1. Earnings in Private General Practice: An Exploratory Study in Bombay

Author/s: George Alex
Publication source: Medico Friend Circle Bulletin 173-174, July/August, 1991
Year of publication: 1991
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, For profit,
Issues addressed: Financing, Costs, Incentives, Regulation,

Objectives:
The study aims to understand the type and nature of medical practice in a city, to evaluate the cost of private medical practice and to document details of expenditure on privately purchased medicines.

Methodology:
The study was carried out in the city of Bombay. A sample of 45 general practitioners and their patients (1 to 5 patients of each practitioner) were selected for the study. The practitioners, selected for the study were from different localities such as rich areas, middle class localities and working class areas. It included doctors, practicing on main roads as well as those practicing in the inner lanes. The researchers visited the doctors and asked them about their earnings and expenditure. Out of 45 doctors, 33 responded giving a response rate of 73.33%. The patients of the doctors interviewed were also interviewed to get information regarding the fees, prescriptions, diagnosis etc.

Findings and conclusions:
The study revealed that 30.33% of the doctors interviewed had 6 to 10 years of experience of private practice and put in 43 hours of work during the week. The mainstay of their income for nearly 66% of the doctor came from their clinics. Fifty-four of the doctors have their own clinics. The average number of patients attended by them per month, were 945. The average investment needed for setting up the clinic was Rs.85000. They were earning an average monthly income of 17,675 rupees because of the service charges and medicines. The income from injections amounted to Rs. 5,466 constituting 29.82 percent of the net income. The consultation fee mostly was merged with the medicine charges. The average net income of the doctors, after deducting expenditures such as drug cost, maintenance charges, attendant's salaries. etc amounted to Rs. 18,332.88. The doctors never disclosed their real income. It was much higher than what was told to the researchers. The expenditure of the doctors constituted only 17.95% of their total income. The major chunk of the expenditure was due to the drug cost, which was around 65% of the total expenditure. Though the doctors were not supposed to earn profit on the medicines dispensed by them, the reality was exactly the opposite. The study has revealed that medical profession is one of the best-paid professions, assuring an average net income of above Rs.16,000/-. Since the doctors earn such a huge amount from the society, they should be made socially accountable. The people have begun to suspect the medical ethics of the private practitioners as more and more evidences of malpractices are coming to light. This has made the regulation of the private practitioners necessary for the betterment of the society.

2. Economic Impact of Tuberculosis on Patients and Family

Author/s: Balambal, R. Jaggarajamma, K. Rahman, Fathima. Chandrasekaran, V. Ramanathan, U And Thomas, A
Publication source: Tuberculosis Research Centre, ICMR, Chennai
of publication: 1997
States covered: Tamil Nadu
Social geography: Rural and Urban
source: Primary
of study: Cross sectional survey.
Type of private sector: For profit hospitals, individual general practitioners (and government hospitals)
Issues addressed: Household expenditure, direct and indirect expenditure on rural and urban patients, impact on school going and pre-school children of TB patients.

Objectives: The study aims to (a) estimate the total costs attributable to TB on patients and their families, (b) gender differentials in their economic impacts and (c) the consequences on other family members, especially children of TB patients.

Methodology:Seventeen focus-group discussions with TB patients were conducted. A total of 304 TB patients (of which 153 were in rural and 151 in urban areas) were studied. Female patients formed 120 of the total. Both qualitative and quantitative data were collected on social and economic status, demographic aspects, employment status, assets, debts of patients and families, expenditure incurred towards illness, and effects of illness on TB patients.

Findings and conclusions: Participants perceived TB caused significant economic loss. The direct costs observed were Rs.1443/-. There was no gender differential. But urban patients had higher direct cost (Rs.1570/-) than those of rural patients (Rs.1338/-). Patients going to private facilities spent 8 times more than those going to General Hospitals or an NGO hospital. Direct medical expenditure for consultation was Rs.613/-, for investigations Rs.149/- and for drugs Rs.591/-. The direct expenditure was least for patients going to General Hospitals, 1.5 times more for those attending NGO hospitals and 5 times more for those going to private hospitals. The average non-medical costs (Rs.353/-) were more or less the same for all patients, irrespective of type of facilities. The average indirect cost for those employed was Rs. 3663/- per patient, irrespective of type of facilities. The rural patients had an average indirect cost of Rs.3610, whereas urban patients suffered an indirect cost of Rs.4100/-. The average workdays lost were 83-82 for males and 85 for females. Out of 83 days, 48 were lost during pre-treatment period and the remaining during treatment period. Thus there was a diagnostic delay of nearly 6 weeks. The working days lost were maximum for the elderly rural illiterates (111 days) and least for young rural patients (15 to 25 days). There was no relationship between the loss of workdays and the type of occupation or the type of health facility attended. The total cost for "shopping for diagnosis", treatment and indirect cost was Rs.3469/-. This was 1.2 times more among urban patients compared to rural patients. The average debts incurred by TB patients were Rs.2079/-. Urban patients had much higher debts than rural patients. A significant number of patients (69% in rural and 67% in urban areas) expressed mental agony arising out of economic impact and lack of attention by family members. The impact on children was significant: more than 50% of patients expressed their inability to attend to the needs of their children. About 12% of children discontinued studies and another 8% took up employment to support the family. Most of them were children of male patients. Most female patients avoid discussing their illness with neighbours. Illness reduced their activities by at least 30% in urban areas and more than 35% in rural areas.

The study concludes that there is need to reduce the direct and indirect costs on patients attending government facilities. This study could not capture cost borne by providers. There is need to carry out such studies. The RNTCP should take measures for early diagnosis of TB. The current delay of nearly 6 weeks in diagnosis is too long. Also, reducing shopping for delay will reduce indirect costs of care substantially. There is also a need to study the impact on pre-school children of TB patients. Policy measures are required to attend to the needs of their children.

3. Efficacy of Private Hospitals and the Central Government Health Scheme: Study of Hyderabad and Chennai

Author/s: Baru R. Purohit, B. and Daniel, Kumar
Publication source: Administrative Staff College of India, Hyderabad
Year of publication: 1999
States covered: Andhra Pradesh, Tamilnadu
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Corporate, Trust Hospitals and Nursing Homes.
Issue addressed: Organization of Private Sector; Cost of Care; Consumer Issues

Objectives:
The overall objective of the study was to look at the efficacy of the CGHS and private hospitals in Chennai and Hyderabad. In order to address this overall objective the age, sex and nature of ailment and treatment were analyzed for all CGHS beneficiaries undergoing treatment in the recognized private hospitals. An effort was made to arrive at costs of specific interventions across types of hospitals in the two cities. In addition select case studies of beneficiaries were used to explore their experiences with the scheme.

Methodology: An analysis of all CGHS beneficiaries treated in the recognized private nursing homes and hospitals from Chennai and Hyderabad was carried out for getting insights into the age/sex distribution; nature of ailment treated; the number of days hospitalised and the cost of treatment. In addition, indepth interviews were done with the three major stakeholders viz. the beneficiaries, the CGHS officials and the owners of private hospitals.

Findings and conclusions: The study finds that many more corporate hospitals are recognized by the CGHS in Hyderabad than in Chennai. For several conditions, there is variability in costs for specific interventions like appendectomy, caesarian sections, deliveries and cataract surgeries across the different types of hospitals. On an average the cost of intervention is twice or three times in a corporate hospital compared to a trust or a single owner enterprise. The study also reveals that the hospitals do not adhere to th government package rates but infact charge the CGHS beneficiaries according to the market rates. This clearly defeats the purpose of a public insurance scheme. The study also points to the loopholes in the working of the scheme and the problems of a public insurance scheme in an unregulated private medical care sector. This study points to the variation in the costs for medical interventions and also to the fact that the difference in cost is borne by the patient. It also shows that the hospitals do not maintain the necessary records and there seems to be a lack of transparency in the process of recognition, billing and referrals from the CGHS to the private hospitals. There is dissatisfaction on the part of consumers regarding the functioning of dispensaries, the availability and quality of drugs provided and the indifferent treatment by some of the private hospitals.

4. Employee Medical Benefits in the Corporate Sector

Author/s: Duggal R
Publication source: Foundation for Research in Community Health, Mumbai
Year of publication: 1993
States covered:
National
Social geography: Urban & Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, Financial Institutions
Issues addressed: Financing, Prices, Organisaion

Objectives: To document and analyse the medical benefits provided to employees of public as well as private sector companies.

Methodology: Out of a total of 1872 companies having a sales turnover of more than Rs. 50 million, 775 companies were randomly selected from the Center For Monitoring Indian Economy's data on larger industrial units. Mailed questionnaires were sent to 641 companies. The researchers decided to visit the remaining 134 companies, anticipating a high non-response rate. Response to the mailed questionnaire was very poor. Only 75 completed questionnaires constituting a response rate of 12% were received. Out of 134 companies visited, 59 responded giving a response rate of 44%.

Findings and conclusions: The details of statutory benefits (compensation paid due to deaths or injuries, maternity benefits, the benefits paid under the mine labor welfare fund, ESI scheme) were not provided by most of the private companies. They were often merged into total medical benefits. Only a few employees were covered under the Employee State Insurance Scheme. This was due to the fact that ESIC benefits are paid only to those workers whose incomes are below rupees 1600 per month. In the sample, the mean income per employee was Rupees 2445, which was much higher than the minimum limit for the ESIC. Most of the companies were paying claims against bills with upper limits. The percentage of the private sector companies paying for such claims was 61%. In the public sector, the percentage was 77%. Thirty seven percent of the companies had owned hospitals or clinics, while 27% of the companies were paying compensation through the group insurance scheme. Lump sum payments were made by 15% of the companies. In the case of lump sum scheme, 6% of the public sector and 12% of the private sector companies paid the benefits where as 4% of the public sector and 11% of the private sector companies paid benefits under the group insurance scheme. The pattern also diferred for the managerial staff and workers. The total medical care and related expenditure was 755.53 million rupees. That is 5.64 million per company and 1648.58 per employee per year. If the average family size is assumed to be 4.5 persons per family then the expenditure by the corporate sector comes to Rs. 366 per capita per year. There was a major difference in the public and private sector in the medical care expenditure. On an average, a public sector company paid 13.56 million rupees per year as against 3.25 million paid by the private sector. This amounted to Rs. 2251.10 per employee per annum for the public sector as against Rs 1225.46 per year for the private sector.

The study has concluded that the medical benefits given by the employers were supplementary to the wages and were meager. The system hardly provided total relief to the employees. The workers were benefited only when the company owned a clinic or a hospital facility. The working class has to review this situation and reform its demands and policies because in pursuit of their demands regarding the employment and wage rights, they have neglected social security issues. They are important for the long-term stability and only with their establishment as a right can the struggle of the working class get extended to the large unorganized sector.

5. Factors Affecting Health Seeking And Utilization of Curative Health Care

Author/s: Chirmule Deepti, Anuradha Gupte
Publication source: Bharatiya Agro Industries Foundation, Pune
Year of publication: 1997
States covered: Gujarat, Maharashtra, Karnataka, Uttar Pradesh, Rajasthan
Social geography: 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: Utiilisation, Expenditure, Quality

Objectives:
To identify the factors influencing decisions regarding the type of health services to be used. To study the preferences of the people regarding the choice of health care provider in relation to their socio economic background. To identify necessary interventions for increasing the reach of health services to the poor people.

Methodology:
The study was conducted in the rural areas of five major states namely Gujarat (Dist. Valsad), Maharashtra (Dist. Ahmednagar), Karnataka (Dist. Dharwad), Uttar Pradesh (Dist. Allahabad) and Rajasthan (Dist.Bhilwada). Data was collected from three thousand households from each of the study areas. For Data collection, an interview schedule was prepared, which contained questions related to the demographic information, socio economic status of the household, morbidity in the previous week, morbidity for specific ailments and type of treatment sought by the people. In addition to the probing list, qualitative information, focusing on health culture of the area and health seeking behaviour was also collected. Anthropologists who resided in the study areas collected the qualitative information. The probing lists or the interview schedules contained questions on morbidity in the household during the week preceding the study.

Findings and conclusions: The study has revealed that in Gandevi district of Gujarat, out of 14464 people, 261 were sick. In Akole District, Maharashtra, the number was 756, where as 487 people in Laila district reported sickness. Fevers and coughs were the most common complaints. Private modern health care services were the popular choice in Gamdevi (Gujarat) and Akole (Maharashtra) constituting 73% and 66.4% where as in Laila, Rajasthan only 9.2% of people sought private health care. Here home remedies were very popular, as 58% of people sought their help. Less than 100 patients from all the areas sought help from the ANMs. Only in Laila (Rajasthan) 3.5% of the people were found to seek treatment from the ANMs. During the study period, there was large-scale prevalence of typhoid in all the villages of Laila district. There it was known as Nikhalo or Miyadi bukhar. But people were treated at home with dietary restrictions and ashes (vibhuti) given by a local healer. This was due to the superstition of the people that the fever was a result of the wrath of the goddess. Since the healer was believed to be the incarnation of the goddess, people often went to him. The government health services were not popular on account of longer waiting period, arrogant behaviour and attitudes of the doctors and non-availability of medicines. In Karchana district (Uttar Pradesh) only 16% of the people used the PHC services. This was the lowest in all districts under study. Several Registered Medical Practitioners were found to be practicing in the study area. Though law has stopped the practice of RMPs, people still preferred going to them since they were easily accessible and often worked on credit. Most of them were from the same community. In Karchana district of Uttar Pradesh they were popularly called 'Zola chaps' since they carried their Zola of medicines with them. The excessive use of injections was the characteristic of these practitioners., One of the reasons of their popularity was that they treated their patients with injections. Since most of the people were on daily wages, they could not afford to stay at home during sickness and thus often insisted on injections.

The utilization of health services was linked with their affordability. People with incomes higher than Rs.10, 000/- preferred seeking private treatment. where as people with lower assets or no assets preferred not to take any treatment or resorted to the PHC facilities. Caste was an important factor in determining the choice of treatment. In Gujarat, 825 of the people from dominant castes sought private treatment while for the higher classes the percentage was 100% and65% of the schedule caste people sought treatment from private practitioners. However no treatment was dependent on caste.

The study concluded that the utilization pattern of health services is determined by many factors such as cost, quality of services, their availability, etc. However quality of services play a dominant role in people's decision about seeking medical help. The study shows that due to the inefficiency of the Public Health Centres people prefer seeking treatment from private practitioners. For example, in Laila (Rajasthan), people did not have any choice but to go to the private practitioners or to seek home remedies since the health infrastructure was not well developed. Economic factors such as poverty restricted the people from having modern scientific health care. Another fact is that there is no gender bias as far as the morbidity or treatment seeking behaviour is concerned. Factors such as caste class etc. are still dominant and are important in determining the type of health care sought.

The first thing that needs to be done is the improvement of the PHC structure. Curative capacities of the PHCs should be enhanced by ensuring adequate supply of medicines and proper training of the personnel. The private practitioners must update their knowledge through continued Medical Education. The private practitioners should be brought under regulation. Doctors of other systems should also be incorporated into the health system along with doctors practicing modern scientific medicine. This can be done through training and education of the practitioners. Poverty is one of the most important reasons for the limited access to the health care facilities. Thus, efforts should be made to improve the overall economic condition through the pursuance of rural education. This will have a positive impact on people's health seeking behaviour. The health infrastructure should be developed in such a way that it would suit the local conditions and would cater to local health needs. The priority of development action should be the development of the relevant health infrastructure.

6. Factors Determining Health of Home-Based Women Weavers - A Case Study of Karur

Author/s: Vijaya S
Publication source: Unpublished M.Phil Dissertation, Jawaharlal Nehru University, 1997.
Year of publication: 1997
States covered: Tamil Nadu
Social geography: Rural,
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Private Practitioners; Chemists, Private Hospitals
Issues addressed: Utilization of Private Sector; High Cost of Care.

Objectives
: The overall objective of this study was to get an insight into the influence of socio-economic factors on the health of home-based women weavers. As a part of this study, a specific objective sought to study the perceptions of these workers towards health services and its utilization.

Methodology:
The study was conducted among women weavers in Karur district in Tamil Nadu. These twenty-five indepth case studies have explored the different aspects of women weavers' lives and work.

Findings and conclusions:
With respect to utilization of services, the type of treatment sought is dependent upon the severity of the illness. For minor ailments like fever, headache, stomach ache etc, treatment is through self-medication on the advice of elders. Sometimes tablets advertised on TV and radio such as Anacin, Metacin, Dolopar, Ibuprofen are bought from pharmacists. Sometimes pharmacists are consulted for prescriptions as well. When the illness really interferes with their work and affects their earnings, they go to the government hospital or to the private clinics. However, because of long waiting time in the government hospitals, they prefer private hospitals for treatment. Despite the difficulties and problems with the government hospitals, 70% depend on them largely because they are unable to afford the cost of private health care for each episode of illness. The study reveals that one third of their earnings is spent on food and a major chunk of 15-20% is spent on medical expenses, which include direct and indirect costs. The absence of social security measures such as maternity benefits, sick leave, workmen compensation and medical care, compounds the problem further. This study once again shows the constraints of resorting to private health care for this section of workers.

7. Financing for Primary Health Care: Sevagram (India). Experiences from Voluntary Sector

Author/s: Jajoo U.M
Publication source: MFC Bulletin 177-178, Nov / Dec, 1991
Year of publication: 1991
States covered: Maharashtra
Social geography: Rural
Data source: Primary
Type of study: Case Study
Type of private sector: Hospitals,
Issues addressed: Financing, payment mechansims, Incentives, Insurance

Objectives:
The following alternative was carried out by a voluntary sector hospital in Sewagram, Wardha in Maharashtra to provide health insurance for the rural population. The insurance scheme was evolved by the Kasturba hospital to finance the provision of health care facilities to the poor.

Methodology:
The hospital provides both indoor and door step medical care to the villages in the vicinity. The system has all the characteristics of a people oriented system such as accountability, acceptability, and affordability. Kasturba hospital at Sewagram is a 501 bedded hospital attached to a medical college. A private trust 'Kasturba Health society' runs the hospital and the college. The trust shares 25% of the total expenditure while 75% of the expenditure comes from the state and central government. The contributions to the scheme are made in kind in the form of grain such as Jowar-Sorgam at the harvest time. This is because payment in this form is easier for the villagers. The grain collected forms the village fund, which is utilized to support the health program. The grain is collected as per the capacity to pay principle. The payment from the lowest income group is 8 payali of Jowar-Sorgam per family per year and from a landowner it is additional 2 payalis per acre. The 8 Payalis of Jowar-Sorgam is equivalent to Rs. 16 at market price. Those who do not contribute to the fund are omitted from the scheme for that particular year. The village fund covers the cost of drugs, mobile transportation team and the balance goes to the payment of the VHW. The hospital adopts the village only if 75% or more people from the village agree upon having such a system in the village. In case of drop in the membership the project people review the situation and take corrective action. Some times due to the political differences with in the village the membership drops. It might lead to closure of the scheme. But such incidences only help in making the people understand the importance of scheme.

Findings and conclusions:
The hospital offers free indoor treatment for the unexpected illness to a person who is part of the scheme. For the expected health related episodes 75% subsidy is provided. The non-members are also allowed to avail themselves of the hospital facilities but only at full charges. Community health workers are the main providers of preventive and symptomatic drug treatment. They work with the help of the visiting health team members. They also make the referrals to the hospital. ANM and the social worker organise the visits for vaccination and Maternal and Child health program. The doctor incharge has the role of supervision, coordination of village meetings and education. The Gram Sabha meets every year before the Jowar collection. The doctor in charge, Social worker, ANM and the VHW, attends the meeting. The villagers discuss among themselves, the performance of the health services and what is required to be done. Over 75% of the people have registered themselves to the scheme. The vaccine preventable diseases such as measles, poliomyelitsis etc. are in control in the area covered by the scheme. The villagers have become aware of the services they get since they pay for it. Since the health team has gained credibility over the years, their advice is often sought by the villagers in other related issues, such as irrigation, dairy development, etc. The insurance scheme at Sevagram is based on the principle of capacity to pay and has proved to be extremely successful. It is people oriented and has provided an alternative mechanism of health financing.

8. Health, Households & Women's Lives: A Study of Illness and Childbearing Among Women in Nasik District, Maharashtra

Author/s: Madhiwalla Neha, Sunil Nandraj, Roopashri Sinha
Publication source: Centre for Enquiry into Health & Allied Themes (CEHAT), Mumbai
Year of publication: 1999
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
Issues addressed: Utilisation, Financing, Costs, Expenditure

Objectives: To determine differences in morbidity, utilisation of health care services and expenditure on health care based on differences in the social position of women (in the context of age, marital status, caste, class and the position of the women in the household).

Methodology:
The study covered 1193 households in rural areas of Igatpuri taluka (817 households) and the city of Nashik (366 households). These households were drawn from 13 villages and five urban clusters. There were 7212 individuals in these households, of whom 3631 were males and 3581 were female. An interview schedule was administered to each household, which elicited information on the profile of the individuals and the household, the illness suffered by any member of the household in the past month and the health care utilisation and expenditure incurred. Data was also collected information on all maternity events (pregnancy, delivery and abortion) in the past year and the use of contraception. The interview schedule was administered to the women of the household above the age of 12 ears. An attempt was made to make the methodology of the study sensitive to women's experience through the designing of the tools, the use of female investigators and the use of a probe list of symptoms to record additional illnesses among women above 12 years.

Findings and conclusions:
The findings of the study revealed that the morbidity rates for males was 330 per 1000 and for females, it was 362 per 1000. Morbidity among adult women was higher than the morbidity among girls, and had a substantially large proportion of chronic and non-infectious illness. Reproductive health problems were more prevalent among young women, while weakness and aches and pains constituted a large part of the morbidity of ageing women. Morbidity is highly correlated with age, marital and occupational status. Apart form these individual factors; it was found that the socio-economic class of the household and the composition of the household were also correlated with morbidity. Cultural factors did inhibit the reporting of morbidity, as was seen in the case of tribal women, who had reported lower morbidity than women living in a similar economic and social environment.

The utilisation of health care by women was quite low. The use of informal care was an important part of women's health seeking. It was found that while the use of home remedies constituted 15% of the services utilised, the use of self-medication accounted for 11% of the total services used. Use of formal public facilities in the rural and urban areas - it was found that 24.2% of all the facilities utilised and 30.3% of the formal facilities utilised by rural women were government facilities or home based care provided by government paramedics. In the urban areas, 10% of the total facilities and 17.3% of the formal facilities used were public sector services. The rate of hospitalisation was significantly higher among rural women as compared to urban women. For certain types of illnesses, such as aches and pains, injuries, weakness and sense organ problems were mostly treated in the informal sector. However, other illnesses such as fevers and GIT infections were invariably treated using formal health care. It was found that financial problems were the cause for not seeking treatment. Care was not sought for 12.4% of the untreated episodes because the health facilities were not accessible or adequate.

The expenditure per capita and per facility in the rural areas was higher than in the urban areas. However, due to more frequent hospitalisation among rural households, the overall expenditure on health care in the form of doctors' fees, the cost of medicines and injections was high. It was found that the expenditure was highly correlated with the duration of illness. The longer the duration of the episode, the lower was the expenditure on it. When medicines alone were dispensed, the per-facility expenditure was Rs.24. However, when injections were administered, the expenditure rose Rs 77. This indicated the economics behind the overuse of injections in the private sector. There was a considerable difference in the expenditure incurred on men and women in each facility.

Twenty Nine of the 82 pregnant women in the rural areas had not sought any ANC care. It was found that 70% of the deliveries were conducted in the rural areas by relatives or untrained midwives. However, in the urban areas too, similar providers conducted one third of the deliveries at home. Primarily, public centres were used for PNC. This was chiefly because immunisation facilities were provided at the public centres and women would specifically access these centres to get the baby immunised. Contraception services were overwhelmingly accessed from the public sector, except the use of medicine shops to buy oral contraceptive pills.

The major source of curative services in the urban as well as rural areas was the private sector. They ranged from quacks, who rode into the village on motorcycles once a week and dispensed medicines to more than 40 patients in a couple of hours to highly trained specialists in the urban centre of Nasik, who charged Rs. 200 to Rs. 500 for a single consultation. Remote villages were served almost solely by quacks, who visited once a week. The study also found fairly well established dispensaries in fairly inaccessible villages, which were prosperous on account of irrigation and capitalist farming. They were also to be found in small villages, which had only a grocery shop and a flourmill, where they could attract patients from remote villages. Slum settlements within the city were totally dependent on private services for treatment. This had a negative impact on the poor women, who were driven out by their inability to purchase services. The varied pattern of morbidity helps to reveal the complexity of women's health problems. Women tend not to report problems related to work and fatigue, childbearing and contraception. Thus, a large proportion of their illness is obscured from view because it does not enter the health system at all. To improve women's health some of the strategies include, women's education, employment, and more accessible health care services. The re-distribution of power within the family can radically alter the decision making process in the household.
It was evident from the study that the health services were both inadequate and unequally distributed. However, it was found that the use of public facilities was extremely limited even where the services are physically accessible, both in the rural and urban areas. The study of urban households revealed the importance of the market as a provider of health services. It was found that the poor households had extremely poor access to formal services and resorted to the use of informal services. They were totally dependent on the private services. There is an undeniable need to strengthen the public services in the urban areas as well as to make them more accessible to the poor. There is also a need to rethink the strategies used for primary health care for the cities, where the services are physically abundant and, yet, completely inaccessible. The problems of the public sector services can be remedied by stricter implementation of guidelines and reorganisation. The fact remains that the government funding for health needs to be increased in order to meet the needs of the rural and urban areas.

9. Health Resources, Investment and Expenditure: A Study of Health Providers in an Indian District

Author/s: Kavadi Shirish (edit)
Publication source: Foundation for Research in Community Health (FRCH), Pune
Year of publication: 1999
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, Financial
Issues addressed: Financing, Prices, Costs, Payment mechanisms, Expenditure

Objectives:
To conduct a comprehensive survey of the nature and volume of health resources available and accessible to the population of a district. To analyse the nature and pattern of health investment and expenditure incurred by health providers.

Methodology:
Ahmednagar district was selected since it was an average district as per the CMIE indices for socio economic development. Data on the health resources in the district was compiled by scrutinising official and private sources. The accuracy and reliability of the data was verified by conducting sub sample survey in villages randomly selected and through administering a questionnaire to personnel in government establishments and private practitioners. The authenticity of the information gathered was ascertained. Further, a postal survey was also carried out through a questionnaire mailed to all the listed health providers who were also asked to identify other practitioners in their locality. A second set of mailed questionnaires to doctors and health establishments addressed issues such as fees from patients and expenditure incurred on maintaining their establishment. This questionnaire was sent only to the respondents of the first round of the postal survey. The response rate was around 20%. Another technique that was used to gather information on medical practice was holding of three workshops for a few selected practitioners from among the respondents to the mail survey. The focus of the workshop was on the setting up of medical practice - the economics of setting up practice, problems and constraints encountered in setting up and continuing practice etc. For the study on expenditure and investment 137 units from 6 talukas were randomly selected from respondents to the mailed questionnaires. The units covered were private practitioners (all systems of medicine) (qualified and unqualified), general practitioners and specialists, public and private health facilities with varying bed strength, located in the urban and rural areas of these talukas. The questionnaire focused on historical information about practice or facility, information on

Findings and conclusions: The study identified 3059 doctors (qualified and unqualified) located in urban and rural areas, representing all systems of medicine. Though doctors from both the public and private sector were included, nearly 92% were from the private sector. Overall the health institutions numbered 860, which included 274 hospitals - with bed strength ranging from 3 to 200 beds, while 565 medical stores were found to be functioning in the district. Non-allopathic health providers, both qualified and non-qualified outnumbered allopathic doctors. Those practising Indian (Ayurvedic and Unani) systems of healing constituted 41.7% of the total, while homeopaths made up 16%, Registered Medical Practitioners' (RMPs) were 3.5% and non-qualified quacks and folk healers formed 0.2%. Dentists accounted for 1.5% for the entire district. The low proportion of nonqualified doctors and RMPs was due to the fact that they were not likely to appear in published lists. The geographical distribution pattern for doctors reflected the same urban bias so evident in all developing countries. Fifty-one percent of the doctors were based in urban areas and 49% of the doctors in the rural areas. The doctors to population ratio in urban areas were 3 per 1000 against the ratio of 0.5 doctors per 1000 population in the rural areas. The propensity of the modern medical practitioners in urban areas was determined by the availability of 'market'. The level of economic development creates this 'market'. The economically five developed talukas had a concentration of doctors accounting for 71% of the total. This unequal distribution was further highlighted in the proportion of doctors to population, wherein the five above-mentioned talukas had a ratio of 1.26 doctors per thousand population. As against this the remaining eight economically backward talukas had a proportion of 0.56 doctors per thousand population. Hospitals (Nursing and Maternity Homes, TB and leprosy hospitals included) were distributed on a pattern similar to that of doctors. The five developed talukas accounted for 80% of the total hospitals, and urban centres 73% of the total. The study found that the private health sector in Ahmednagar district began expanding during the 1980s. This trend conformed to the national trend. During this period there was an increase in the number of private medical colleges in the State contributing to an increase in the number of doctors passing out. The non-availability of sufficient public sector jobs and the reluctance of doctors to serve in rural public health services contributed to the further growth of the private sector. Faulty government policies were also responsible for the growth of the private health sector. Besides supporting the establishment of private medical colleges, the government created opportunities for doctors to avail themselves of loans for setting up medical practice. For e.g. the Maharashtra State Finance Corporation and Nationalized banks extended loans to doctors to set up dispensaries and nursing homes. This availability of capital gave a boost to the private sector.

The study shows that the investment in the private health sector was made mainly for the creation of infrastructure. Money was spent on buildings, furniture and medical equipment. The public sector barely expanded during this period. Very little investment had gone into creating new public health facilities. Very rarely did additional investment go into expanding medical care services. This showed both the non-availability of funds in the public sector and also the low priority the government attached to health services. The study showed that the burden of expenditure incurred by health providers was on recurring heads of expenditure. Thus, the salaries, drugs and maintenance of equipment consumed the bulk of the funds spent by health providers in delivering health care.

10. Heath status, Socio-economic Conditions and Expenses for Delivery: A Household-level Analysis of Pregnant Women in Dindugal slum areas

Author/s: Muraleedharan V R and Saradha Suresh
Publication source: Report submitted to the UNICEF, Chennai
Year of publication: 1999
States covered: Tamil Nadu
Social geography: Urban
Data source: Primary.
Type of study:Prospective study. In fact, this study also has control groups for measuring effectiveness of interventions to improve
Type of private sector: For profit private hospitals and nursing homes.
Issues addressed: Utilization of private and public maternity services

Objectives:
The primary objective of this household-level survey is to understand the various socio-economic factors that influence the state of health of pregnant women and the new born babies, and the utilization of private and public health care facilities in the slum areas in Dindugal town (Tamil Nadu). More specifically, this study analyzes: 1. Differentials in the health status of pregnant women, new-born babies and their socio-economic conditions; and 2. Differentials in the use of antenatal care of pregnant women, and expenditures for delivery with respect to socio-economic conditions.

Methodology:
The survey tracked 1273 pregnant women in 61 slums in Dindugal town during the period May 1998 September 1999. The survey tracked every single known pregnancy in these slum areas. A detailed questionnaire was administered for collection of both qualitative and quantitative data directly from pregnant women. An important aspect of this study was that it collected hemoglobin levels of women during all three trimesters. The following information was collected by the survey. Details of family members (such as age, sex, relationship with the woman, occupation), socio-economic risk factors for poverty, previous pregnancy details (such as menstrual history, white discharge), history of ante-natal check-up (such as weight, hemoglobin in each trimester, details of medicine taken, illness during pregnancy, nutrition supplementation), delivery details (such as type and place of delivery, duration of hospitalization, bleeding during and after delivery, sex and birth weight of baby, condition of the mother and the baby during one month after delivery, details of breast feeding, expenditures for delivery purpose). Typically, the field investigator with a help of an assistant followed up all pregnant women during their entire pregnancy period, and also one month after the delivery. This report has used only a portion of the collected data, which is relevant to the specific issues examined.

Findings and conclusions:
For the purpose of this annotation, only results pertaining to objective 2 are summarized here:

Ante-natal care, place and type of delivery: All deliveries at the Municipal Maternity Home (MMH) were normal. 35% of total deliveries were made in private hospitals; 55% in government facilities, and about 10% at home. 59% of all C-sections were delivered in private hospitals. The remaining (41%) were made in government hospitals; 13% of all deliveries made in private hospitals were C-section deliveries; and 55% of (1273) women in non-UBSP areas had taken IFA tablets as nutrition supplement during pregnancy period. Overall, the mean Hb level among those that had IFA supplement (9.89) was not significantly different from those that did not have IFA supplement (9.85) (N=212 panel data) But this observation does not hold good at dis-aggregated level. Among women from the lower poverty risk group, those that had IFA supplement had a higher mean Hb than those that did not have IFA supplement.

Place of delivery and socio-economic conditions: Those who had Home deliveries belonged to the highest poverty-risk category, while those who had deliveries at private hospitals were from the lowest poverty-risk category. But it should be noted that a sizable number of women from both low and high poverty-risk categories used public health care facilities.

Expenditure pattern: Variations in expenditures with respect to place and type of delivery, and socio-economic risk factors. As already noted, all deliveries registered at home and Municipal Maternity Hospital were normal deliveries. The mean expenditures per delivery at Home and MMH were Rs.295.00, and Rs.238.00, respectively. But the difference in mean expenditure per normal delivery between General Hospital (GH) (Rs.485) and MMH (Rs.238) was substantial. It should be noted that most of those that had delivered at Home, GH or MMH belonged to higher poverty-risk groups. On average, a slum women spent Rs.1895 for a normal delivery, compared to Rs.8774 for a C-section delivery in a private hospital. Whereas in GH, it worked out to Rs.485 and Rs.2410, respectively, for normal and C-section delivery. The difference is quite substantial indeed.

The study makes the following observations. For all home deliveries, there is an enormous variation across socio-economic risk groups. In the case of normal deliveries made at private hospitals, there is much greater variation expenditure among women with lower poverty-risk index. In the case of GH, the variation is greater among those with higher poverty-risk index. Most women who had C-section deliveries in private hospitals are from households with low poverty-risk index. But the spread in expenses appears large. Quite a few women had spent more than Rs.10000 per C-section delivery. This is also true of women who had C-section deliveries in Government Hospitals. Although the mean expenses in GH are Rs.2410, several women had spent more than Rs.4000 for C-section delivery.

The study makes three key observations:
A large majority of slum population bear a considerable amount of financial burden for delivery purpose at public health care facilities. Such expenses are not uniformly borne by all sections of the population. For example, out of pocket expenses per normal delivery in Municipal Maternity Home varied from Rs.45 to Rs.2000. The financial burden seems to fall to a greater extent on the poorest groups than on others. Also, in the case of C-sections in government hospitals, variations in out of pocket expenses per delivery is quite large: Many women from poorer groups spend more than Rs.4000.00 per C-section delivery. A considerable number of women from high poverty-risk groups had chosen private facilities for deliveries and had spent as much as Rs.15000 per C-section.
Evidence strongly suggests that efforts to improve women's Hb level from pre-pregnancy period would have greater beneficial effects on the new-born babies than if they were confined to only pregnancy period.
The rate of C-sections in government or in private facilities appears more closely associated with socio-economic risk factors than with health status of pregnant women. Nearly 16% of all deliveries in private hospitals were C-sections, while it was 12% in GH. This is indeed on the higher side for a slum population, considering the fact that those who had normal deliveries were of similar health status. The study suggests that a mere increase in budgetary allocations will not be adequate to achieve poverty reduction in urban slum areas. We need to address systemic reforms issues in providing health care for the urban poor.

11. Hospital Based Urban Health Care Services

Author/s: Gill Sonya, Lalitha D'Souza, Anagha Pradhan and Dina Patel
Publication source: Foundation for Research in Community Health (FRCH), Bombay
Year of publication: 1996
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Hospitals
Issues addressed: Utilisation, Costs, Quality, Organisation,

Objectives:
The present study explores the nature of health needs and problems for which people seek the out-patient services of the public hospital, the level of care needed for these ailments and people's help-seeking behavior and utilization of the health care services.

Methodology: The location of the study was The King Edward Memorial (KEM) Hospital, Bombay which has a bed strength of 1800 and 28 departments belonging to the basic and superspecialities. On an average, 5,000 people daily attend the out-patient clinics (OPDs) in the hospital. The study focussed on the users of (OPDs) in four basic specialties - General Medicine, Paediatric Medicine, General Surgery and Gynaecology-Obstetrics. were selected. The total sample size was 1,763 and was distributed over the selected departments using the proportionate probability sampling (PPS) method. All relevant attendance data was obtained from the medical records department of the hospital. A semi- structured interview schedule was administered to the respondents. The data was collected in two phases i.e. before and after the patient had seen the doctor. Data on the healthcare services in Greater Bombay was collected from the Public Health Department of the Municipal Corporation. Data on the morbidity recorded at and utilization of municipal dispensaries in the F/South Ward was collected from the ward Public Health Department. Brief visits were made to 3 dispensaries in this ward.

Findings and conclusions: Over half the users i.e.54% belonged to the urban unorganized sector and two-thirds of the user households had per-capita income of less than Rs.500 per month. However, over half the users (54%} were drawn from the close vicinity of the hospital itself, with only a quarter (23%) coming from Greater Bombay. As a specialist clinic, the gynaecology OPD was utilized equally by women in the suburbs and the inner city. In the range of diagnosed conditions, diseases due to infections took up over 1/4th of all OPD cases, ranging from 40% in Medicine and Paediatric Medicine OPDs to 20% in surgery to 12% in Gynaecology OPD. The majority of the people (60%) needed secondary level care; this indicated a limited scope for decreasing the load on public hospitals so long as specialist services are centralized in them. The gynaecology OPD was the most optimally used for the secondary and tertiary level services associated with a teaching hospital. Public hospitals in Bombay are free and have openly accessible facilities. It is often assumed that people 'unnecessarily' use higher level facilities for lower levels of health care. However, not only was specialist care indicated in about half the cases, but over 2/3rds (70%) of the users had sought prior treatment. The provider most commonly contacted (50%) at the onset of the illness was the private practitioner. Long lasting relationships, close proximity to their residence and convenient timings were some of the reasons for resorting to private practitioners. There were, however, limits to continuing private treatment. Lack of quick relief that people associated with minor conditions and the prospects of costly treatment led them to seek higher care. The most common reason for changing the prior provider, especially the private practitioner (57%) was due to 'no relief' for the patient. The unplanned expansion of private practitioner services in the localities served by the dispensaries was highly visible. According to Municipal Corporation data estimates, there was one private practitioner for less than 2000 people in the municipal ward (4.2-lakh population) in which the hospital was located. In comparison, the dispensary was meant to serve a population of 50,000. The public system could hardly match the coverage of the private sector or consider itself the main provider of first level care.

There was thus an urgent need to review the organization and performance of the public primary care services. At the same time, the development of a referral system would need to view the existing health care services as a whole, integrating both the public and private services into a holistic urban health system. There is a need to integrate health care services within a properly functioning referral system. Such a system is urgently needed in the urban setting where the over supply of medical human power, duplication of services and increasing competition and costs of care adversely affect the poor and lower income population. This, however, needs to be done in stages. The access of the poor to the quality services of the public hospital should not be cut off without providing an adequate at the first level of care. Strengthen the first level of services in the public sector based on the dispensaries, maternity homes, health posts and health centers. All facilities should have a catchment area; timings should be such that it should be convenient for working people; there should be adequate supply of essential drugs. To increase the quality of services in these units the first referral specialist clinics and a wider range of basic investigations could be decentralized. These clinics could be the out-reach services of the local hospital, simultaneously providing the necessary experience to medical students about conditions and health needs in the community. Develop a system of monitoring of private practice patterns and mandatory record keeping by practitioners. This would form the basis for integrating them within the referral system. A properly worked out system of referrals is needed for accessing the hospital, including communication and referring back the patient to the original doctor. Administrative reorganization of the urban public health departments to achieve co-ordination and decentralization.

12. Hospital Services in Urban Tamil Nadu: a survey of maternity services in Madras city and Chidambaram / Cuddalore region

Author/s: Muraleedharan V R
Publication source: Report prepared for Citizen, Consumer and Civic Action Group (CAG), Chennai, October 1997
Year of publication: 1997
States covered: Tamil Nadu
Social geography: Urban
Data source: Primary
Type of study: Primary
Type of private sector: For-profit, corporate hospitals, Government hospitals.
Issues addressed:Prices and Costs of private care, consumer satisfaction, physical facilities available in private and public hospitals,

Objectives:
The study has two objectives: (1) to understand the experience of women who had been delivered of a child either in public hospitals or in private hospitals, and (2) to understand the nature of private and public hospitals providing maternity services in urban Tamil Nadu.

Methodology:
The study involved two different surveys: In survey I (related to objective 1) 377 women (285 from Madras city, and 92 from Chidambaram/Cuddalore region) who had delivered a baby either in government or private hospitals were interviewed. Survey II collected information from 30 hospitals (22 from Madras city and 8 from Chidambaram/Cuddalore region) to throw light on facilities available. The surveys were conducted during January - March 1997, covering deliveries made during October - December 1996.

Findings and conclusions: Survey: I On average, a sum of Rs.12, 965 was spent for a caesarean delivery in private hospitals in Madras city, while in Chidambaram/Cuddalore region, the corresponding amount was Rs.6985. Considerable variation in expenditure exists across private hospitals. For example, in Madras city, it ranged from Rs.3000 to Rs.30, 000. For a large number of caesarean deliveries, the expenses incurred were between 10 to 15 thousand rupees in private hospitals in Madras city. A noteworthy point is that 75 of 129 caesarean cases surveyed in private hospitals in Madras city had spent equal to or more than 10,000 rupees. Of these 75, twelve belonged to the poorest income groups (less than Rs.20,000 per annum per family). A large majority of women in public hospitals (61% in Madras city and 96% in Chidambaram/Cuddalore region) had paid speed money to the providers. In the case of private hospitals, 16% in Madras and 88% in Chidambaram/Cuddalore had paid for services that were not billed. Only about 50% of users of public hospitals said they had access to clean drinking water. In the case of private hospitals, more than 90% had access to drinking water in both the study regions. More than 70% in private hospitals, and 90% in public hospitals in both regions said that they found the consulting rooms very clean. In Madras, more than 70% of users found toilets clean in both private and public hospitals; whereas in Chidambaram/Cuddalore, it was 20% and 2% for private and public hospitals, respectively. Nearly 100% of users in private hospitals found garbage bins for use, while about 80% in public hospitals had access to garbage bins. Waiting time for antenatal checkups: a third of the users in private hospitals in Madras said that often they waited for less than 15 minutes for regular antenatal check up; while only 9% of the users in Chidambaram had such low waiting time. Only 7% in Madras said they had to wait for more than 30 minutes, while it was 33% in Chidambaram region. Only 33% in private hospitals in Madras paid an advance before admission. In Chidambaram/Cuddlaore, only 7% paid any advance. In the case of public hospitals, 2% in Madras and 6% in Chidambaram/Cuddalore had paid an advance (note: this is for being delivered of a baby). Users were asked to identify services that require improvement from their point of view: more than 80% in Chidambaram/Cuddalore said they would like authorities to do something about maltreatment in both private and public hospitals. About 50% in private hospitals said that the staff were very helpful. In Chidambaram/Cuddalore, only 20% in public hospitals said their staff was helpful. In Madras, about 60% in public hospitals said they found the staff very helpful. Overall, about 70% in private hospitals characterised their general experience as "good". Users of public hospitals in Madras showed a similar response, while it was only 6% in Chidambaram area. But, it is noteworthy that more than 95% overall had felt "secure" during their stay for delivery.
Survey II: Some of the large private hospitals in Madras city have an occupancy ratio of less than 25%. The average occupancy ratio for private hospitals is 54% (figures for sample public hospitals were not available). Overall, smaller hospitals have a higher occupancy ratio. Larger private hospitals (in terms of bed size) have a lower ratio of auxiliary personnel to physicians employed than smaller hospitals. Data for Chidambaram/Cuddalore region were not available. Average charges for urine test; ECG and x-ray in private hospitals in Madras city are Rs.56, Rs.67 and Rs.75, respectively. Average charge for ultrasound (maternity related): Rs.202 (max:350; min:50). Average charge for labour room per delivery: Rs.306 (max: 500; min: 125) Average charge for anesthetist (per procedure for delivery): Rs342 (max: 600;min: 150). Average charge for OT per delivery: Rs.533 (max: 700; min: 400). Fifty percent of the private hospitals surveyed in Madras operate in their own premises. 65% of the private hospitals have an emergency ward. All the private hospitals in Madras said they had a back up for power supply; while none in Chidambaram/Cuddalore region has a back up. In the case of public hospitals, none has any back up for power supply. Most hospitals (private and public) had drainage connection. None of the private hospitals in Chidambaram had space for washing patients' clothes (it is important to note that none of the public hospitals have answered this question). What is important to note is that very few (only 4 out of the entire sample hospitals) said they had play area for children. This is important since many women (from the poorer families) would be accompanied by younger siblings, who would require some play area. Often it is difficult for the women to leave their children due to lack of domestic support for various reasons. Only half the sampled hospitals in Madras have been declared baby-friendly.

This preliminary study of maternity services in urban Tamil Nadu has thrown up important policy issues for consideration. A substantial amount is being spent for delivery (in both private and government hospitals). But it is not clear whether the amount spent reflects the quality of care received adequately. More specifically, it is not clear how far the variations in costs of care/services provided can account for the variations in total expenditure incurred for such care/services. This problem remains for all types of services, whether in private or public health sector, from primary to tertiary care level. Needless to say that it will be a very difficult exercise to undertake, but it is equally important to emphasize that without such studies no meaningful approach can be designed and adopted to assess how efficiently the health care sector functions. This leads us to the next issue arising out of this study. There is a complete lack of database on the hospital sector. For example, there is no reliable list of even the number of private clinics and hospitals in Madras city. As for government run hospitals, the Health department maintains a list, although there is no consistency between the data sets maintained by various directorates within the Health Department and those published in the Administrative Report of the government of Tamil Nadu. There is no data on manpower employed in various hospitals, nor about volume of services provided annually or monthly, and many other rudimentary aspects that are required for public policy purposes. Besides, private hospitals/clinics also are also reluctant to participate in such studies because of the fear that such information may be used against them by consumer activists groups and others. Such apprehensions are not without any basis. The question of government's credibility is also part of the problem. It is important to impress upon the providers the urgency of sharing such information and promote a more healthy atmosphere among the various stakeholders, the health care professionals, policy makers, patients, employers who pay for their employee's health care, and consumer activists. Such an atmosphere is essential in order to identify feasible areas of reforms and how they can be effectively introduced and sustained. There is an impression amongst many (including the most well-meaning) people that providing a high quality of care would necessarily entail greater expenditures. There are reasons to believe that this so called "quality-cost" trade-off is often a myth. The study suggests that there is scope for reducing costs of providing health care (whether in government or private health care institutions) without compromising on the quality of care.

13. Household Survey of Medical Care

Author/s: National Council for Applied Economic Research
Publication source: National Council for Applied Economic Research, New Delhi
Year of publication: 1992
States covered: National
Social geography: Rural & Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, Laboratory, ISM, Unqualified practitioners,
Issues addressed: Utilisation, Expenditure, costs,

Objectives: In 1990, under the aegis of their "Market Information Survey of Households", the National Council of Applied Economic Research (NCAER) conducted a household survey on medical care in all major states and union territories. The study was undertaken in the pre-monsoon period, during May-July. Data was collected on the prevalence of reported morbidity, health care utilisation, and out-of-pocket health expenditure.

Methodology:
The sample was a multi-stage stratified sample. All the districts in the states and union territories were selected. For the rural sample, 2-5 villages per district were selected, with a probability of selection equal to the proportion of the population of that village in the district population. In all, 1061 villages were selected. All the households in the village were listed, and then classified according to levels of income. Households were then randomly selected from each income slab. For the urban sample, all 41 cities of the country with a population of above 5 lakhs were included. The remaining cities/towns were classified into 5 strata on the basis of population size, and a random sample taken from each stratum. The 632 cities and towns selected covered 61 per cent of the total urban population. Once again, all the households in each city/town were listed, and the households randomly selected from each income slab.

Findings and conclusions:
The illness prevalence rate for all India worked out to 67.70 per episode per 1,000 population for urban areas, and 79.06 for rural areas. Assam, J & K, Kerala, Meghalaya and Pondichery reported a higher rate of illness than the all India average. The prevalence rate by class shows that in households with low-income category, it was 77.21 per 1,000 population, in the middle income category it was 63.07 and in the high income category it was 57.62. The allopathy system of treatment was the most favoured. For 55% of the illness episodes, private medical practitioners were utilized, as compared to 38 to 39 percent for the services of Government doctors. Himachal Pradesh, Jammu & Kashmir, Orissa, Rajasthan and the Union Territory of Pondicherry showed a high reliance on government doctors. The situation was similar in the urban areas of Delhi and rural Andhra Pradesh. The study also brought out that households with low-income category utilize the government doctor more. It brought out the fact that with increase in the income levels of the household the dependency on Government doctor seems to come down in both rural and urban areas of the country. Looking at source of medical care, the study found that 43% of the illness episodes were treated in private hospitals or clinics. The PHC and SC catered to 8.2% and 5.8% of the cases respectively. In nearly 20% of the illness cases, the rural households travelled more than 10 kms for treatment. In Meghalaya, 54.56%, and Orissa, 33.47% of rural illness cases, patients travelled more than 10 kms. The average household expenditure for treatment of illness worked out to Rs.142.60 per illness episode in urban areas, and Rs.151.81 per episode in the rural areas. Fees and medicine category account for nearly two thirds of the total households expenditure on the treatment of illness. The average expenditure goes up from Rs.122.55 for low-income household to Rs.225.85 for the high-income households in urban India. In the case of rural India, the average goes up from Rs.138.55 to Rs.194.59 per illness episode when we go from the low to the high-income category.

14. Illegal Abortion in Rural Areas

Author/s: Bardhan Amita, M.E Khan, L. Ramachandran, R.K Upadhyay, Saraswati Swain
Publication source: Indian Council of Medical Research (ICMR) New Delhi
Year of publication: 1989
States covered: Uttar Pradesh, Rajasthan, Haryana, Orissa, Tamil Nadu
Social geography: Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Unqualified Practitioners
Issue addressed: Utilization, Quality, Regulation

Objectives: To study the prevalence of illegal abortions. To study the socio-demographic profile of the women seeking illegal abortions. To identify the factors responsible for illegal abortions. To study the complications encountered by providers, procedures used, duration of pregnancy and measures undertaken for handling the complications. To study the cost involved in such abortions.

Methodology:
The study was conducted in five states - Uttar Pradesh, Rajasthan, Haryana, Orissa, and Tamil Nadu. Two districts in each state were selected on the basis of the family planning performance i.e. good and poor. In each district two Public Health Centres (PHCs), one of them with MTP services was selected following stratified random sampling technique. Ten villages from each PHC were selected randomly for community survey. A sample of 500 households per PHC and one eligible woman per household was selected randomly. A sample of 20 villages per PHC and 3 providers per village were also selected randomly for provider survey.

The tools used for the data collection were interview schedule for providers, household information form, and interview schedule for community members and guidelines for case study. Two surveys were conducted. They were the provider survey & the community survey. In the provider survey, people were identified who acted as informants such as community level health and family planning workers, village heads and other influential persons, druggists, indigenous practitioners in order to find out who the providers of induced abortions were. The field investigators contacted the sources and after taking them into confidence, they sought from them the names, addresses and identification of the providers of illegal abortions. After preparing a list of the providers, these providers of illegal abortions were approached and interviewed. The providers were asked about the types of services they provided and also about specific issues related to induced abortions such as the methods used for conducting the abortions, type of cases they dealt with, gestation period and other such questions. The community survey was carried out immediately after the completion of the provider survey. The married (eligible) women who were aged between 15-45 years were interviewed. The focus of the survey was to find out the characteristics of the community members i.e. their age, sex, education, occupation etc, awareness of induced abortions, awareness about the place of the availability of the services and other related issues.

Findings and conclusions: The study revealed, that the extent of illegal abortion was 13.3 per 1000 pregnancies, in comparison with legal abortion i.e. 6.1 per 1000 pregnancies, which was high. Knowledge about inducement of abortion to get rid of unwanted pregnancy was 85.5% and about its safety, i.e. upto 4 months, was 85.2%. However, the awareness about the provision of legal abortion, i.e. MTP services was as low as 36.5%. The sources of information about abortion were mostly neighbors and friends who constituted around 27%.

Among the providers of health services, around 63.1% of the women preferred the qualified government doctors The reasons were that doctors were experienced, efficient and people had faith in them. However, it was revealed that the services were not available free in the Government set up. The next majority of respondents around 19.2% showed their preference to 'provider's home / place' i.e. the private hospital / clinic. The reason was that it was easily accessible and people were aware of its existence. Private doctors conducted abortion in the first trimester and occasionally beyond 3 months of pregnancy in their own clinics. They followed the method of vacuum aspiration and had not come across any complications. Fees charged were Rs.150 - 200/- per case. Government doctors were found to be conducting abortion in their private clinics. The reasons given were that clients desired special attention and secrecy and also that they could attend the cases carefully and devote more time, outside hospital hours.

The dais' abortions were regarded more as a social obligation rather than a professional need since this profession did not generate adequate income and also it was not well respected. They charged for their services either in cash (Rs. 50- 100) or in kind. They used indigenous methods and techniques for conducting abortions such as insertion of herbs and foreign bodies into the vagina and use of indigenous preparations containing roots, leaves, pools etc that were orally consumed. In Tamil Nadu the dais gave Erbolin tablets to the patients to be consumed orally and they claimed that the abortion was complete in two days without any complications. The utilization of dais was much less in Tamil Nadu and U.P, whereas in Orissa and Rajasthan there was dependence on local dais for abortion.

From the interviews with the women, it was evident that the awareness about MTP and the facilities provided by Government were very poor. Around 37.9% did not know whether abortion was illegal or legal and 21.1% thought that abortion was illegal. The media played a very small role in disseminating information on abortion. There is an urgent need for giving wide publicity about free abortion facilities at the Government centres. The knowledge about the complications of abortion during the second trimester and afterwards needs to be provided. For better MTP services, more centres in rural areas need to be equipped and authorized.

Expanding the infrastructure facilities and training doctors should improve the accessibility of MTP services. The training of the doctors should inculcate a spirit of service and ethical considerations. The doctors should be educated not to exploit the client's predicament. The unauthorized providers of abortion should be educated about the possible risks involved in illegal abortion as well as the ethical aspects in order to discourage them from doing so. The unauthorized providers of abortion should be counseled to refer the clients approaching to them to the Government hospital / PHCs and they should be given incentives for this. A very wide and intensive dissemination of information about all aspects of abortion and the MTP facilities available at Government hospitals and PHCs is urgently required.

15. Impact of Tuberculosis on Private for Profit Providers

Author/s: Balambal, R. Jaggarajamma, K. Rahman, Fathima. Chandrasekaran, V. Ramanathan, U and Thomas, A.
Publication source: Tuberculosis Research Centre, Chennai
Year of publication: 1997
States covered: Tamil Nadu
Social geography: Urban and Rural, Poverty
Data source: Primary
Type of study: Case Study
Type of private sector: Qualified allopathic private practitioners
Issue addressed: Private Sector, Private Providers, Utilization of Private Sector Quality of Private Providers.

Objectives:
The purpose of the study was to look into the diagnostic and the treatment practices of qualified private practitioners and also to assess their willingness to collaborate with the Revised National Tuberculosis Control Programme.

Methodology: This study was conducted in the urban areas of Chennai and the rural areas of Chinglepattu. Altogether 303 qualified private practitioners from both rural and urban areas were interviewed. For the purpose of this study a private practitioner is defined as a person with a basic medical qualification either in allopathy or one of the indigenous systems of medicine.

Findings and conclusions: The study revealed that the median age of practitioners was around 42 years and a majority were males. Fifty-nine percent of the qualified private practitioners in rural areas and 42% in urban areas had a basic MBBS degree. Most of them were in general practice followed by practice in private hospitals. The study revealed that there were a few differences in the practices of urban and rural practitioners with respect to tuberculosis. They were aware of RNTCP and DOTS. The techniques that they relied on were mostly chest radiography and not on sputum examination. As far as therapeutics was concerned they prescribe short-term chemotherapy but do not use intermittent regimes. The study found that they maintained very poor patient records and although they used government facilities there was no feed back to any government agencies. The study revealed that the most important reason for referring patients to government centres was the poor socio-economic status of the patient. Apart from this reason, 35 percent of rural private practitioners refer cases to government hospitals for management of clinical complications. Contrary to Uplekar's findings, this study showed that a majority of non-allopathic practitioners did not prescribe allopathic medicines. There was much variability in the costs incurred by patients, which ranged from Rs 101 to as much as Rs 5000. Interviews with patients revealed that 62% of the patients went to government facilities for financial reasons and 30 % as a result of referrals. In Tamilnadu, qualified allopaths in rural areas were very few.

A number of issues are thrown up through this study which are important for policy. These include the uneven distribution of qualified private practitioners affects accessibility. While these practitioners may be aware of RNTCP, there is still a need to train them in diagnosis and treatment. There is a need to develop a reporting system of patients treated for TB to the public health system. The poor and complicated cases treated in the private sector are being referred to the government hospitals. Therefore it is important that government hospitals are strengthened. The issue of the diagnostic tools being used for diagnosing TB is important since the private practitioners rely largely on radiography rather than on sputum testing.

16. Improving the Performance of Reference Health Center A Case Study of Urban Health Center, Dharavi, Bombay.

Author/s: Garg Renu
Publication source: Dept. of Health Studies, TISS, Bombay
Year of publication: 1995
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Case Study
Type of private sector: Hospitals, Practitioners, Not for Profit
Issues addressed: Utilisation, Organisation, Quality

Objectives:
To assess the role of the Dharavi Urban Health Center, in providing primary health services to the residents of Dharavi.

Methodology:
The location of the study was Dharavi situated in the 'G' north ward of Bombay. The study was conducted between June, 1994 and Oct 1994. For the study, both qualitative and quantitative methods were used. Around 2,018 households were surveyed using multistage sampling technique. A structured interview schedule was administered to the respondents. The interview schedule consisted of demographic, socioeconomic, utilization of health services, maternal and child health services, reasons for use and non-use of the UHC. In addition semi structured interview of 50 General Practitioners were interviewed to study the pattern of referral services from private sector. The qualitative methods involved key informants, focus group discussions with community members, community health workers and anganwadi workers,

Findings and conclusions: The overall utilization of the UHC is low for all the services. The UHC is bypassed by the catchment population, as most people prefer to use private sources for minor ailments and rely on the teaching hospital close by for major illnesses. Private practitioners are preferred especially for the treatment of minor ailments. Private practitioners are in the vicinity and they offer quick cure and provide personalized treatment. The poor who are daily wage earners find the timings of private practitioners suitable. The other factors responsible for the low utilization of the UHC are inconvenient timings; non- availability of medicines and the feeling that the services provided by private practitioners and the teaching hospital are better. Although most of the people utilize private practitioners for minor illnesses, they depend on public facilities for major illnesses. More than half of the [55%] private practitioners referred patients to the teaching hospital, while 15% of them referred their patients to other private practitioners. For investigations, voluntary agencies offering subsidised services were preferred. The reasons for the non-referral of patients to UHC by the private practitioners were that they had a poor opinion about the quality of services provided by the UHC and that they lacked competent staff. Rapid urbanization all over the world, especially in developing countries has led to the growth of urban poor who constitute nearly 60% of the population in some cities of the developing countries. The complexity of their health problems needs a comprehensive health and social action. The existing model of healthcare system in urban areas has not been successful in meeting the healthcare needs of the poor. A reference health centre can be an important means of improving urban health services by bridging the gap between the functional roles of apex hospitals and first contact level health facilities. Referral protocols should be evolved and communication links should be developed with health posts, dispensaries and private practitioners to improve the referral system

17. Induced Abortions in a Rural Community in Western Maharashtra: Prevalence and Patterns

Author/s: Ganatra BR, SS Hirve, S Walawalkar, L. Garda, V N Rao
Publication source: K E M Hospital Research Centre, Pune.
Year of publication: 1996
States covered: Maharashtra
Social geography: 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, Expenditure, Quality, Regulation

Objectives:
To explore maternal deaths in rural western Maharashtra and to examine the choices among providers and the expectations and experience of abortion services from a woman's perspective.

Methodology:
The study was conducted in the districts of Pune, Ahmednagar and Aurangabad in Western Maharashtra. The study area covered 139 villages with a total population of 324,431. A total of 1853 women who had abortions during the 18 months study period were identified. Information was collected through case finding methods such as self - reporting, snowball sampling, community women's group, schoolteachers and health functionaries within the community. Public, private and non-formal service providers for abortion services were also consulted. A structured interview schedule with open and close-ended probes was used for the married group and in-depth unstructured interviews were used for the unmarried women. Dummy or diffuser interviews based on the same questionnaire were used on other women simultaneously so that those women with abortion cases are not singled out for unwarranted attention. Out of 1853 women interviewed, 1717 were married; of these 196 could not be interviewed either because they refused to be interviewed or subsequently migrated out of the study area. There were 136 unmarried women. This included never married (45) separated (66) and widowed (25) women. Out of 136 unmarried women, 32 could not be interviewed and information about these women was collected through secondary sources.

Findings and conclusions: A total of 1950 induced abortions occurred in the study period as some women had had more than 1 abortion. Only 1 death (of an unmarried 16 yrs old girl) was reported. The vast majority of women (81.3 %) had their pregnancies terminated in the private hospitals. Private sector providers included gynecologists, general practitioners and those trained in ayurveda but using modern methods for conducting abortions. 52.5 % of abortions in the private sector and 49.9 % of all abortions took place with providers who were either not legally recognized as MTP service providers or were performing abortion in a place that was not legally approved. 2 % of the married women used traditional practitioners such as traditional birth attendants, herbalists or quacks. The cost of individual abortion in private hospitals was higher as compared to public hospitals where the cost was Rs. 412 and in the private hospital Rs. 540.
Sex - selection abortions were becoming common. In the rural community, nearly one in every six-pregnancy terminations among married women was because sonographic sex determination showed a female fetus. Knowledge of legality of abortions was low among abortion seekers. Post - abortion care was lacking. There was a need for post - abortion services for psychological morbidity as well as contraceptive counseling. Unmarried women include not only the known vulnerable group of unmarried adolescents but also widowed and separated women who are completely out of the purview of most health care programs. Unmarried women constitute a special group of abortion seekers. They have different needs and they behave differently from the married women. The significantly higher use of traditional providers by this group is a reflection of the fact that this group is marginalised both by social stigma and the exploitation and insensitivity of service providers.

18. Involvement of Indian System of Medical Practitioners in the Delivery of RCH Services in Rural Areas

Author/s:K.G. Medical College, Lucknow, State Institute of Health & FW, Jaipur & State Institute of Health Management & Communication, Gwalior
Publication source: Indian Council of Medicals Research (ICMR)
Year of publication: 1999
States covered: Uttar Pradesh, Madhya Pradesh and Rajasthan
Social geography: Rural
Data source: Primary
Type of study: Case Report: Prospective/ Randomized Control Trial
Type of private sector: Indian Systems of Medicine
Issues addressed:Government Policy, Practitioners with Public Sector for RCH Services, Utilization of Private Services

Objectives:
The objective of this study is to involve ISMPs to improve the utilization of RCH services in rural areas with the existing infrastructure available at PHC/CHC/ district level.

Methodology:
The project was implemented in three states of U.P., M.P. and Rajasthan. Poor family performance was chosen as the criteria for selecting these three states. In each state, one district with poor family planning performance (CPR 40%) was selected through random sampling technique. Within the selected district, two PHCs were selected randomly for the experiment and the two for control purposes. Similarly, two urban wards were also selected, one for experiment and the other for control purposes. In each of the selected PHC, the identification of ISMPs was done and their willingness for involvement in the study was sought. About 75 ISMPs were trained in batches on the various aspects of RCH are. Monthly monitoring was done about their involvement for RCH care in the community.

Findings and conclusions: Progress Report: The baseline survey of ISMPs and the community have been completed and the ISMPs selected for the project trained in batches. The data received form the centres, Utter Pradesh, M.P and Rajasthan have shown an upward increase in the referral of various RCH services by the ISM practitioners by propagating the distribution of contraceptives, antenatal and natal care, MTP, provision of Iron and folic Acid, Vitamin A and ORS packets as well as referral of children of immunization.
Current Status: The post intervention survey of Lucknow (UP) and Gwalior (MP) centres is yet to be completed. It is expected that by March 2000 the post intervention evaluation data will be available for impact analysis.

19. Issues in Worker's Health of the Unorganised Sector: A Case Study of some Steel Utensil Making Units of Wazirpur,

Author/s: Mudgal Jyoti
Publication source: M.Phil Dissertation Jawaharlal Nehru University, New Delhi.
Year of publication:
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Private Practitioners
Issues addressed: Utilization of Private Sector

Objectives
: This broad based study focuses on the multiplicity of sources of ill health and the social dynamics of this process. It also addresses the health-seeking-behaviour of the workers.

Methodology: The study is based on an in-depth exploration of the issues concerning steelworkers in the unorganized sector of Delhi industrial area in Wazirpur. It is based on interviews with 200 workers, along with their trade union traders and the entrepreneurs who provide employment.

Findings and conclusions:
This study provides interesting insights into the relationship that owners have with workers in these industries. Though legally the sector is covered by the Employee State Insurance Scheme (ESIS), the management creates many hurdles in order to avoid registering workers. This is a method by which owners protect their own interests. These owners are often small or petty owners whose capital is too small to cover workers' risks. These owners prefer to help workers by sending them to private practitioners and are willing to pay for it thereby avoiding the legal complications. Very few among the 200 workers ever register with the ESI and even fewer get treated at the ESI hospitals. In fact, the workers themselves choose to go to the private sector in order to minimise conflicts with owners and some even hide their injuries to retain their jobs.

20. Law and Health Care Providers: A Case Study of Legislations and Legal Aspects of Health Care Delivery

Author/s: Jesani Amar
Publication source: Centre for Enquiry into Health & Allied Themes (CEHAT), Mumbai
Year of publication: 1996
States covered: National
Social geography:
Rural and Urban
Data source: Secondary & Primary
Type of study: Review Paper
Type of private sector:        Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit,
Issues addressed: Regulation, Personnel, Licensing, Consumer, Quality

Objectives:
To document, collate and critically examine the legislations and regulations applicable to the practitioners and institutions.

Methodology:
Questionnaires were sent to all health secretaries of the law and judiciary ministries of all states asking for information regarding various aspects of health such as 1) legal requirements for setting up the individual practice, nursing homes or hospitals 2) legal action taken against an unqualified, unregistered doctor, 3) constitutions of the state and district consumer councils. 4) minimum physical standards prescribed for the private hospitals and nursing homes and their inspections. 5) legal requirements for establishing and running the pathological laboratories blood banks, radiology units etc. The responses were inadequate, as all the questions in the questionnaire were not answered. The researchers also studied the functioning of various medical councils and tried to obtain information from them. The available legislations were then studied and analysed with the help of expert lawyers.

Findings and conclusions:
The laws affecting the healthcare professionals cover a wide range of areas such as medical education, entitlement to medical practice, control over medical practice, ethics, drug laws, control over hospitals, etc. The study has given a brief account of various laws related with the above mentioned aspects. Some of the laws covered by the study were Indian Medical Council Act, 1956, concerned with modern medicine, Medical Council Act 1955, Maharashtra Medical Council Act 1961, Homeopathy Central Council Act 1973, The Dentists' Act 1948, Nursing Council Act 1947, etc. It has been evident that all the Acts follow a similar pattern. The only exception is The Dentists' Act where there are no state laws. Various medical council acts have also given directions regarding the functioning of the medical councils.The researchers found that the councils were not operating in the manner, prescribed by the law. Structural constraints such as paucity of funds, political interference, bureaucratic pressures, etc further limited their efficiency. Malpractices were evident in their functioning.
Only two legislations governing hospitals and nursing homes were found. The Bombay Nursing home Registration Act: - It was enacted with three distinct purposes 1) to provide for the registration of the nursing homes. 2) To affect the inspection of the nursing homes. 3) To provide for other purposes connected with the registration and inspection of nursing homes. The law has given clear directions regarding the registration, penalty for offences, registration renewals etc. The Act also empowers the state Government to frame rules and regulations regarding the registration. Delhi Nursing homes Registration Act.1953: - It incorporates all the aspects of the Bombay nursing home registration Act. Another regulation, which the researchers found out, was The Karnataka Nursing Home (regulation) Ordinance.1976.

Malpractice despite legislations, are rampant in this area. The negligence on the part of the medical personnel falls under the preview of Tort laws. However, in India the courts were hesitant to hold the medical practitioners responsible for the negligence during treatment. But now the situation is changing and the patients are given more weightage in the matters of medical negligence. The medical practitioner is liable for the death of the patient under section 304-A of the Indian Penal Code. In order to punish a doctor, the patient or his relative has to seek redressal in the criminal court. Hospitals are also liable of being prosecuted by the aggrieved person.

The study has concluded that there are very few health legislations available in the country. The laws are differentially applied to the public and private sector. There is a need for the formulation of comprehensive healthcare Act to regulate the vast health sector. The experiences from the developed countries also show that the objective of provision of universal healthcare was not achieved until the private and public sectors were brought under the purview of law. The legislations play an important role of formalising the state policy. They guarantee a certain amount of stability in the health policies formed by the government. In India, the issue has remained unresolved for over fifty years and is likely to be so for the forthcoming period.

21. Living and Working Condition of Coir Workers and their Implications for Health? A case study in Alleppey district

Author/s: Nair, Bindu B.
Publication source:        Unpublished M.Phil dissertation submitted to Jawaharlal Nehru University, New Delhi, 1993.
Year of publication: 1993
States covered: Kerala
Social geography: Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: individual private practitioners
Issues addressed: Utilization of Private Services: -Government of Private Services Private Practitioners.

Objectives
: The main objective of the study was to develop insights into the working and living conditions of the coir workers and the implications for the health and well being of workers in this sector. Within this larger objective, the study gives some information regarding the utilization of health care services.

Methodology:
Information was elicited through a case study of yarn spinning units under co-operative societies in Kokkothamangalam village of Shertallai taluk in Allepey district. The study includes four categories of workers:-those who are directly recruited under the society, members who hire workers from outside to get work done in their homes, non member households doing similar work and members who themselves work. One hundred and fifty workers were randomly selected from two societies with the largest number of workers. While seventy-five of them represented the first category of workers as described above, twenty-five each were picked up from the rest of the categories. Information elicited by administering pre-tested interview schedules, through informal interviews and information from secondary sources.

Findings and conclusions: It has been found that in the unorganized coir industry, workers suffer from a range of work related health problems, even within the cooperative institutions. The terms and conditions of work are far from the norms recommended. Neither the cooperative society nor the employers are able to extend help for accidents and injuries. Maternity benefits are also not available. A large majority of workers utilize government health services, which have a poor delivery system in this area. In addition, workers are forced to spend a considerable part of their earnings on buying medicines. Treatment in private hospitals means an additional expenditure for consultation. This becomes a burden on the workers who are already underpaid. State intervention in health services and improving workers welfare are considered important requirements for policymakers. For the poor, treatment in private hospitals becomes an additional burden. The study also points to the availability of private hospitals and practitioners in rural and urban areas in Kerala.

22. Modernization of Fish Economy and Its Impact on the Well Being of Fishermen: A Case Study

Author/s: Pepin S
Publication source: Unpublished Ph.D. thesis, Jawaharlal Nehru University, 1986.
Year of publication: 1986
States covered: Kerala
Social geography: Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Individual Private Practitioners; Alternate Systems.
Issues addressed: Utilization of Private Sector; Government Hospitals, NGOs

Objectives:
This study examines the well being of fishermen in relation to the basic needs viz. Nutrition, health, education and related services, the availability of and accessibility to health services provided by the government and other agencies. The main objective of this study was to analyze the production relation in fish economy and its impact on the well being of fishermen.

Methodology:
This study was conducted in a village in Kanya Kumari district. Two major castes viz. Paravas and Mukkuvas among the fishermen have been represented here. The households in this village are stratified according to the kind of technology used for fishing viz. artisan fishing crafts and gears and mechanized crafts. In addition the merchants cum moneylenders and the middlemen cum money lenders featured in the stratification of the households. A total of 149 households representing these various strata were studied in depth to explore linkages between the ownership pattern, the credit and marketing system, type of technology used and its impact on the well being of fishermen.

Findings and conclusions: The section on accessibility to and utilization of health services shows a plurality in provisioning. There are government, private NGO and traditional healers in and around the village under study. The village is seven kilometers from the PHC and under this PHC there are 15 maternity centres, 21 allopathic private medical practitioners, 23 homeopaths, 8 Ayurvedic physicians and one siddha private practitioner. Eighty-eight percent of the households surveyed did not visit the PHC. The reasons included distance from the village and availability of other health institutions within the village. This study revealed that for common fevers about 73 percent of them used allopathic medicine, while 27 percent used indigenous medicine. Other diseases for which they resorted to allopathic medicine included ulcers, tuberculosis, appendicitis, whooping cough, scabies and diarrhoeas. For conditions like measles, chickenpox, jaundice and sprain/dislocation of bones, they resorted to traditional healers or indigenous practitioners whom the households perceive as 'effective' treatment. The utilization of private hospitals was less when compared to the 'non profit' institutions, followed by government hospitals. This study points to the plurality in provisioning and utilization patterns among the fishermen in Kanya Kumari district. With fishermen the presence of an active NGO, the hold of private practitioners is not as high. The type of facility chosen varies according to the nature of illness and even for a given condition the individual may resort to several healers. In this plurality of utilization pattern, the role of the private practitioner is not very prominent.

23. Morbidity Pattern, Health Care utilization and Per Capita Health Expenditure in a Rural Population of Tamil Nadu

Author/s: Rajaratnam J.R. Abel, Duraisamy. Sr, John, K.R
Publication source: National Medicine Journal of India, Vol. 9, no 6. Pp.1996
Year of publication: 1996
States covered: Tamil Nadu
Social geography: Rural
Data source: Primary
Type of study: Cross-sectional study
Type of private sector: Private practitioners, Indigenous practitioners, Allopathic
Issues addressed: Utilization of private services, Morbidity, expenditure

Objectives:
To collect information on the existing morbidity pattern, pattern of health care utilization and the per capita health expenditure so as to provide a need based health care delivery to a rural population.

Methodology:
The study was conducted in the K.V. Kuppam Block, North Arcot Ambedkar District, Tamil Nadu. It was a cross-sectional study, interviewing respondents form 300 households, from 3 panchayats using a multistage sampling technique. Information relating to 1440 persons was collected. The morbidity date was obtained initially for the week prior to the day of interview, followed by one week to one month and then for two months to one year.

Findings and conclusions: During 1990-91, 825 of the 1440 persons (57.3%) did not have any illness. Sex had no bearing on the number of incidents of illnesses. Of the 60 children less than 2 years of age, 42 (70%) had one of two incidents of illness. The period prevalence of infective and parasitic diseases was found to be 21.9% with an average of 3 episodes. Services rendered by private practitioners (registered, non-registered and indigenous) were utilized by 59% of the households and 79% of the households had used allopathic treatment at some time. The average per capita per annum health expenditure was RS 89.9 (Rs 449 per household). This increased significantly with increase in the household size (p<001) and per capita income (p<0.01). The health-seeking behaviour of this population can be changed if efficient services are rendered through government primary health centres and sub-centres. This would allow the existing voluntary agency to withdraw without much change in the per capita health expenditure.

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[ Complied by Sunil Nandraj (Centre for Enquiry Into Health and Allied Themes, Mumbai), V.R. Muraleedharan (Indian Institute of Techonology, Chennai), Rama Baru, Imrana Quadeer, Ritu Priya (Centre of Social Medicine and Community Health, JNU, New Delhi))