be to develop a healthy relationship between the private and public health care system in the state.
21. Characteristics of Private Medical Practice in India: A provider perspective
Author/s: Bhat Ramesh
Publication source:Health Policy And Planning; 14(1):26-37, OUP, 1999, London
Year of publication: 1999
States covered: Gujrat
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:Practitioners, Hospitals, Laboratory/investigation, ISM, For profit
Issues addressed: Financing, Quality, Costs,
Objectives: To identify areas of intervention so that the private health sector becomes responsive to the problems of its growth and to understand the views of each stakeholder.
Methodology: A sample of 500 doctors was selected randomly from a list of 2920 doctors registered with the Ahmedabad medical Association {AMA}. A questionnaire was sent to 495 private doctors. 108 doctors responded to the questionnaire. Respondents included both graduates and post-graduates. The mailed questionnaire was followed by an in-depth interview of 22 private doctors selected randomly from the list of 500 doctors. No statistically significant differences were found between the questionnaire responses and the interview results. The questionnaire consisted of a set of closed -ended questions and a few open ended questions which pertained to the operational activities of private practitioners and their opinions regarding cost, quality of care and regulatory mechanisms affecting private medical practice. A number of questions required the ranking of factors to arrive at the most important factor. A 5-point scale was used to rank the factors and the average score was arrived at using the rank information and number of observations.
Findings and conclusions: Around 84% of the respondents {General Physician, Gynecologist, Surgeons and others} experienced growth in their practice. The reasons they gave for was experience of the doctor, availability of specialized skills and technology, accessibility of private medical services, increasing demand for health care, promotion of private medical practice by private practitioners. Fifty percent of providers have a maximum patient load of 26 or more per day. Discussion with the doctor suggested that a doctor could see only 25 patients a day and spend 20 minutes with each patient, which works out to 8 hours a day, that is the maximum time the doctor can work. But the study found out that 45% of the doctors spend less than 15 minutes on each patient so that they are able to see more patients. Fifty percent of the private doctors occasionally referred patients to other specialists. In case of investigations, 56% doctors referred patients frequently to diagnostic facilities. The study indicates that recommendations by physicians are generally based on quality and proximity factors.
The fee setting practices of providers are primarily determined by cost considerations (47%). There is very little influence of professional medical bodies on deciding the fees charged by providers. Only 11% of providers decide on fee on the basis of association recommendations. In leaving fee-setting decisions to the providers, the existing cost inefficiencies considerably influence their decisions. It thus becomes important for the professional medical bodies to evolve some norms and appropriate practices for the provider payment system. Only 59% of the providers indicated that patients ask for a copy of the prescription and diagnosis. About 90% of providers indicate that private practice has become capital intensive. Factors that affect the establishment cost of private facility are location of the clinic, which is mostly in commercial areas, sophisticated equipment and new technology, maintenance of the clinic, manpower and other related costs.
In the present survey, 92% and 5% of the establishments are registered as sole proprietor and partnership firms, respectively, with unlimited liability. The perceived risk of these organizations is generally highest and therefore normal channels of finance are not easily available to them. This affects the capital cost of medical establishments. The survey results indicate that 46% of provider's do not use any borrowings to finance their total capital employed. In these cases, all investments are financed by the owner(s). On the other hand, 35% of the providers used heavy debt to finance their investments. Only about 19% of the providers use moderate levels of debt to finance their capital investments.
Private providers experience shortage of paramedical staff, hence they hire untrained people to man their health care facilities. The providers considered 'cost of hiring' as the second most important problem associated with manpower. Of the providers, 94% consider seasonal fluctuations in patient flow as the most relevant risk factor, 88% of the providers consider cost-recovery as the second risk factor, 79% consider risk arising out of regulations as the third risk factor. According to the private providers interviewed the regulation giving more rights to consumers through the Consumer Protection Act has also increased their risk environment. Prevalence of undesirable practices over prescription of drugs was ranked as the most common malpractice, followed by fee-splitting practices, inadequate measures of disposal of waste and over-prescription of diagnostics. Awareness about private health sector regulations: Around 93% of the providers were aware of the Consumer Protection Act {COPRA}. More than 50% of the providers were familiar with the Indian Medical Council Act, the Medical Council of India Code of Medical Ethics. Providers exhibited low awareness about the drug-related legislations.
The Government and professional medical bodies need to make a concerted effort to address the above mentioned issues in the findings in a holistic manner and develop appropriate strategies to handle the various concerns. The information dissemination role of government and professional bodies, developing and strengthening the institutional mechanisms for a continuing medical education programme, developing appropriate and effective regulations and the development of standards should be given priority. Important implementation issues to address in the future should be: first, prioritisation of issues both within and outside the government, second, the development of institutional mechanisms and management structures within the government and professional medical bodies to address public policy on the private health sector.
22. Contribution of Other Services Sector to Gross Domestic Product in India: An Evaluation
Author/s: Kansal S M
Publication source: Indian Statistical Institute, (published in EPW, Sept, 19, 1992)
Year of publication: 1992
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, For profit
Issues addressed: Financing, Costs, Payment Mechanism, Regulation
Objectives: The study attempts to bring out the disparity in income between different categories of private practitioners, and between doctors
Methodology: A survey of 200 medical practitioners was conducted in Delhi. A questionnaire was canvassed to the medical profession by investigators. Various visits were also made to collect information about charges, either directly from the respondents or indirectly through the patients. The private practitioners were selected on the basis of a stratified random sample. Stratification was done on the basis of zone (area) and qualification of doctors.
Findings and conclusions: The study reveals that the average monthly income of a doctor practicing at a clinic/residence works out to about Rs.29,800 and for a doctor running a nursing home, about Rs.80,000 per month. The ration of expenditure to gross receipts works out to around 18 percent for doctors practicing in clinics and around 25 percent for the nursing home doctors. In terms of qualification, it was found that post-graduates from the gynecology specialization were the maximum earners. In clinics, the net average monthly income was Rs.53,870 and in nursing homes it was Rs.1,03,530. Comparing this income with that of government doctors, it was found that in government service about 84 percent of doctors receive total emoluments below Rs.10,000. In contrast, only 10 percent of private practitioners fall in that category. The condition of privately employed medical personnel is extremely growing as compared to government employees in the same categories.
23. Cost-effectiveness of Public-funded Options for Cataract Surgery in Mysore, India
Author/s: Singh A J, Paul Garner and Katherine Floyd
Publication source: Lancet, Vol 355. January 15, 2000. Pp180-184.
Year of publication: 2000
States covered : Karnataka
Social geography: Rural
Data source: Primary
Type of study: Policy paper; evaluation of interventions
Type of private sector: NGO hospitals.
Issues addressed: Quality of service delivery, government policy, cost-effectiveness
Objectives:This paper assesses the cost-effectiveness of public-funded options for delivering cataract surgery in Mysore, Karnataka state, India.
Methodology: Three types of delivery of cataract surgery were studied: mobile government camps, walk-in services at a state medical college hospital, and patients transported in from satellite clinics to a non-governmental hospital. The article assesses outcomes in a systematic sample of patients operated on in 1996-97 by follow-up at home: average costs by provider derived from actual expenditure during the year.
Findings and conclusions: Almost half the patients operated on in government camps were dissatisfied with the outcome. More than one third were blind in the operated eye. User satisfaction was higher with other providers (medical college hospital 82%); non-government hospital 85% and fewer patients remained blind. Camps were low-cost options, but the poor outcomes reduced their cost-effectiveness to US$97 per patient. The state medical college hospital was least cost-effective, at US$176 per patient, and the non-governmental hospital was the most cost-effective at US$54 per patient. The government of India should review its policy for government camps surgery, and consider alternatives, such as transporting patients to better permanent facilities. India and other developing countries should monitor outcomes in cataract surgery programme, as well as through put.
24. Cost of Health Care
Author/s: Duggal R, Amin S
Publication source: Foundation for Research in Community Health (FRCH), Bombay
Year of publication: 1989
States covered: Maharashtra
Social geography: Urban & Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Utilisation, Financing, Costs, Expenditure
Objectives: To document and critically analyze various aspects of household health expenditure and to evolve a methodology for the study of health expenditure.
Methodology:The study was conducted in six villages of Jalgaon district in Maharashtra and six wards (including two slums) of Jalgaon city. Jalgaon was selected for the study in terms of its socio economic development. A stratified random sampling method was employed to select 1,629 households from both rural and urban areas of Jalgaon City. An interview schedule was administered to the household at three points of time during the year, in order to take into account the seasonality factor. The recall period was 30 days.
Findings and conclusions: The findings of the study showed that the overall monthly prevalence rate was 148.89 illness episodes per 1,000 population, and the incidence rate was 96.56 per 1000 population. Of the acute illnesses 83.45% were treated by the private practitioner / hospital, whereas public facility utilization was only 9.07%. Of these cases, 70% received injections as part for their treatment. The study brought out the fact that the perception of illness depended on the purchasing power and the income level of the people. The lowest class had the highest non-utilization rate, the lowest private facility utilization rate and the highest public facility utilization rate. The per capita annual expenditure incurred by the household on health worked out to Rs.182.49. This was 7.64% of the total consumption expenditure, and 9.78% of the reported income.
25. Critical Condition: A Report on Workers in Delhi's Private Hospitals
Author/s: Workers Solidarity
Publication source: New Delhi
Year of publication: 2000
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Case Study
Type of private sector: Corporate Hospitals Trust Hospitals
Issues addressed: Working conditions, health personnel, costs, private hospitals, subsidies
Objectives: This report examines the status of the permanent as well as the contract workers in Delhi's eight large private and charitable hospitals.
Methodology: Data on the wages, and working conditions of the Class IV employees in these hospitals was obtained through interviews. The data also shows the extent of contractualisation of this category of employees and their poor working conditions. Further,the report examines the extent to which these hospitals comply with conditionalities for receiving subsidies
Findings and conclusions: The study reveals that in all these hospitals there is a difference between the wages of permanent workers and the contract wageworkers. In the older thrust hospitals, the proportion of permanent workers is higher than contract workers. However, in the more recently established ones, the proportion of contract workers is higher. This report gives an insight into the poor working conditions of contracted employees who often work without adequate rest in addition to insecure working conditions. This report shows that none of the 'for profit' and 'non profit' hospitals honour the conditionalities of the government which stipulates that a certain proportion of beds be earmarked for treating poor patients free of cost. This study shows how the large private hospitals cut their costs by engaging employees at low wages and poor working conditions, which will definitely have an adverse impact on the quality of care provided. In addition, the lack of adherence to conditionalities is a serious area of concern, which the government should address.
26. Diarrhoea in Rural India, A Nationwide Study of Mothers & Practitioners, All India Summary
Author/s: Viswanathan H, Rohde J E
Publication source: Indian Market Research Bureau, UNICEF, New Delhi
Year of publication: 1990
States covered: National
Social geography: Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Nonqualified practitioners, rural doctors,
Issues addressed: Utilisation, Quality, Regulation
Objectives: The study aims to understand and document the range and diversity of KAP regarding diarrhoea across India.
Methodology: There was a two-stage research design : a qualitative exploratory stage followed by a quantitative assessment stage. In the qualitative stage, two villages per representative district from each of the 35 socio-cultural regions of India were selected and two focus group discussions with mothers of children under five per village held. In addition, there were four in-depth interviews with mothers whose children had current diarrhoea, eight depth interviews of health practitioners, including PHC/ICDS frontline workers, and four in-depth interviews among medical retailers per region. In the quantitative stage, by stratified random sampling, there were 144 focus groups with mothers, 61 interviews with mothers of children with diarrhoea, 256 depth interviews with health providers, 136 depth interviews with retailers, and interviews with 9.927 mothers of under fives in 408 villages. Also 12-15 rural doctors, within 10 km distance of five small towns per state, were purposively selected, and interviewed a total of 266. A salt-to-taste study was done to test if the sodium concentration of fluids prepared by salt-to-taste technique fell into acceptable limits: 20 mothers of children under three per village, from 3-4 villages around three towns each, were selected purposively from three states.
Findings and conclusions: Period prevalence of common illness among under fives was estimated. Mothers appeared to have a casual attitude to normal diarrhoea, though health practitioners had a more cautious approach. Though a majority of mothers had contacted doctors, most of them were unaware of the signs and symptoms of dehydration. The causes of childhood diarrhoea was believed to be related to food, the physical condition of the child, climatic conditions and, to a lesser extent, supernatural forces. Though breast-feeding was continued, and withholding nourishment was not commonly noticed, a considerable number of women reduced quantity and frequency of food given. Education had a strong correlation to both knowledge and practices. 83% had sought help from private practitioners, and only 7.5% from government health centres. Of the 266 rural doctors interviewed, only eight were MBBS, 62% had no medical qualifications, and 61% practiced more than one type of medicine. It was estimated that the number of non-qualified rural medical practitioners at 1 million almost all were solo practitioners located in clinics. Though 60% were aware of ORS, it was used generally secondary to medicines. Only 2% of the recent episodes were prescribed ORS and only 2% of mothers had used ORS for a recent episode, while 17% were aware of it. There was discordance between states with the highest awareness and those with highest usage.
27. Disease Surveillance at District Level: A Model for Developing Countries
Author/s: Jacob John, Reuben Samuel, Vinohar Balraj and Rohan John
Publication source: The Lancet. Vol. 352. July 4, 1999. Pp.58-61.
Year of publication: 1999
States covered: Tamil Nadu
Social geography: Rural
Data source: Primary
Type of study: Policy paper.
Type of private sector: Solo and small hospitals and nursing homes.
Issues addressed:Disease surveillance system, partnership between private and public systems, monitoring and evaluation of programs.
Objectives: This paper describes a vaccine-preventable disease surveillance system that was developed in North Arcot District (Tamil Nadu). This model disease-surveillance system (called the NADHI, meaning river in Tamil) was developed in late 1980s for a project to control poliomyelitis. The model later expanded its scope.
Methodology: This system combines government and private sectors, with every hospital enrolled and participating. Reports were scanned daily on a computer for any clustering of cases. Interventions included investigations, immunization, antimicrobial treatment, health education and physical rehabilitation of children with paralysis.
Findings and conclusions: All vaccine-preventable diseases have declined markedly, whilst malaria and HIV infections have increased steadily. The annual expense was less than one US cent per head. The reasons for the success and sustainability of this model include simplicity of reporting procedure, low budget, private-sector participation, personal rapport with people in the network, regular feedback of information through a monthly bulletin, and the visible interventions consequent upon reporting. The author argues that this district-level disease surveillance model is replicable in developing countries for evaluating polio eradication efforts, monitoring immunization program, detecting outbreaks of old or new diseases and for evaluating control measures.
28. Determinants of Access to and Utilization of Health Care Services in Kerala
Author/s: Shenoy K T
Publication source: Clinical Epidemiology Resource and Training Centre, Medical College, Thiruvananthapuram, June 1999
Year of publication: 1999
States covered: Kerala
Social geography: Rural and Urban
Data source: Primary
Type of study: Cross-sectional survey
Tye of private sector: For Profit hospitals
Issues addressed: Utilization of private services, morbidity pattern and expenditure
Objectives: To study the utilization pattern and factors determining the utilization of private and public health care services, and patterns of expenditure.
Methodology: 1001 households (504 from rural and 497 from urban areas) from 5 the panchayats of Thiruvananthapuram, district were studied using multistage cluster sampling and the subjects were evaluated. Data on the following variables was collected: Socio-economic status, demographic status, morbidity in the past one month, access to and utilization of private and public health care services. Data on pattern of severity of illnesses, distance traveled to seek care and expenditure incurred were also collected. The data was analyzed using univariate and multi-variate logistic regression methods.
Findings and conclusions: Out of 2237 participants with morbidity in the past one month, 1552 utilized health care services (private 1044 and public 508). Logistic regression showed that people in the age group 45-49 were significantly less likely to use private services compared to adults in the age group 14-44 years. The lower socio-economic groups were significantly less likely to use private services than higher SE groups. The urban subjects were significantly less likely to use private services than rural subjects. Patients with chronic illness were significantly less likely to use private services compared to those with acute illness. Patients who traveled long distance (more than 5 km) were significantly less likely to use private services compared to those who traveled less distance, Private services are more used than the public services. Strategies to improve public health care services need to be planned for better access and utilization.
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