private health sector in india section iii

1. Patient Provider Interface: A Public Survey

Author/s: Medico Friend Circle
Publication source: Medico Friend Circle, Bombay Group, Mumbai
Year of publication: 1993
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit
Issues addressed: Quality, Regulation, Utilisation,

Objectives: The study aims to (1) understand patient's views on the present health care system to look at their experiences with the various health systems, and (2) study their perception on various aspects of present health care systems.

Methodology: A short questionnaire was published in the letters to the editor column of various newspapers, both in the English and the vernacular press. Also, various organization working with various groups were asked to give the questionnaire to the people and these were then collected from them.

Findings and conclusions: Nearly seventy-seven percent of the total episodes of 208 reported approached private health care. Among these, 69.7% suffered from acute illness, 5.3% received GP care, followed by 34.6% of the episodes, which received consultant care. With regard to waiting period newly, 61.1% of the episodes felt it was unreasonable. They had to wait for more than 20 minutes. According to information provided on figures, 40.9% of the episodes were not informed and 25.5% were informed only partially. With reference to information on side effects, 53.4% of the episodes reported that they were not given any information. Questioned on the reasonability of charges, 44.2% felt the charges were unreasonable. An equal number, 45.2% of the episodes, felt the charges were reasonable. Of them 58.7% were not given any receipt for the payment made and 64.9% of the respondents felt that there should be standardization of fees. The main expenditure per acute episode for non- hospital cases was Rs.182.

2. Perception of Users about Health Care Services in a General and Superspeciality Government Hospital of Delhi

Author/s: Pushp Lata, Ingle G.K, Singh, Saudan.,
Publication source: Maulana Azad Medical College, New Delhi.
Year of publication:
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:
Issues addressed: Consumer Issues, Public Hospitals, Satisfaction of Patients.

Objectives: In the developing world especially in India, there is a paucity of literature pertaining to users' satisfaction, hence a study was conducted to find out the perception of users about health care services provided in a General and Superspeciality Govt. Hospital and users' willingness to pay.

Methodology: Two hundred and forty patients from the outpatient Department (OPD) and 160 Indoor users of General hospital and 120 Indoor users of Superspeciality Hospital of Delhi were interviewed. Twenty OPs and 20 Indoor users from each discipline (except psychiatry) were interviewed. A sample frame was designed to include all the OPDs and wards of the hospitals. Indoor users were interviewed after they had received the discharge slip. OPD users were interviewed at the final exit point. Users were taken into confidence and relevant information was recorded on a restructured proforma.

Findings and conclusions: Out of 280 Indoor users 271 (96.8%) were satisfied. In General Hospital satisfaction was 94.4% and in Superspeciality Hospital 100% satisfaction was observed. Total of 97.9% users were satisfied with Doctors' services, 97.85% with Nurses' services, 97.9% with drug supply and 92.5% users were satisfied with investigation facilities in the hospital, A total of 95.3% users were satisfied with the hygiene in the ward, 96.9% with the quality of food provided in the hospital. A total of 68.9% of users were dissatisfied with the hygiene of toilets and bathroom. Out of 280 users, 166 (59.3%) were willing to pay. The percentage of users willing to pay according to different characteristics viz. age, sex, literacy, occupation and per capita income were as follows: 66.7% in 31-45 years vs 32% in > 60 years age group, 60.3% Males vs 58.1% females, 94% Graduates vs 35% primary educated, 100% semiprofessionals vs 32% unskilled worker, 87.5% with per capita income Rs. 2000/- 2999/- vs 41.7% with per capita income below Rs. 1000/-. The willingness to pay was directly proportional to the level of satisfaction.

Out of 240 OPD users, 214(89.2%) were satisfied and 26 (10.8%) were not satisfied with the hospital OPD services. A total of 92.2% were satisfied with Doctors' services, 44.2% with the investigation facilities, 58% with drug supply and 79.2% were satisfied with registration in the hospital. The percentage of users willing to pay according to different characteristics viz. age, sex, literacy, occupation, per capita income were as follows: 61.9% in 18-30 years vs 38.6% in 31-45 years age, 55.9% males vs 50.8% females, 33.7% illiterate vs 100% post graduates, 35.1% unskilled worker vs 84.6% clerk, shop owner, farm owners, 83.3% with per capita income Rs.3000/- and above vs 39.4% with per capita income less than Rs. 1000/-. There was no statistical relation between willingness to pay and level of satisfaction. Other studies from urban areas show that the users of public hospitals belong to the middle, lower middle-income groups and the poor. Apart from showing high levels of satisfaction with in-patient care, this study suggests that there is an association between satisfaction levels and willingness to pay. There is ample evidence to suggest that professionals and semi professionals are more willing to pay for services, compared to the unskilled workers.

3. Pharmacies, Self-medication and Pharmaceutical Marketing in Bombay

Author/s: Kamat Vinay
Publication source: Unpublished
Year of publication: NA
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:        Practitioners, Hospitals, Pharmaceuticals, Laboratory Investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Quality, Regulation, prices, Incentives,

Objectives: The study was conducted with a primary objective of critically examining the role played by the pharmacists, shop attendants, wholesalers, salesmen, and pharmaceutical representatives in the active promotion of the ethical sale of medicines over the counter promoting self-medication in India.

Methodology: The study was conducted in the city of Bombay between the months of April and August 1992 and between August to December 1993.The researcher interviewed 75 pharmacists in the city, 25 each from different localities such as low income, middle income and high income. The researcher actually participated in the day-to-day activities of the six identified pharmaceutical shops to get more information about their working pattern. Exit interviews were carried out of randomly selected sample of 150 people consisting of 70 males and 80 females. Drugs sales data was recorded for three full days in each of the six shops. The researchers interacted with 35 medical representatives informally and in-depth interviews were conducted with 14.

Findings and conclusions: Proliferation of the pharmacies: The large number of chemist shops in the study area had led to the cutthroat competition among the chemists. The survey of 75 chemists showed that 57% of the shops were started as pharmacies. The rest were started in the beginning as grocery shop, general store, a cosmetic shop, hair cutting saloon, dispensary, etc. The oldest shop in the study was established way back in 1910.

In most of the cases the shops were not managed by the pharmacists themselves but through the family members or salaried personnel. The customers were usually attended by the clerks or the shop attendants and not by the pharmacist. A majority of the pharmacists interviewed were unable to give the average per day figures of their customers. Rough estimates suggested that the figure was between 125 to 175 customers per day. Almost all the pharmaceutical shops under study insisted on the prescription regarding the drugs such as barbiturates, tranquilizers, sedatives, anti depressants such as calmpose, valium, etc. The customers requested for the medicines with or with out the prescription. The drug sales data revealed that out of 1599 customers interviewed, 64% purchased the medicines without a prescription. Seventy-four percent of such customers were from a high-income locality.

The purchase of the medicines was always dependent on its price. People with low incomes often consulted the shop attendant if the prices of the drugs were above their purchasing capacity. The attendants often suggested to them various options of buying only a few drugs which were very necessary and which were within their budgets. It was observed that in the low-income locality, 75 rupees was the upper limit of the people to spend on drugs. If the cost exceeded this limit, the attendant would give a word of caution to the customer. The maximum difficulty was found to be with the chronic patients than with the occasional buyers of the drugs. They were the ones affected the most by the rising prices. In one of the shops the researcher observed that people always grumbled about the prices of the drugs, which they purchased regularly.

It was observed that less than 25% of the customers buying medicines on prescription asked for the bill. The shopkeepers were reluctant to give bills as well. Many times patients were in a hurry and thus did not have the time for the bill. The bill was demanded only when the patient was hospitalized or the medicine was expensive or reimbursement was assured.
There was a chain of commissions and sub-commissions between the pharmaceutical companies, whole sellers and retailers. Various incentives such as percentage in the profit, cash discounts, credits, bonuses were given by the companies to their wholesale buyers and by the whole sale buyers to their retailers. The sales personnel of the companies always highlighted the bonus schemes, which the company was offering along with the purchase of the drugs. Many times the retailers first asked about such schemes even before getting to know about the merits of the drugs. Some shops also gave medicine on credit to a few selected customers. The pharmacy owners also offered gifts such as letter pads, calendars, etc. to the local doctors who in turn give prescription to their patients on same pads indirectly suggesting to them to go to that particular shop. In 75% of the pharmaceutical shops visited, the owners informed the researchers that around 35-40 salesmen visited their pharmacies every week from the wholesalers or the distributors. Medical representatives play a crucial role in promoting company's products because they maintain contacts with the doctors and give them various samples of their company's drugs. Seventy-two percent of the pharmacists admitted that they recommended substitutes when their stock got over. However only 345 said that their patients accepted the substitutes suggested. In one shop the researcher found that 50% of the patients came back to return the substitutes suggested by the chemists. None of the pharmacies covered in the study had maintained systematic stocks of the inventory to keep track of their stock position.

The study has concluded that the retail medicine business in Bombay is a lucrative one because of the high volumes of sales and profit margins. However, it has become an attractive place for businessmen who want to make profits with out fulfilling the legal requirements such as licensing, qualification required to run the business, etc. The medical shops rarely insist on the prescriptions. Drugs such as steroids, antibiotics, psychotropic drugs are bought over the counter. Often the customer does not follow the prescriptions. The pharmacy personnel are also responsive to the demands of the patients, as they fear of losing business. Social and economic class difference is observed in the practice of self-medication as the people in middle or higher income classes resort to it the most. The purchase of the over-the-counter drugs is influenced by the pharmaceutical industry as they promote such practice through various incentives and benefits they give to the pharmacists. Aggressive marketing strategies such as counter pushing, substitution are used by the M.Rs to increase the sales of their company. More attention should be paid at the system of promotional activities and the pharmaceutical marketing as it indirectly promotes self medication, use of irrational drugs, etc. The regulatory mechanism should be improved to keep a check on the malpractices in the pharmaceutical industry and enforcement of the regulation. Further study, which will lead to the self-medication, should be carried out to find ways of educating consumers on this aspect. Education and training of the staff at the pharmaceutical shops can be another way by which awareness regarding this issue can be promoted. Short-term training programs for the shop attendants should be arranged to give them adequate knowledge of the drugs that they dispense. Consumer education can be the most effective way of regulating the malpractices fostered by the pharmaceutical industry. Till this happens, the risks of pathogens developing drug resistance will persist.

4. Physical Standards in the Private Health Sector- A Case Study of Rural Maharashtra

Author/s: Nandraj S, Ravi Duggal
Publication source: Centre for Enquiry into Health & Allied Themes (CEHAT), Mumbai
Year of publication: 1997
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: Quality, Regulation, Personnel, Licensing,

Objectives: To study the existing physical standards of health care in rural areas provided by private practitioners & hospitals

Methodology: An average district was selected on the basis of CMIE socio economic indices of development. Two talukas one economically developed (Karad) and economically backward (Patan) were chosen for the study. The researchers had to compile a list of the practitioners and institutions existing in the two selected talukas of the district. The researchers used various sources such as handbooks, membership lists compiled by various local associations of doctors to get the information. Key informants such as drug stores, senior doctors, and government health officers were also contacted. A sample of fifty-three private practitioners and forty-nine private hospitals was selected. The tools consisted of a structured interview schedule along with an observation schedule and checklist for equipment.

Findings and conclusions: One-fourth of the practitioners were found to be unqualified, with the economically backward taluka, having nearly five times as many unqualified practitioners as the economically developed taluka. Of the total sample of practitioners, 40 per cent were allopaths, 52.5 per cent from Indian systems, and only 7.5 per cent were homoeopaths. In the economically backward district, however, a whopping 75 per cent of practitioners were from Indian systems, with only 8.3 % practicing allopathy. Even the non-allopathic and unqualified practitioners largely practiced modern medicine, despite not being trained for it. Though only 30 per cent of the sample were qualified allopaths, 79 per cent practised only allopathy. If you add this to those practising allopathy along with the system in which they were trained, the percentage of those actually practising allopathy goes up to 94.

Only 55 per cent of our total sample had the appropriate registration, and even amongst the qualified practitioners, only 72.5 per cent were registered. Only 38 per cent of the practitioners maintained any sort of case records, and in most cases this was merely a record of the medicines administered and amount collected/due. Essential equipment and instruments such as thermometers, sterilisers, examination table, weighing machine, sheets, towels, wash basin were sorely lacking in most functioning clinics. In Patan, only 36.4 per cent of practitioners had a thermometer, and only 9.1 per cent had any sutures or ligatures. Of the 49 hospitals surveyed, none have been registered by any authority, although the Bombay Nursing Home Registration Act is supposed to apply to all of Maharashtra. Most of the hospitals had between six and 15 beds. As many as 29 per cent of the hospitals were being run by doctors trained in other systems of medicine but they were providing allopathic cures. There were only three qualified nurses in the entire sample. Only 2 per cent of hospitals were treating emergency cases. Only 18 per cent of hospitals had the minimum facilities for pathological tests. None of the hospitals surveyed had blood banks or quick access to one. Only one quarter of the hospitals had uninterrupted power supply, and not a single hospital had an ambulance. Of the hospitals surveyed, 39 per cent functioned without a full-time doctor or visiting consultant. There were 14 hospitals, which did not have any nurses, at all even unqualified ones! In 71 per cent of the hospitals, not a single bedpan was available. Though most of the hospitals providing surgical services had OTs, only 71 per cent had an operating table, and 39 per cent shadowless lamps. Only 10 per cent of hospitals had an ECG monitor, 65 per cent a steriliser, and 56 per cent an oxygen cylinder. The findings of this study bring into sharp focus the haphazard growth of the private health sector, the unreliable quality of care, the poor implementation of existing legislation and the lack of standardisation in health institutions.
The study has revealed the inadequacy of the physical standards in private hospitals as well as in private clinics. It shows that the large-scale growth of private sector has not resulted in provision of health care to the masses. There are inequalities in the distribution of the health services. The situation warrants government intervention at the earliest. Private health services should be relocated and should be brought under regulation. Maintenance of records regarding fees, patients, diagnoses, etc. should be made compulsory. Minimum physical standards should be laid down and be made legally binding to make the private health sector accountable and people oriented. This study makes it obvious that there was an absence of state regulation and no minimum standards were laid down for the functioning of private hospitals. Even where regulations exist on paper, they are not enforced. The State and medical councils must ensure that only qualified persons practice. The government should encourage, through licensing and incentives, a more widespread geographical distribution of practitioners and hospitals to prevent over-concentration in urban areas. There must be regular medical and prescription audits, with renewal of licenses and registration dependent on such audits.

5. Prenatal Sex Determination Tests and Female Foeticide in Bombay City

Author/s: Kulkarni S
Publication source: Foundation for Research in Community Health (FRCH), Bombay
Year of publication: 1986
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Hospitals, For Profit
Issues addressed: Utilisation, Quality, Regulation

Objectives: To study the extent of spread of sex determination tests and female foeticide in the city of Bombay. Also to study any other aspects related to sex determination and female foeticide, and to know the views of doctors on this issue.

Methodology: 50 private gynecologists were selected randomly and approached with a questionnaire. Information was also collected through personal interviews. The second part of the study, which was to collect information from genetic laboratories, could not be undertaken since the laboratories refused to give any information.

Findings and conclusions: Eighty-four percent of the doctors performed amniocentesis. Eighty-seven percent of them have been performing these tests over the last five years. On an average, 42 doctors, between them perform 271 sex determination tests per month, while 64.37% of doctors perform the tests solely for sex determination. According to 73.8% of the doctors, 51-100% of the women who come for sex determination tests belonged to the middle class. According to a big majority of the doctors, the tests are accurate in 95-100% of the cases. Most of the doctors said that the majority of the women who come for sex determination have two or three daughters.

6. Prescription Audit Analysis - A study of Drug Prescription Practices in India.

Author/s: Ray Krishnangshu, Jaishree Mitra Ghosh, S.B Chaudhri, Adhip Mandal, Shivani Prasad
Publication source: Voluntary Consumer Action Network (V- CAN), Consumer Unity & Trust Society, Calcutta.
Year of publication: 1996
States covered: Rajasthan, West Bengal, Gujarat, Maharshtra, Tamil Nadu, Andhra Pradesh
Social geography: Urban & Rural
Data source: Primary
Type of study: Cross Sectional, Prospective
Type of private sector: Pharmaceuticals, Practitioners, Hospitals
Issues addressed: Utilisation, Regulation, Quality, Costs, Consumer, Licensing

Objectives: To explore the prescribing practices of both general practitioners and consultants practicing either privately or attached to Government organisations. To ascertain the cost effectiveness of each prescription by estimating the total cost v/s rational cost.

Methodology: The study was conducted in 6 states, Rajasthan (Jaipur, Ajmer, Masuda, Beawar, Chittorgarh) West Bengal (Calcutta), Gujarat (Ahmedabad), Maharashtra (Bombay), Tamilnadu (Cuddalore, Trichy) and Andhra Pradesh (Vijaywada, Guntur, Tenali, Mangalagir. Around 2000 prescriptions were randomly collected either from local pharmacies or directly from consumer interviews. All prescriptions were entered into the specially designed prescribed Proforma. These prescriptions belonged only to allopathic doctors. In the Government hospitals prescriptions were collected mainly from the O.P.Ds. For assessing the rationality of each prescription, the 'Prescription Audit Guidelines' by WHO and modified guidelines developed by Phadke A and others (FRCH,1995) were followed. The guidelines included completeness of each prescription, scrutiny of each prescription and rationality scoring. The cost of each prescription was calculated. All incomplete and illegible prescriptions were excluded. The cost of each drugs was calculated from the available current price lists mentioned in latest editions of MIMS, CIMS, Drugs Today and Indian Pharmaceutical Guide. Interviews with chemists were also conducted to ascertain the costs of the drugs.

Findings and conclusions: West Bengal (Calcutta): A total of 250 prescriptions were analyzed. Out of these 125 prescriptions (50%) were considered incomplete, 65 prescriptions were obtained from General Practitioners in which 50% were rational, 31% were acceptable and 19% were irrational prescriptions. Forty prescriptions obtained from consultants in which 75% were rational, 20% acceptable where as 5% were irrational. Amongst all prescriptions 8% of the prescriptions were grossly unscientific and alarming and most were obtained from private practitioners. Consultants were more rational than fresh medical graduates were. The average estimated total cost of eligible prescriptions (125) was Rs.72.81, whereas the rational cost was Rs. 58.62. The average cost difference was Rs. 14.19
Andhra Pradesh: A total of 307 prescriptions were analyzed. Out of these 88 prescriptions (20%) was incomplete. 108 prescriptions were obtained from General Practitioners in which 61% were rational, 20% were acceptable and 19% were irrational whereas out of 99 prescriptions by consultants 65% were rational 21% were acceptable and 14% irrational. About 4% of all prescriptions turned out to be alarming. General Practitioners and consultants wrote equal amount of rational prescriptions, which showed that post - graduate studies did not necessarily improve the quality of prescriptions prescribed by consultants. The average estimated total cost of eligible prescriptions (219) was Rs. 57.25 whereas the average rational cost was Rs. 42.80. The average cost difference calculated was Rs. 14.45.
Rajasthan: A total of 291 prescriptions were analyzed. Out of these 70 prescriptions (27%) were incomplete. 133 prescriptions were obtained from General Practitioners in which 50% were rational, 33% acceptable and 17% were irrational. Out of 74 prescriptions by consultants, 54% were found to be rational, 30% acceptable and 16% were irrational. About 5% of all prescriptions were alarming. Prescriptions obtained from Jaipur showed an increase in the number of incomplete prescriptions and consultants wrote the majority of rational prescriptions. The average estimated total cost of eligible prescriptions (221) was Rs. 63.25 whereas the average rational cost was Rs. 29.75. The cost difference calculated was Rs. 33.50
Maharashtra: A total of 350 prescriptions were audited. Out of those 91 prescriptions (26%) were incomplete. Prescriptions were obtained from General Practitioners in which 46% were found rational, 33% acceptable and 21% were irrational. Ninety eight prescriptions were obtained from consultants in which 64% were found rational, 20% acceptable and 16% irrational. About 8% of all prescriptions were alarming. Consultants were comparatively more rational than General Practitioners. The average estimated total cost of eligible prescriptions (259) was 48.15 whereas the average rational cost was Rs. 32.60. The average difference calculated was Rs.15.55
Gujarat: A total of 304 prescriptions were analyzed out of which 65 prescriptions (21%) were incomplete, 174 prescriptions were obtained from General Practitioners among which 50% were rational, 24% were acceptable and 26% were irrational. 65 prescriptions were obtained from Consultants. Among them 75% were rational, 15% were acceptable and 10% were irrational. About 10% of all available prescriptions were alarming. Consultants wrote the majority of rational prescriptions. The average estimated total cost of eligible prescriptions (239) was Rs. 62/-, whereas the average rational cost was Rs. 57/-. The average cost difference calculated was Rs. 5/-.
Tamilnadu: A total of 269 prescriptions were analyzed. Out of those 40 prescriptions (15%) were incomplete. Prescriptions were obtained from General Practitioners and among them 50% were rational, 25% were irrational. Fifty-two prescriptions were obtained from consultants in which 48% were rational, 36% acceptable and 16% were irrational. The number of rational prescriptions by both General Practitioners and Consultants were more or less equal. The number of acceptable prescriptions was higher amongst the consultants. The average estimated total cost of eligible prescriptions (229) was 79.50 whereas the average rational cost was Rs. 58/-. The average cost difference calculated was Rs. 21.50
Practitioners prescribed the costliest prescriptions on diseases that required only symptomatic medicines. These diseases include common cold, viral fever, general debility in elderly people, diarrhoeal diseases etc. Useless prescriptions of antibiotics or restoratives in such conditions increased the total cost of therapy. These costly prescriptions were rampant amongst both General Practitioners as well as Consultants but comparatively lower in the prescriptions available from Government Hospitals.
Cost versus rationality assessment: The average cost of rational prescriptions obtained from total samples was Rs. 40.85 whereas the average cost of alarming and irrational prescriptions was Rs. 114. It was clearly evident that the cost difference between the rational and alarming groups was Rs 73.15. It was also evident that the degree of irrationality in prescribing habits accelerated the cost of therapy and vice - versa. Since faulty drug information or biased prescribing habits cause the irrationality, the correction of both these pertinent factors might protect the consumers from financial loss and exposure to hazardous formulations.

7. Present Day Private ICU / ICCU in the City of Mumbai and the Patients Right to Healthcare

Author/s: Parmar Heart
Publication source: Bombay University, Mumbai
Year of publication:
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Hospitals, Laboratory/investigation, ISM, For profit
Issues addressed: Quality, Regulation, Licensing

Objectives: To study the extent to which patients' rights are respected or violated by private Intensive Care Unit (ICU) / Intensive Critical Care Unit (ICCU) in Mumbai. To study the infrastructure, equipment, staffing and overall functioning. To examine the existence and non existence of regulation by various bodies expected to be responsible and their role.

Methodology: 40 private hospitals were selected from the central and western suburbs of Mumbai which displayed an ICU / ICCU board. The hospitals included those that were run individually, partnership ventures and those run by businessmen in collaboration with practicing doctors. A questionnaire was administered to either the owner doctor, Resident Medical Officer (RMO) or nurse on duty. The questionnaires were prepared based on a review of standard critical care books and literature available. Attempts were made to check and know about the working conditions of equipment, oxygen cylinders and central oxygen.

Findings and conclusions: There was absence of new and sophisticated gadgets that were needed for critical care. Life saving drugs was not stored in sufficient quantity. All hospitals in the sample employed non-allopathic doctors on a round the clock duty for critical care, where experienced, qualified specialists were needed. Basic cleanliness was absent. The charges per day levied on patients were exorbitant. There was total lack of holistic approach and teamwork amongst the specialists. There were no attempts made to upgrade the unit or the application of basic knowledge and concepts in critical care. During many discussions, cardiologists, physicians, surgeons and others who ran such hospitals themselves admitted that such units cannot be proclaimed as ICU / ICCU at all. The study found that many of those deaths in private ICU / ICCU could have been prevented, if the admission had been made in an higher level institution. Many of the deaths were hushed up and the belief of the public that 'death in ICU / ICCU is expected' was taken advantage of. The lack of awareness about what is expected in terms of 'critical care' has helped the mushrooming of these units. The study also found out that the phenomenal mushrooming of private ICU / ICCU hospitals parallels the commercialization of the medical profession after 1985 onwards. Kickbacks and commission in medical practice has been responsible for admissions to such units.

As a first step, people should be made aware of their rights and doctors their duty vis-à-vis health care for people. The patients should have access as a mater of right to 'minimum standards' of these services for which admissions are done. There is a need to lay down standards for every hospital and nursing homes, and they must be made legally binding. There is also a need to formulate laws, rules and regulations for private hospitals. Lastly, current private ICU / ICCU hospitals in Mumbai must recognize and adapt to the realities of available resources rather than permitting inadequate care detrimental to the health and life of the public and against all human rights.

Present Day Private ICU / ICCU in the City of Mumbai and the Patients Right to Healthcare

Author/s: Parmar Heart
Publication source: Bombay University, Mumbai
Year of publication:
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Hospitals, Laboratory/investigation, ISM, For profit
Issues addressed: Quality, Regulation, Licensing

Objectives: To study the extent to which patients' rights are respected or violated by private Intensive Care Unit (ICU) / Intensive Critical Care Unit (ICCU) in Mumbai. To study the infrastructure, equipment, staffing and overall functioning. To examine the existence and non existence of regulation by various bodies expected to be responsible and their role.

Methodology: 40 private hospitals were selected from the central and western suburbs of Mumbai which displayed an ICU / ICCU board. The hospitals included those that were run individually, partnership ventures and those run by businessmen in collaboration with practicing doctors. A questionnaire was administered to either the owner doctor, Resident Medical Officer (RMO) or nurse on duty. The questionnaires were prepared based on a review of standard critical care books and literature available. Attempts were made to check and know about the working conditions of equipment, oxygen cylinders and central oxygen.

Findings and conclusions: There was absence of new and sophisticated gadgets that were needed for critical care. Life saving drugs was not stored in sufficient quantity. All hospitals in the sample employed non-allopathic doctors on a round the clock duty for critical care, where experienced, qualified specialists were needed. Basic cleanliness was absent. The charges per day levied on patients were exorbitant. There was total lack of holistic approach and teamwork amongst the specialists. There were no attempts made to upgrade the unit or the application of basic knowledge and concepts in critical care. During many discussions, cardiologists, physicians, surgeons and others who ran such hospitals themselves admitted that such units cannot be proclaimed as ICU / ICCU at all. The study found that many of those deaths in private ICU / ICCU could have been prevented, if the admission had been made in an higher level institution. Many of the deaths were hushed up and the belief of the public that 'death in ICU / ICCU is expected' was taken advantage of. The lack of awareness about what is expected in terms of 'critical care' has helped the mushrooming of these units. The study also found out that the phenomenal mushrooming of private ICU / ICCU hospitals parallels the commercialization of the medical profession after 1985 onwards. Kickbacks and commission in medical practice has been responsible for admissions to such units.

As a first step, people should be made aware of their rights and doctors their duty vis-à-vis health care for people. The patients should have access as a mater of right to 'minimum standards' of these services for which admissions are done. There is a need to lay down standards for every hospital and nursing homes, and they must be made legally binding. There is also a need to formulate laws, rules and regulations for private hospitals. Lastly, current private ICU / ICCU hospitals in Mumbai must recognize and adapt to the realities of available resources rather than permitting inadequate care detrimental to the health and life of the public and against all human rights.

8. Preventive Measures against Hospital Aacquired Infections : Awareness and compliance by health care delivery staff with special emphasis on AIDS

Author/s: Suresh R
Publication source: MPH dissertation, Achutha Menon Centre for Health Services Studies, Thiruvananthapuram, Kerala, 1999
Year of publication: 1999
States covered: Kerala
Social geography:Data source: Primary
Type of study: Cross sectional survey of medical and paramedical staff
Type of private sector: For profit and government hospitals
Issues addressed: Quality of care.

Objectives: (1) To assess the extent of knowledge about AIDS (especially about its spread) among the health service delivery staff,
(2) to observe the actual practice followed by them in preventing HIV infection and (3) to study the reasons for non-adherence to guidelines, if any.

Methodology: The study sample consisted of a total of 379 staff including doctors, nurses, laboratory technicians and nursing assistants working in different hospitals and laboratories in Thiruvananthapuram district. The survey was carried out during January February 1999. Two hospitals and one laboratory, and two blood banks from public sector, and three 75-150 bedded private hospitals and three small private clinics were selected. The researcher included, in the study, all the staff on duty at the time of the visit. Both direct observations of staff activities and discussion with them provided the data for the study.

Findings and conclusions: The results of this study indicate that there was no significant difference in knowledge between those who were trained and untrained. The knowledge on AIDS control measures as perceived by the individuals was quite good irrespective of whether they received training or not. In actual practice, the correct procedures were not followed. This was more obvious in wards while the procedures were followed to a certain extent in operation theatres. Blood banks maintained a very high standard on control measures but laboratories were not up to the mark. The main obstacle in the way of implementing the AIDS control measures appears to be operational. The main problem seems to lie in the system itself. The system suffers from two flaws: one is money-driven and the other is management-driven. Both will have to be weeded out in order to have successful control of AIDS.

9. Private Nursing Homes / Hospitals: A Social Audit

Author/s: Nandraj S
Publication source: Committee for Regulating Private Nursing Homes and Hospitals, Mumbai High court
Year of publication: 1992
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Quality, Regulation, Personnel, Licensing,

Objectives: To find out the conditions of private nursing homes/ hospitals in the city of Bombay and to find out the functioning of private nursing homes/hospitals. This study was undertaken for the committee set up by the Bombay High Court to go into the regulation and the laying down of minimum standards for nursing homes and hospitals.

Methodology: The nursing homes/hospitals were selected on a random sample basis from each of the wards in the Eastern zone of Bombay. The researcher visited twenty-four nursing homes/ hospitals and physical verification was done along with a checklist and an interview guide.

Findings and conclusions: Fifty percent of the nursing homes are either in a poorly maintained building or they are in dilapidated condition. A seventh of them are run from sheds or left in slums. Most of the nursing homes are congested, lack adequate space. The passages are congested, and entrances are narrow and crowded. Seventy-seven percent do not have scrubbing rooms. Less than a third have qualified nurses. Seventy-seven percent of the nursing homes that have an Operation Theatre did not have a sterilization room while 66.7% did not have a generator. None of the nursing homes incinerate infectious waste material but instead dump it in municipal bins. None of them keep records of notifiable diseases.

10. Private Nursing Homes and Their Utilization: A Case Study of Delhi

Author/s: Nanda, P. and Baru, R.,
Publication source: Voluntary Health Association of India; New Delhi, 1993.
Year of publication: 1993
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Nursing Homes, Private Practitioners
Issues addressed:Heterogeneity of Private Sector; Organization of Private Sector, Subsidies Received, Government Policy, Utilization of Private Sector, Regulation, Staffing

Objectives: To study the trends, characteristics and services offered by the private medical sector in Delhi. To discern the factors that influence the choice of health care and gauge how the trends in privatization affect individual choice.        .

Methodology: This study of nursing homes and hospitals was conducted in Delhi. The nursing homes were selected on a stratified, random sample in order to capture the variation and heterogeneity of institution according to ownership and size. A total of 68 nursing homes from upper income, middle class colonies and resettlement colonies were covered. In addition to the institutional study, the profile of users of medical services was undertaken.

Findings and conclusions: There were approximately 1200 to 1300 nursing homes and about 7000 private medical doctors in Delhi. A very small percentage of the nursing homes had obtained government support in terms of land, custom duty exemption, or tax exemption. An exercise to rank the areas where there is maximum return revealed that these were OPD followed by maternity, general surgery and investigative facilities. A majority of these nursing home offer out patient services but confined in patient services to maternity and surgical services. The promoters of small nursing homes are mainly from both business and professional backgrounds while a majority of the promoters of middle and large enterprises hail from business families. Getting information on staffing was difficult. However, the promoters expressed difficulty in getting nurses. They recruit mainly grade 'B' nurses and the turnover rate among them is found to be high. Further, the prevalence of consultants attached to these nursing homes is found to be high. The social background of the users is related to the size of nursing homes. The small nursing homes cater mainly to low-income families; the medium sized nursing homes are used mainly by middle-income families. The second part of the study focusses on trends in utilization among residents from resettlement colonies. For initial treatment the preference is for the private practitioner and 60 percent of the people interviewed in the resettlement colony opted for it. However, when it came to major complaints requiring hospitalization a high 80 percent opted for government hospitals. This study also highlights the utilization of Ayurveda and homeopathy along with allopathic services. The interviews at the government hospital show that for minor treatment both the lower and middle income use these services. The lower income group uses the private sector very little. The usage of private nursing homes increases with income levels.
This study provides insights into the heterogeneity in provisioning of services and plurality in utilization patterns. The heterogeneity and haphazard growth of the private sector clearly points to the need for some planning, which would include registration and regulation. The utilization of medical cares shows that a high percentage of people resort to the individual private practitioner for initial treatment. However, for minor and major ailments people use the government and municipal hospitals. Although more poor people use the government hospitals, the middle and higher income groups also use them for major ailments. These trends have implications for policy since high utilization for out patient services in the private sector must not be equated with high utilization for inpatient treatment as well. Secondly, a fairly high percentage do use the public sector. Therefore, this aspect needs to be considered while making a policy. A low rate of registration of private nursing homes in Delhi is of concern since registration is the first step towards any other effort at future regulations. Here, there is a need to document the experiences of registration and the constraints faced. There is also a needs to create systems for monitoring quality of services and cost of care.

11. Private Practitioners and their Role in the Resurgence of Malaria in Mumbai (Bombay) and Navi Mumbai (New Bombay), India: Serving the affected or Aiding an Epidemic?

Author/s: Kamat Vinay
Publication source: Unpublished
Year of publication:
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:Practitioners,Laboratory/investigation,ISM, Unqualified practitioners, For profit, Not for profit
Issues addressed: Utilisation, Prices, Costs, Quality, Regulation

Objectives: To study the practice the role of private general practitioners (GPs) in the management of malaria at a time of a 23 severe malaria epidemic

Methodology: An ethnographic study was carried out in Mumbai and Navi Mumbai. The study consisted of a sample of 48 private practitioners. The study utilised interviews, followed by a discussion of the data gathered through unstructured interviews with practitioners and patients, complemented by observational data on doctor-patient encounters gathered at 16 clinics over a nine-month period.

Findings and conclusions: The findings of the study suggest that many practitioners in Mumbai and Navi Mumbai were poorly qualified and did not play a supportive role in the ongoing efforts of the public health departments of the two cities to bring the epidemic under control. The majority of the practitioners had adopted diagnostic and treatment practices that were not consistent with the guidelines laid down by the WHO and India's National Malaria Eradication Programme (NMEP). Very few practitioners, especially those practising in low-income areas, relied on a peripheral blood-smear test to make a diagnosis. Practitioners whose clientele was mostly the poor, commonly resorted to giving one-day treatment that often included injectable antimalarials and broad-spectrum antibiotics to febrile patients. Such practitioners volunteered to justify their mode of diagnosis and treatment by asserting that they were only responding to the demands placed on them by their patients who could not afford a blood-smear test or a full prescription. The study argues that practitioners, who acquiesced to patient demands, were at once exacerbating the health problems of their patients and jeopardizing the prospects of the epidemic in the two cities being brought under control. Driven primarily by profit motives, the need to retain the patronage of patients and maintain one's popularity in a highly competitive health arena, such practitioners practiced medicine that was unethical and dangerous. A plea is made for a more empirically grounded and ethnographically authenticated health policy.

12. Public Private Partnerships in Health Sector: Issues and Prospects

Author/s: Bhat Ramesh
Publication source: Indian Institute of Management, Ahemdabad
Year of publication: 1999
States covered: Rajasthan, Maharashtra, Tamil Nadu, Delhi, Punjab, West Bengal
Social geography: Rural and Urban
Data source: Secondary
Type of study: Review cum Policy paper
Type of private sector: Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issue addressed: Partnerships, Incentives, Organisation, Utilisation

Objectives: Today most of the state governments face the problem of shrinking budgetary support and thus findi it difficult to provide and expand health facilities and thus cater to the health needs of the people. To overcome this problem, several state governments are trying to involve private sector in public health care activities and to work jointly. This is done in the hope that private sector involvement would bring investment into the health sector and would provide health services to the people.
The paper has given an account of the policy initiatives by various state governments to develop such relationships between the public and private sector.

Methodology: Policy Context: The government budgetary allocations for the health sector are low and with the changing technology the government are not able to cater to the health needs of the people at various levels such as primary, secondary and tertiary. Emphasis has been given on the control of communicable diseases overlooking the important curative and tertiary areas. In most states the salary component accounts for over 70% of the total budget. Due to the economic pressures, governments are cutting down their expenditure and this has affected the improvement of quality as well as the quantity of the curative health care. The option of meeting this expenditure through user fees has been tried out by various state governments. However, this could not provide a solution since the receipts were less than the expenditure. In 1992-1993 the average hospital receipts were 1.4 % of the total hospital expenditures. The involvement of the private sector is another option. In recent years, the private sector has emerged as a dominant sector. In 1997, the private expenditure on health was estimated to be 4.25% of the GDP. Recent data has suggested that 80% of the qualified doctors work in the private sector. In recent times, government has started looking at Public-Private Partnerships as a viable option for the health care delivery.
Public-Private partnership initiatives: Offer of sites for the specialty/superspeciality hospitals in Punjab: Government of Punjab had proposed to start a partnership venture for setting up specialty or super specialty hospitals. The share of the government was supposed to be in the form of subsidized land. The bids were invited for six locations having an area of 5 acres to 10 acres. In response Punjab Urban Development Authority received 20 bids out of which 12 respondents were short-listed. However, the bidding institutions insisted on specific locations and a workable agreement could not be reached. In a few cases land was allotted but later the deal was cancelled. In 1997 the government revived the proposal and invited fresh proposals for 5 specified locations. However PUDA did not provide adequate information about the locations. No detailed policy document was available regarding this proposal. The total expected costs were 500 million, excluding the land costs. Only those bidders who had at least 10 years' of experience could set up the hospitals. The response to the new proposal was very poor. Only five applicants showed their interest in the proposal. The entire process of revising of initiative took 2 years and the selection was not finalized. The Director of health services, Government of Delhi proposed to set up 10 hospitals as joint ventures on the sites available with the government. It was planned to acquire the hospitals from the Municipal Corporation of Delhi. The proposal indicated that government 's contribution would not exceed 26% of the total share capital. It was in the form of the land price. In cases where land prices were less than 26% of the total share capital, the government had promised to contribute other resources to meet the capital requirement. The government laid down the condition that 1/3rd of the broad nominees would be from the government. The applicants were given the option of either setting up hospital or a superspeciality facility. Each facility was expected to offer free care to a certain percentage of Out Patient Department and In Patient Department patients. The bidding institutions were required to specify the percentage of OPD and IPD care they propose to provide. More than 30 applicants responded to the proposal since it was commercially attractive. However the proposed location of the facilities attracted public attention and a public interest litigation case on social grounds was filed in the Delhi high court. The court issued a stay order against the scheme.
Private Investment in Medical Institutions: The policy document of the Rajasthan government was the most comprehensive policy statement on public private partnership by any state government. In order to encourage private investment in hospitals, nursing homes, diagnostic centers, etc. Medical and health departments of the Government of Rajasthan came out with a policy in 1996. In the policy statement, the government specified the need for development of effective secondary and tertiary care system. It acknowledged the financial crunch faced by the government and the need for efficiency and better clientele servicing. These were specified as reasons for involving the private sector in health care. The policy document of the Government of Rajasthan provided land at subsidized rates as well as the duty exemption and other benefits to attract private investment. GOR also provided fiscal incentives on all medical equipment, plants and machinery under a condition that they were from the approved list of DOHFW and the facilities were set up before 31 March 1999.A time frame of two years was given from the date of allotment for the use of the allotted land. However, the implementation of the policy was difficult due to the procedural constaints. The proposed locations were not declared at the beginning and it led to a considerable amount of confusion. Getting clearance from various departments was a difficult task. As a result, the policy proved to be unsuccessful.
Involving Industry and Non Government Organizations in Running Public Health Centers (PHCs): The Government of Tamil Nadu evolved a scheme involving the industry in improving the performance of the PHCs. The industry was supposed to adopt a local PHC. They had the responsibility of maintaining, and equipping the facility. The scheme got a reasonable response from the companies and they adopted the PHCs, which were in their vicinity. In Gujrat, an NGO, SEWA-Rural was given the responsibility of the PHCs in one district. The government financed the project. The PHCs were to be manned by the SEWA people. The institution was required to fulfil all targets set under various health schemes, which the government had fixed from time to time.
Private involvement in MOFW, GOI RCH program: The RCH implementation scheme declared by the government has made a provision for hiring services of private anesthetists on payment of Rs.500. per case. In case of MTP, the district can engage the services of a private doctor once in a week or a fortnight for performing MTPs and they would be paid Rs. 500 per visit. The schemes also included number of other measures such as involving NGOs for various components of the RCH program.
Contracting out of Services: Another way by which public private partnership was formed was through contracting out of the clinical and non-clinical services. On clinical side it included speciality care services reaching to the targeted population. Non-clinical services included services such as dietary services, laundry services, Security, etc. The Directorate of health and Family Welfare allowed the District Health Committee to hire the services of private doctors on a contract basis. The West Bengal government and DOHFW decided to employ private practitioners on the PHCs to fulfill the manpower requirements. It also proposed to bring 341 PHCs under the control of Panchayat Samities, which would also have the power to employ the private practitioners. The contracting out of the non clinical services such as dietary services, laundry services, security, etc. was done in states such as Maharashtra, Tamil Nadu, and W. Bengal. In recent times a new trend of contracting out of the specialized and super specialised health care departments has emerged. Maintenance of equipment's and facilities is another area where contracting out is done.

Findings and conclusions: The study has concluded that in our country, the Public-Private initiatives are in a premature state. Without the availability of a proper institutional mechanism, these ventures have a very low success rate. While designing a Public Private Partnership (PPP) venture, the government should pay attention to the following aspects
Information: The process of PPP starts with the policy statement from the government, defining the scope and nature of any proposed partnership. The central and state governments should clearly define its policies regarding partnerships . It should specify the terms and conditions under which such partnerships can take place. The clarity of the information would make it easier for the private bidders to take decisions. Along with the availability of information the other thing required is the appropriate mechanisms to involve the stakeholders and the transparency. The involvement of the partners and the stakeholders in the process can be a way of ensuring a close partnership.
Co-ordination and monitoring: The finalisation of the partnerships requires co-ordination between various departments such as finance, urban development, industry, etc. Inter departmental policies should be carefully formed to make the partnerships convenient. The experiences of various states have suggested that in the past the governments lacked in developing mechanisms to co-ordinate between various departments. Another important area is the monitoring of the PPP ventures. With out a proper monitoring mechanism, the private sector might operate unregulated and might exploit people. The authority should ensure that the private partner meets all the requirements regarding safety, quality, etc.
Public Goal and Private Initiative: The partnership between the public and the private sector should be evolved taking in to mind the surroundings and the local needs. The issues of quality and cost are the issues on which there is a difference of opinion. Consumer protection has to be ensured. The issue of equity which has been the primary principle of the public sector should be assessed along with the private motive. Ensuring equity and the access is the most difficult task. To find the appropriate way out, various mechanisms such as strengthening the public facilities along with the growth of the private sector should be tried out.
Market subsidy and Incentives: In most of the cases of the public private partnerships, the government input comes in the form of the subsidized inputs such as land. This is done to encourage the private investor to come forward. The private provider in return has to provide free care to a section of the society. There is a need to find out more such ways of PPP.
Institution and Organisation: There are various institutional and organizational issues, which emerge during the process of public private partnerships. The issue of staffing and control over the staff is a key area where more study has to be done. Because too much of control would hamper the process since the private providers would hesitate to come forward.
The study has emphasized the importance of the Public Private Partnerships as a form of privatization. If implemented properly, these ventures could provide an efficient and equitable option of health care delivery.

13. Public Health-Urban Society Interface: A Study Of Pneumonic Plague In Surat

Author/s: Shah Ghanshyam
Publication source: Centre for Social Studies, Surat
Year of publication: 1996
States covered: Gujrat
Social geography: Urban
Data source: Secondry
Type of study: Case study, Review paper
Type of private sector:Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Utilisation, Quality, Regulation

Objectives: The outbreak of a deadly infectious disease (widely believed to be the pneumonic plague) which gripped Surat in 1994, created widespread panic not just in the country but throughout the world. Though the disease was controlled within a week, it had raised many fundamental and still unresolved issues concerning the state of the public health system and the path of urban development in India.

Methodology: This study treats the Surat episode as a symptom of a socio-political disease related to the value system of the populace, the lopsided nature of development, the crises in governance, and a fragile and fragmented civil society.

Findings and conclusions: In Surat, the plague first broke out in the outskirts. Floods preceded the plague in Surat. Constant rain for nearly three months followed by the floods caused unusual water logging in many parts of the city. After the floodwater began to recede people began to clean their surroundings. In this process, some might have handled or come in contact with dead and infected rodents and developed the disease. The disease however immediately spread to all parts of the city, including the posh areas. The local population was the most affected and a larger number of males than females were victims of plague. The news about the outbreak of the plague was not equally disseminated to all the citizens. The doctors were the privileged group that first got the news of the outbreak of the plague. At the first instance people from the lower middle and lower classes were deprived both of information and medicine. Following the death of a few people, rumours spread about poison in water and release of poisonous gas in the air. These had communal overtones, in which the members of the minority were the victims of suspicion for the act.

As soon as the news broke out, doctors in the area immediately closed their dispensaries. Besides a large number of private practitioners, many doctors employed or attached to the charitable public hospitals also absconded from the city. Among the doctors as many as 70% fled from Surat and not all those who remained, attended their duties. But a few performed their duty with sincerity and many out of moral conviction. The doctors of the New Civil Hospital (NCH) worked against all odds but a few attended duties out of fear of suspension from the job. The apathetic attitude rendered by the doctors towards their services made people very angry and as a result a small crowd of 200 people ransacked the clinics of several doctors. Cases were filed against medical practitioners who ran out of the city, on the ground of negligence of duty. An agitation was launched against important municipal officials such as the Administrator, the Deputy Commissioner (Health), the Director of Urban Development and the Deputy Health Commissioner.

After the floods, the SMC health department in the second week of September registered more than 2000 cases of diarrhoea and gastrontitis. Quite a few died of a 'mysterious disease' that was neither diagnosed as malaria nor pneumonia. Private doctors did not report deaths of such instances to the SMC and they failed to detect fatal cases. The surveillance team was not quick enough to act swiftly and their presence was not felt by the cross sections of the society. Municipal staff deployed to collect garbage, spraying of insecticides and distribution of medicines was inadequate. Half of them abstained from duty till they were threatened for penal action. At the same time those who were performing their duty were not protected by minimum measures for safety and protection like gloves, mask, goggles etc. Quite a few sanitary workers were bare footed collecting garbage and carcasses.

There was no co-ordination among various departments, needed for the efficient management of the crises. The information network regarding the diagnosis and treatment was narrow. Many staff members were excluded from getting information and hence were alienated from the working of the hospital. Conflicts between the hospital staff and the officials of the health department (services) came to the fore during the crises, which further lowered the image of the public health system. Record keeping was adhoc and apathetic. Drugs were not available in the required quantities especially, in the initial, crucial stage. 'Secrecy' in keeping evidence created distrust in the diagnosis and in the functioning of the public health system. Besides scarcity of drugs, the public was given contradictory information regarding the disease, administration of drugs and number of deaths. The members of the public depended upon getting information from private doctors who were by and large indifferent to public health.

The plague in Surat is a warning of a series of epidemics that the country could face in the coming years with changing ecology, environmental degradation and uneven growth. Policy makers in and outside the government have to deal with the main social cause of the disease, and not just merely the symptoms. The fragmentary approach to economy and health has to be replaced with a holistic approach. Preventive medicine should be the core of the public health system. The public health system has to be expanded to meet the needs of the poorest of poor.

14. Quality of Heath Services In Rural India - A Comparative Study of Three States

Author/s: Khan M.E, A.K. Tamang
Publication source: Operation Research Group (ORG), Baroda
Year of publication: 1987
States covered: Bihar, Gujrat, Himachal Pradesh
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: Quality, Utilisation

Objectives: To study the functioning, the quality of services provided, and the obstacles faced by the PHC/Sub center. To analyze peoples' perception about the functioning of the PHC / Sub center and the reason (given by them) for its non-utilization.

Methodology: The study was conducted in Bihar, Gujrat and Himachal Pradesh. Within each state 2 districts, and within each district one PHC was selected. One PHC in one district of each state selected was a tribal or a remote primary health center. A multi disciplinary approach was adopted. The data for the study was collected using anthropological approach as well as through intensive in-depth discussion with state and district level officials, PHC doctors and field staff, village health practitioners, and community members.

Findings and conclusions: One of the major problems of the state of Bihar was rampant corruption at all levels of government services together with the total lack of authority among the programme managers in giving reward or punishment for the work of their subordinates. In Bihar, it was found that the PHC doctors were primarily busy in private practice as government had allowed them to practice privately during their off-time. However, most of them first attended their private practices and then came to the PHCs, often very late. As a result, the patients in a hurry or in an emergency had no choice but to pay the doctor his fees for consultation or go to some private practitioners. Private practice was observed in Gujarat too. In all the three states it was found that doctors were not ready to serve in backward and tribal areas. They preferred to work privately so that they could earn more money. Doctors joining government service insisted on getting posted at their place of preferences. Doctors who agreed to serve in tribal areas practiced privately in those places. Doctors were found to charge patients for injections and medicines during OPD. The higher authorities ignored these facts, perhaps because they did not have doctors to replace them.
The poor turnout of patients in PHCs particularly in Bihar was largely because of low credibility of the doctors among beneficiaries and also their lack of confidence about the availability of doctors at PHCs. This was of the highest order in Bihar. Doctors were available at the PHCs only for 2 hours a day, in Gujarat 3 hours a day. In Himachal Pradesh where the non-availability of doctors was not an issue, one doctor was available to attend OPD for 7 hours. The supply of medicines was inadequate, irregular and non-need based. This led to the discreditation of the government health care services. Government health care services were worse in Bihar, followed by Gujarat and Himachal Pradesh in that order.

In all the states excessive emphasis was given, to the achievement of Family Planning targets by the district and PHC level authorities. It was done at the cost of other health care programmes. In all the 3 states, the performance of the workers was evaluated mainly by his/her sterilization target achievements and those who were not able to achieve the target had to pay bribes. The health and Family Planning delivery system in these 3 states were unable to deliver the services to rural masses. The health services were only accessible to a few . Corruption and weak administration, inadequate logistic support in the form of material and manpower training, inaccessibility of healthcare services, absence of proper monitoring system and overemphasis on achievement of sterilization target, were some of the obstacles in the healthcare systems in the 3 states.

15. Quality of Primary Health Care with specific regard to Gender Dimensions

Author/s: Community Health Department
Publication source: Christian Medical College, Vellore, Tamil Nadu
Year of publication: 1999
States covered: Tamil Nadu
Social geography: Rural
Data source: Primary
Type of study: Cross sectional survey, and policy paper.
Type of private sector: Registered Medical Practitioners, Private general practitioners.
Issues addressed: Utilization of private and public services, quality of services, government policy.

Objectives: The primary objective of this study is to examine the gender dimensions of the quality of health services provided for RTI by primary health centres in Dharmapuri and Villupuram districts of Tamil Nadu. Among many specific objectives, this study also seeks to examine the utilization of health services for RTI and STI and compare utilization by gender.

Methodology: Twelve Health Sub-centres were chosen from each of Dharmapuri and Villupuram districts, by the probability proportion to the population size sampling procedure. From each sub-centre, one village was chosen by random sampling. The survey in each district included three components: demographic, clinical and qualitative.

Findings and conclusions: The government was the predominant provider of ante-natal care in both districts. However, the proportion attending antenatal clinics in the referral centres was 3% in Dharmapuri and 9.7% in Villupuram district. This is lower than the expected 20%, indicating that the high-risk approach is not being used. A large proportion of the population goes to local RMPs (Registered Medial Practitioners) and private practitioners for health care. The predominant reason is the quality of care and client satisfaction. Different reasons are given for not using government services: Some PHCs are inaccessible and lack transport facilities, while some others provide poor quality of care. The response has been good wherever the doctors and attending staffs have been kind to the patients. Corruption and lack of punctuality also contribute to the negative image of government hospitals. 8.3% of all pregnancies in Dharmapuri and 2.7% of pregnancies in Villupuram end in induced abortion. Qualitative studies show that the primary reason for thisi s sex-selection, which is common in these districts. More than 50% of abortions are conducted in government health centres in Dharmapuri, while in Villupuram only 25% of abortions are conducted in government health centres. RTIs are found in 41% of ever-married women between 15-49 in Dharmapuri and 35% in Villupuram. The prevalence increased with age at marriage in Dharmapuri but not in Villupuram. The RTis higher among the widowed, divorced and separated as compared to currently married women. RTI decreases with increasing education. PHCs and HSCs are grossly inadequate for the management of RTI. Family planning is still an area of need. Female infanticide and foeticide are significant problems in Dharmapuri. There is an urgent need to address this issue. People prefer not to use government services. The reasons for this include quality, inaccessibility, attitude of staff, lack of supplies and corruption. There is a scope for greater sensitivity to gender issues in many training programmes.

16. Regulation of Private Health Sector in India

Author/s: Bhat Ramesh
Publication source: (Book), Private Health Sector Growth in Asia: Issues & Implications ed. William Newbrander
Year of Publication: 1999
States covered: National
Social geography: Rural & Urban
Data source: Secondary
Type of study: Review cum Policy Paper
Type of private sector:        Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit,
Issued addressed: Regulation, Quality, Financing

Objectives: The private sector plays a dominant role in India's health care delivery system. The factors such as New Economic Policy, influx of medical technology, growing deficits of the public sector hospitals and rising middle class have contributed to its large-scale growth in the last decade. But this growth has not been without its consequences. The private health services are costly and many times ignore the quality factor. There is no serious effort to regulate the private sector and so that it can be used as an effective means of health care delivery. The Consumer Protection Act, Medical Council of India and State Medical Council have been discussed in the study of health care delivery. The Consumer Protection Act, Medical Council of India and State Medical Council have been discussed in the study.
Methodology:

Findings and conclusions: The Consumer Protection Act is the most commonly recognised legislation among all. A survey conducted in Ahmedabad has shown that 93% of the medical practitioners are aware of the Act. COPRA was promulgated in 1986 to protect the interests and rights of the consumers. The main purpose of COPRA is to resolve the complaints of the aggrieved consumers in a less costly and less time consuming manner. The redressals are made by quasi judicial bodies formed at district, state and national level. The medical practitioners have argued that they should be kept out of the scope since their services are personal services. The supreme court has clearly stated that any paid medical service does fall under the scope of COPRA. However, COPRA has not been very successful in providing protection to the consumers as far as the medical sector is concerned. In the cases of medical negligence the responsibility of proving negligence lies with the consumers. The effectiveness of COPRA is in doubt also because of the number of cases pending with the courts. A study in Gujrat has shown that 50% of the cases filed were pending. However, a survey conducted to assess providers' opinion has shown that 64% of the providers believed that COPRA is an effective tool for protecting the interests of the consumers. Fifty-nine percent of the respondents feel that the act would increase the cost of diagnosis, while 91% believe that the cost and the use of diagnosis have increased and 58% of the respondents thought that the Act would increase the amount of time a doctor spends on each patient. A number of questions need to be resolved to make this act effective. 1. There is a danger of practitioners practicing defensive medicine or in other words over diagnosis. 2. There is no provision of action against the petitioners filing false cases against the doctors. 3. The absence of medical professionals in the implementation. The upper committee of the upper house of parliament has recommended that the doctors should provide information about their fee structure to MCI and then MCI should make it public. There is also a need of an orientation program for the newly graduated doctors. The Medical Council of India came in to being by an Act of Parliament, The MCI Act, 1956. The council is composed of one nominated member from each state, one elected member from each university, one member from each state registered, seven members from those enrolled in any of the state medical register and 8 members nominated by the government. The functions of MCI include giving recognition to medical qualifications, maintaining register, maintaining standards for post graduate medical education, defining a professional code of conduct, etc. However it cannot provide redressal to the grievances of an aggrieved person.The other main activity of the council is to maintain and monitor medical ethics for practitioners. The ethics are based on the Geneva declaration adopted by the General Assembly of World Medical Association, 1949. Though MCI has produced a list of medical misconducts that can be brought before the council, it does not specify punishments for such misconducts. The State Medical Councils have been created by various state governments for registration of practitioners, maintaining the standards, etc. The councils perform the same tasks as that of MCI, at state level. There are very few examples of the councils intervening directly into the matter and taking action such as cancellation of registration of a practitioner. The role of the government is also limited. The government officials intervene only if they feel that the councils have not followed the provisions of COPRA. Thus it can be concluded that MCI and SMCs have largely failed to regulate the medical profession and protect the rights of the consumers.

17. Report on the Census of Private Medical Institutions in Kerala

Author/s: Unknown
Publication source: Not Known
Year of publication: 1995
States covered: Kerala
Social geography: Rural & Urban
Data source: Primary
Type of study: Cross sectional
Type of private sector: All systems of medical institution.
Issues addressed: Assessment of institutional capacity and workforce.

Objectives: To find out the number of private medical institutions in Kerala state under various systems of medicine, and the strength of medical and para-medical staff employed in these institutions.

Methodology: Details were collected panchayat-wise. Statistical investigators attached to 811 zones for collection of agricultural statistics were entrusted with the field work. Statistical inspectors, Taluk Statistical Officers and District level officers supervised the fieldwork. The investigators were directed to prepare a list of the private medical institutions under their jurisdiction by local inquiry before the commencement of the canvassing of details in the prescribed format.

Findings and conclusions: As on 31 March 1995, there were 12,618 medical institutions in the state. This shows an increase of 31% over 1986. There were 4288 allopathic medical institutions, 4922 ayurvedic institutions, 3118 homoeopathic and 290 other systems of medical institutions in the state. A total of 70,924 beds were available in all institutions, compared to 50,766 beds in 1986 – an increase of 40%. Forty five percent of allopathic institutions had inpatient facility, whereas only 4.7% of ayurvedic institutions, and 1.4% of homoeopathic institutions had inpatient (bed) facilities. The survey revealed that while there were 12,473 doctors and 15.221 paramedical staff in 1986, there were 19,963 doctors and 28,641 paramedical staffs in 1995. Nearly 50% of doctors were employed in allopathic institutions. This was followed by ayurvedic (30%) and Homoeopathic (17%) institutions. In the case of paramedical staff (including ministerial staff), allopathic institutions employed about 88% of the total employed in all institutions. Some of the private institutions provided training facilities to paramedical personnel. The study revealed that 155 institutions had training facilities for nursing, 52 institutions had facilities for laboratory technicians and 19 provided training for family welfare programmes. Three hundred and five units had intensive care units, 83 had scanning facilities, and 64 had echo test facilities and 18 had laser rays treatment facilities - these details were not collected during the 1986 survey. The survey revealed that 13% of 4288 allopathic hospitals had only one doctor. Forty two percent of these had two to four doctors. In the case of ayurvedic and homoeopathic institutions, 53% and 76%, respectively, had one doctor. This means that on average, 46% of all medical institutions had only one doctor. The survey also revealed that about 30% institutions treated less than 1000 patients per year. Only 300 of them treated more than 25000 patients per annum.

18. Review of Private/Public/NGO Sector Collaboration with in TB Care in India

Author/s: Priya, Ritu.
Publication source: DFID Consultancy, July 19, 1997.
Year of publication: July 19, 1997.
States covered: National
Social geography: Rural and Urban
Data source: Secondary Review with interviews
Type of study: Review cum Policy Paper
Type of public sector: Individual Private Practitioners, NGOs.
Issues addressed:Quality of Private Services; Public-private Collaboration; Cost of Care; Impact of High Cost on Vulnerable sections.

Objectives: To review the existing grey literature on private/NGO/public sector collaboration with the Revised National Tuberculosis Programme. To synthesize the above information in a background document.

Methodology: The document was based on extensive review of available studies and consultations with persons from both public and private sectors who were involved in the tuberculosis programme.

Findings and conclusions: Based on the review of literature, the author says that there is a need to make a distinction between private practitioners, NGOs and Voluntary Public Action (VPA). These groups represent heterogeneity in terms of location, training and systems of medicine practised. Therefore, any effort at collaboration will have to contend with these complexities in provisioning. The quality of private services for both general and tuberculosis treatment are variable. For tuberculosis there are serious shortcomings in terms of diagnostic testing and treatment regimens followed. In addition, there is no mechanism to check these services. The major cause of default in the treatment process of tuberculosis is the 'high cost' of treatment in both the public and private sectors. This has serious consequences for access to TB care to the lower socio-economic groups. There is little in way of collaboration between the public and private sectors. NGOs have had a longer history of involvement with TB care. Here again, there is heterogeneity in the NGOs with those involved in advocacy, networking, production of IEC material, training of professionals and those, which deliver services for TB care. There is collaboration between NGOs and the public sector RNTP at the macro level but in a rudimentary form at micro levels.
The policy recommendations are made in light of the involvement of the private sector. Here, specific suggestions for involvement of private practitioners for case finding, testing and as observers for the DOTs programme are made. In addition, the author suggests that additional inputs are required for providing information to PPs for management of tuberculosis in terms of diagnosis and treatment regimens. This review lists a number of possibilities for collaboration of the private sector with the Tuberculosis programme. It makes concrete recommendations about the inputs that are required to help private practitioners for diagnosis and treatment of TB.

19. Socio-economic and Political Determinants of People's Responses to their Health Problems: A Case Study of New Seema Puri - A Resettlement Colony in Delhi

Author/s: Gupta Snehlata
Publication source: M.Phil Dissertation Jawaharlal Nehru University, New Delhi. 1990.
Year of publication: 1990
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Individual private practitioners
Issues addressed: Utilization of Private Sector, Characteristic of Practitioners

Objectives: The objective of this research was to understand the health situation of a specific group of people within their socio-economic, political and cultural milieu.

Methodology: The study was conducted among the slum dwellers in one of six blocks in New Seema Puri resettlement colony of Delhi, during the years of 1988-89. Ninety-seven households, that is 20 percent of the total, constituted the sample for observation. Qualitative information was gathered through interactions with local institutions, groups and individuals and quantitative information was collected through a questionnaire formulated on the basis of key issues that emerged through the qualitative analysis.

Findings and conclusions: The main thing that the study points out is the range of providers. They vary from traditional and R M P to full fledged MBBS doctors and charitable hospitals, Red Cross and St. Stephens dispensary all of which charge fees. Of the 30 private practitioners, the majority were unqualified. They had picked up practice by working as assistants or apprentices to doctor, compounders and dispensers. With their low cost, availability and easy access, they used their good bedside manners to gain popularity. They used instruments like thermometer, stethoscope, tongue depressor as well as intra-venous sets and treated people on credit as well. The charitable hospital charged only Rs. 2/- for OPD in contrast to Rs. 5/- by the unqualified practitioners. However, the indoor charges were much higher. People in distress were ready to pay but the treatment they received was not necessarily comforting. This study showed that the economically 'better off' in the slums use the government hospitals and go to private practitioners. They are in a position to choose the services as and when required. For the people in the poorer categories access to medical services is limited due to their resource constraints. For general ailments, adult male earners usually go to private practitioners. Those who cannot afford to go to qualified practitioners go to the 'local quacks'. They prefer to go to these quacks instead of a government hospital since they need not lose their daily wages or spend on transport. Thus one sees a differential pattern in resort across economic categories.

20. Study of Gynecological Disorders in Women from the Slums of Mumbai

Author/s: Parikh Indumati. Vijaylaxmi Taskar, Neela Dharap, Veena Mulgaokar
Publication source: Streehitakarini, Mumbai
Year of publication: 1994
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:        Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Utilisation, Quality,

Objectives: To determine the levels, patterns of Gynecological morbidity, Women's perception and assessment of their gynecological health, medical assessment and laboratory test, the women's health seeking behaviour.

Methodology: The location of the study was a slum of Bombay City. Data for this study was collected by conducting surveys on married women of the slum. The survey comprised a socio-demographic survey of respondents, their reported symptoms and morbidity and reproductive histories, a clinical examination and a Laboratory test. Qualitative data was obtained through group discussions with health workers. Informal interviews were conducted with health practitioners. Interviews were also conducted with 100 community women on their perception of disease pattern among them. Interviews were conducted through Marathi language. A random sample of 10% was drawn i.e, out of the estimated 15000 women, 1500 women were drawn as samples since efforts were not made to keep the sample size constant. As a result of migration and demolition of their huts, 50% of the samples size was lost. The refusal rate of respondents was 28%. The sample at the end comprised a total of 756 women. After the interviews, respondents were asked to attend the Streeihitkarini Clinic for medical examination. If women were reluctant to attend the clinic then examination were occasionally conducted at convenient locations close to the homes of the respondents in well-equipped medical vans. Female gynecologist conducted examinations. The examination samples were sent to Bombay Hospital for testing. Those women who were in need of treatment were immediately provided with medical care.

Findings and conclusions: Since the sample was drawn from a single homogeneous slum, the variations in the women's income and education of hygiene levels were narrow. Women in the slum sought health care provisions from health workers, local medical practitioners, faith healers, pharmacists and also group of local women. Many of the health workers could not perceive a gynecological problem. Of the 22 local health practitioners only 4 were women. Not a single male practitioner had conducted a gynecological examination. Diagnoses were made and treatment given on the basis of reported symptoms. A large majority of practitioners did not consider gynecological illness serious unless cancer was suspected and only a few cases were women referred to public gynecological clinics. Women also visited faith healers especially for reasons of infertility. Interview with one faith healer showed that he treated gynecological problems by mystical healing powers and incantations (meditation and reciting mantras). It was also found that women sought medication for gynecological problem from a few local pharmacist and paan - shopkeepers in order to save time and money needed to visit a doctor or clinic and also to spare them the awkwardness of undergoing a medical examination. Women sought more of home remedies for their gynecological problems than seeking healthcare provisions in hospitals. Other findings include the high prevalence of gynecological morbidity among the slum women. 70% women reported gynecological complaints. Large proportions of women almost 3 in 4 were diagnosed as having one or more gynecological morbidity. Contraceptive users and sterilized women suffered from a high level of morbidity. Older women had reduced risk of STDs. Many women perceived gynecological problems as a normal aspect of womanhood. Prohibitive cost of treatment acted as a barrier in seeking healthcare. Also many were inhibited in discussing gynecological problems with male practitioners. They relied heavily on home made remedies. These results stress the fact that gynecological morbidity is unacceptably high and constitutes a major public health problem. There is an urgent need to incorporate reproductive health services, treatment of STDs, gynecological infections within the scope of family welfare programs. Attention also needs to be given to the private healthcare providers, who are consulted more often by patients. In short the results present a forceful plea for greater attention to and investment in the reproductive health needs of the poor Indian women.

21. Study of Knowledge, Assessment and Practice of ISM practitioners and Health Functionaries in the Context of Delivery of MTP Services in Bihar and Maharashtra.

Author/s: Kumar Dilip, Bella Patel, Ranjana
Publication source: Operations Research Group (ORG), Baroda.
Year of publication: 1992
States covered: Bihar, Maharashtra
Social geography: Rural
Data source: Primary
Type of study:        Cross Sectional B Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit,
Issues addressed: Knowledge, Quality, Regulation

Objectives: To assess the extent of knowledge of Indian System of Medicine (ISM) practitioners and health functionaries about MTP. To assess to what extent and how they administer MTP and act as referral points. To ascertain from ISM practitioners and health functionaries their opinion about acceptability of MTP among currently married couples. To assess the current level of availability of MTP services and future needs.

Methodology: The study was carried out in two states of India, Bihar and Maharashtra. To ensure geographical representation, the states were divided into three regions and atleast two districts were selected from each region. In the second phase of the study, a minimum of six PHCs was selected from each district. All the villages within each PHC area were covered. In all, around 500 villages were covered in both the states to get the required number of ISM practitioners. A total of 2492 ISM practitioners, 110 Medical officers, 794 health workers and 599 Dais were interviewed.

Findings and conclusions: In both the states, most ISM practitioners had entered the practice either through paternal inheritance or by working as compounder under a practitioner or by reading books on their own. During the survey it was found that a good number of ISM practitioners did not confine to their own system and over a period of time started practicing 'Allopathy'.

The ISM practitioners by and large had correct knowledge about the 'safe', "some what risky" and "very risky" periods during pregnancy for conducting MTP or abortion. In comparison, to other practitioners, the Ayurvedic practitioners, who also practiced allopathy possessed better knowledge about the risks associated with abortion. A majority of the ISM practitioners in Bihar (95%) and Maharashtra (86%) reported bleeding as a major complication following abortion. The other possible serious complications such as uterus and cervical injuries etc. could not be perceived by most of them. In both the states the Ayurvedic and Homeopathy practitioners who practiced allopathy as well, had a better knowledge of possible complications following an abortion. About half of the ISM practitioners in both the states said that stopping of bleeding was an indication of successful completion of abortion. According to 70% of ISM practitioners in Bihar and 50% in Maharashtra, the major sources of MTP services were private clinic and district hospital. Most ISM practitioners from Bihar (79%) and Maharashtra (82%) reported that the pregnant women sought their help or advice for getting aborted. Seventy-one percent of ISM practitioners from Maharashtra and 53% from Bihar reported that they referred abortion cases to the PHC or the district hospitals. However, 22% of the ISM practitioners in Bihar and 14% in Maharashtra reported that they themselves conducted abortion or provided women who wanted to abort with oral medicine to induce abortion.

The ISM practitioners learnt abortion techniques, while they underwent training or picked up the techniques or the name of medicine from the doctors under whom they worked before establishing their own clinic. In Bihar, the majority of the ISM practitioners, who were involved in this activity, gave oral medicine to get the pregnancy aborted, this kind of practice was more frequent among the Homeopathy practitioners. While in Maharashtra, though use of oral medicine for abortion was less prevalent, the Ayurvedic doctors generally followed this approach. As far as use of sophisticated techniques like D & C were concerned, the ISM practitioners from Maharashtra were better placed compared to those from Bihar. In Bihar, the majority of the ISM practitioners conducting abortion, conducted it at the clients' house while in Maharashtra, the ISM practitioners used their own house or clinic for conducting abortion. The interest of ISM practitioners to participate in MTP programme : 55% of ISM practitioners in Bihar and 75% of ISM practitioners in Maharashtra approved of women undergoing abortion. 83 % of the ISM practitioners in Bihar and 73% of the ISM practitioners in Maharashtra were interested to participate and get involved in MTP programme.

Most of the dais in both the states had knowledge about the "safe period" (13 weeks of pregnancy) and the "very risky" period (after 13 weeks) for undergoing abortion. 57% of the dais in Bihar and 49% in Maharashtra reported bleeding as one of the major possible complications of undergoing abortion. In both the states 24% to 26% of the dais , were totally ignorant of the possible complications of undergoing abortion. About 50% of the dais in both the states provided help or advice to women seeking abortion.Among the dais, 82% in Maharashtra and 51% in Bihar referred abortion-seeking women to the PHC or the district hospital.

Most of the ISM practitioners particularly from Bihar were interested to get involved in the programme. In fact they wanted to undertake MTP themselves, as they would get enough number of clients. However, they were not fully confident of the knowledge they had and they wanted to undergo training. They also wanted to have necessary equipment; some of them were even prepared to pay for the equipment supplied by the government. The functionaries and dais by and large displayed their partial knowledge about abortion/MTP. In particular, they could not perceive serious complications associated with abortions. Informal discussions with certain community members in the villages surveyed indicate that many dais were involved in illegal abortion and their partial knowledge about the harmful effects of the crude and frequent abortions would be dangerous. However, the dais were not honest enough to admit the facts and only very few agreed about their current involvement in induced abortion. The trained dais mentioned that they started referring the cases to PHCs where MTP facilities were available.
Thus the study suggests an urgent need to extend MTP services to large number of PHCs and dais may be given some incentives to encourage more and more referral cases. The ISM practitioners certainly constitute a reckonable force for using them mostly as motivators. However, the pure Ayurvedic and Homeopathy doctors who felt abortion is against religion and society norms should be handled more cautiously and need to be given reorientation training to affect change in their views

22. Sunder Nagri Mein Ulti-Dust Ka Prakop Va Uski Roktham-1988

Author/s: Priya, Ritu, Sumitra And Maharani
Publication source: Sabla Sangh, Delhi, 1989 (Supported by ICSSR).
Year of publication: 1989
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Case Study
Type of private sector: Individual private practitioners
Issues addressed:Utilization of Private Practitioners for Cholera, Public Hospitals, knowledge of Private Practitioners.

Objectives: The report is based on a study of the gastroenteritis/ Cholera outbreak in the slums of Delhi in 1988. The objectives of this study were to examine the nature of the problem and debate on whether it was an epidemic or not. Examine the role played by different agencies viz. Public and private health sectors, affected people and the media in recognizing the epidemic. Examine the nature of the official control measures undertaken. Study the treatment seeking behaviour of affected persons and the communities. Study the impact of all these initiatives on the control of the problem.

Methodology: The study is based on interviews with key officials in the Delhi Health Service Administration and a detailed study of one of the slums, which was officially rated as the most affected. In the slum, interviews were held with the different health care providers. In addition a household sample survey was conducted among 161 households who had been taken ill.

Findings and conclusions: The findings from this study that are relevant for the private sector are early detection of he cholera epidemics was done by the public institution. Both the private practitioners and large sections of the community did not recognize the early warning signs. This study highlighted the crucial role for emergency services and accessible medical care facilities in preventing deaths. The private practitioners did not adequately provide this kind of emergency care. The private practitioners were the first level of resort, 43% of those affected sought the services of a private practitioner for less serious conditions. 75% of those who were seriously ill resorted to the government hospital. The control measures propagated by the government dispensaries, mobile teams and hospitals recommended the use of oral dehydration solution. However, very few private practitioners were prescribing it. The special public sector measures to provide medical care during the epidemic was only partially effective because centralized system was developed for the identification of cholera cases. This was being done at the Infectious Disease Hospital, which is located at a distance of 30 kms. This study shows that the private sector is not reliable for dealing with epidemics caused by infections diseases. The public sector is crucial for public health surveillance and control of epidemics. Efforts need to be made to involve local private practitioners in the government camps during such crises. They should be also be given information on management of such epidemics. This study showed that the public sector adopts more rational practices for prescribing drugs compared to the private practitioners. Therefore there is a need for systems to be developed for involving private practitioners in the early detection, treatment and management of such epidemic like situations.

23. Tackling TB : The Search for Solutions.

Author/s: Uplekar M W, Sheela Rangan
Publication source: Foundation for Research in Community Health {FRCH}, Pune.
Year of publication: 1996
States covered: Maharashtra
Social geography: Urban & Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector:Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not - for profit
Issues addressed: Partnerships, Incentives,

Objectives: This study attempts to understand the nature of the social and operational constraints affecting TB control and identify ways to remedy them. To examine the role of private health providers in control of TB. To determine the areas and possible means of intervention for strengthening TB control.

Methodology: The study was conducted in the rural and urban areas of Pune district, Maharashtra. Data collected was both qualitative and quantitative in nature. Interviews were held of 605 households in 12 villages (in 6 primary health centre areas) and 408 households in urban areas in 42 census blocks, a total of 1013 households. Informal interviews with 299 TB patients in 6 PHCs and 3 urban TB clinics were conducted. Data was collected from the healthcare providers such as the health functionaries at different levels of PHCs and urban clinics and private medical practitioners in selected rural and urban areas. Data was also collected from the supervisory and administrative staff at the district TB center and the state TB directorate. Other sources of data collection included observations, informal interactions and focussed group discussions, case studies with both the users and providers of health services.

Findings and conclusions: People who developed symptoms of TB generally went to private medical practitioners for treatment. The patients were rarely subjected to sputum examination. The emphasis always was on diagnosis based on the x-ray of the chest. Patients of TB preferred the services of private doctors for 2 reasons- less waiting time and convenience of clinic timings. But patients did end up in the public health services either by themselves or referred by private doctors chiefly due to their inability to pay for prolonged care in the private sector. Non-adherence to treatment by patients is known to be a major impediment in controlling TB. The reasons for this were high cost of care, disappearance of most of the troublesome symptoms on partial treatment, and also non-availability of services, low image of public services in people's mind. According to the study, about a third of the patients had incurred debts in order to bear the expenses of their treatment. Rural patients had spent almost double the amount spent by their urban counter parts. In the private sector, drugs and doctors were the main item of expenditure; in the public sector, travel and prescribed medicines often as a result of shortage of drugs, were the main items of expenditure. In the case of urban patients, spending drastically dropped once they were registered with the public health services. In rural and urban areas, all kinds of private medical practitioners entertained patients of TB. They were oblivious to the detrimental effects of their management practices like x-ray based diagnosis, use of multiple irrational drug regimens, lack of education of patients, lack of patient follow up and total absence of maintenance of any kinds of records. These practices were due to inadequate basic training, lack of continuing education, a casual approach to public health importance of diseases and the influence of promotional tactics of drug companies.
Training for health workers must be made simple, demonstrative, on-site, periodic and cover not only the technical and managerial aspect but also the social and behavioural dimensions to help them tackle effectively the problems of non-adherence to treatment at the field level. PHCs have to be strengthened by providing them with adequate resources, and this will need proper monitoring and surveillance from the levels above. Diminish the DTCs role in curative care: poor functioning of the PHCs make patients from rural areas crowd at the DTC. This has converted the DTC into a TB clinic restricting its functions chiefly to providing curative care. This has affected its importance and essential functions of the DTC like training, support, supervisions, surveillance and monitoring of lower levels. The curative component of the DTC maybe restricted to providing care to problem cases that cannot be tackled at the lower levels.

It is essential for the programme managers to take the initiative to establish communication and seek graded involvement of private doctors and the NGOs into the main programme, since they cater to the TB patients. Depending upon their willingness to cooperate and adhere to the basic tenants of the programme, diagnostic treatment and patient follow-up services maybe made available to the private and voluntary providers. Ways to regulate the harmful practices of private providers should also be monitored. Strengthening peripheral services alone will not suffice if the higher levels continue to be indifferent, contented with modest achievements and reluctant to ensure that the programme operates effectively. It is for them to be sensitive to the need of the people and the programme functionaries, provide moral support, encouragement, and freedom to innovate and rewards for performance. Programme directors should ensure that their programme does not suffer as a result of shifting priorities and that other programmes and services do not deteriorate due to their domination.

24. The Development of Public Health Services and their Utilization: A case study of The Bombay Municipal Corporation

Author/s: Kakade Narendra
Publication source: Unpublished M. Phil Dissertation, Jawaharlal Nehru University, New Delhi, 1998.
Year of publication: 1998
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross sectional
Type of private sector: Individual private practitioners; hospitals
Issues addressed: Public hospitals; utilization of private sector

Objectives: The study explores the distribution of health services in the urban slums of Bombay. The objectives of the study are:
The development of provisioning in the public health services of Bombay Municipal Corporation (BMC) since independence.. The nature of curative health services available in the city and their utilization. The differences in terms of health services offered by BMC across its administrative wards.

Methodology: The study adopts a qualitative research design in which extensive secondary data was gathered mainly from reports of Public Health Department and the administrative department of Bombay Municipal Corporation. In addition, informal interviews were held with Medical and Health officers of BMC.

Findings and conclusions: The findings of the study are that there is an overall decrease in the expenditure on health by BMC. The major part of the expenditure is on big hospitals i.e. teaching hospitals rather than dispensaries and health care centres. Of this a large proportion is spent on establishment than on diet or other equipments for patients. BMC pays more attention to the curative services than preventive care. The sharp growth of the private health sector towards the end of the sixties was prompted by several factors: the falling state-spending for health, the increasing numbers of medical personnel, who could not find adequate employment in the health institutions, a growing middle class dissatisfaction with public sector and willingness to payto the private sector. It is the poor who are the major public hospital users who show a preference for private providers in the first instance and come to public hospital only when their conditions get serious or their finances are low. Therefore, they accept whatever care they get. This leads to the dubious money making practices of private hospitals like-unnecessary investigations and irrational therapies. Even though there is not much pressure on the public hospitals to be quality conscious, this aspect has to be stressed or else, their place will be overtaken by the private sector and will lead to weakening of health planning. The public systems work in an inefficient manner thereby making people resort to private clinics. Right from the time a patient queues up for registration as an outpatient or an in-patient, to getting a bed and other diagnostic facilities, medical attention etc., a huge investment of time and money is needed.

25. The Household Management of Diarrhoea in the Social Context: A Study of a Delhi Slum

Author/s: Bhandari Nita
Publication source: Ph.D. Thesis, Jawaharlal Nehru University, New Delhi
Year of publication: 1992
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Individual Private Practitioners
Issue addressed: Private Sector Utilization for Diarrhoea, Practices of Private Practitioners.

Objectives: To study the occurrence of diarrhoea and its management within an urban slum.

Methodology: The study was conducted in a Jhuggi Jhompri cluster in New Delhi and the study sample consisted of 60 families with at least 1 child aged less than 5 years. In addition to the health seeking behaviour of families, the providers were also studied.

Findings and conclusions: The study shows that diarrhoea is the second most common illness for which treatment is sought outside the home for nearly 60% of the cases. Private sources of care are preferred, as they are perceived as being more effective and providing prompt care. However, the very poor often seek care from a government hospital since they cannot afford private care. An in-depth study of the providers of all systems of medicine reveals that these practitioners use inappropriate and irrational drugs for the management of diarrhoea. A majority of them place excessive emphasis on using drugs rather than fluid replacement therapies. This study points to the dependence of urban slum populations on private practitioners who have varied backgrounds and training. Their practices are far from rational in the management of diarrhoea in children. This is the trend that has been observed in the management of other communicable diseases as well. Given the fact that people do utilize their services for primary level care it is extremely important to register and train them in rational therapeutics.

26. The Private G P and Leprosy A Study

Author/s: Uplekar M W, Cash R A
Publication source: Foundation for Research in Community Health (FRCH), Bombay, Mumbai
Year of publication: 1991
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Laboratory/investigation, ISM, Unqualified practitioners, For profit
Issues addressed: Quality, Utilisation, Knowledge, Personnel,

Objectives: The study examines the KAP and beliefs about leprosy among private doctors with a view to identifying areas of investigation and interaction for their active cooperation and participation in leprosy control.

Methodology: Three slum areas in Bombay were selected: one with only municipal services, one with only NGO - run services and a third with both. GPs in the third area had been exposed to intensive leprosy training five years previously. Listing of all doctors in the was done and GP's selected by simple random sampling. GPs were interviewed using an open-ended structured questionnaire. Totally 106 GPs were interviewed.

Findings and conclusions: The doctor's responses on types, diagnosis, treatment, and cause of leprosy indicated a gross lack of knowledge and awareness about leprosy. About 20% of doctors from all three areas felt worried about their private practice being adversely affected by treating leprosy patients in their clinics. Doctors in the third area who had received training, were comparable to others, showing that the training effect had diminished over time with regard to knowledge, but the difference was seen in the attitude. The majority of GPs in this area thought it safe not to isolate leprosy cases while on treatment and to let cured patients work in public places. Though most doctors answered questions on diagnosis correctly, they still preferred referring these cases to specialists for treatment.

27. Treatment of Tuberculosis by Private General Practitioners in India

Author/s: Uplekar M W, Shepard D S
Publication source: Foundation for Research in Community Health (FRCH), Bombay
Year publication: 1991
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, ISM, For profit
Issues addressed: Quality, Personnel, Knowledge,

Objectives: The study examines the prescribing pattern of private medical doctors practicing in the low socio-economic areas of Bombay.

Methodology: A list of all doctors practicing in a large low-income settlement of Bombay was prepared, and 143 selected from 287 by simple random sampling, which included 79 allopaths and 64 non-allopaths. Doctors were visited individually and provided a slip with a request to write a prescription for a TB patient, including drugs used, dosages and duration.

Findings and conclusions: Among the doctors listed, 22% refused to participate. 102 prescriptions were finally analysed. The study shows a lack of awareness among doctors, who treat TB patients in their own clinics, and about the standard drug regimens for treatment of TB, recommended by national and international agencies. These doctors, most of which were inappropriate and expensive, prescribed eighty different regimens. Many non-allopaths prescribed more expensive regimens, but irrespective of their background and training many doctors used modern chemotherapeutic agents in the treatment of TB.

28. The Traditional Herbal Medicine System of Chotanagpur: A study of its present Status & Future Prospects

Author/s: Chand S K
Publication source: Research Department of Xavier Institute of Social Service (XISS), Ranchi, Bihar
Year of publication: 1988
States covered: Bihar
Social geography: Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, ISM, Unqualified practitioners
Issues addressed: Utilisation, Quality

Objectives: To find the extent of the popularity of the herbal system of medicine among the tribal population of Chotanagpur and to collect information regarding the healing properties of the herbs.

Methodology: The study was undertaken in Chotanagpur which represents areas of concentration of different tribes, such as Munda, Oraon and the Ho tribes who use herbal medicine for treating various kinds of diseases. As part of the study a total of 913 households were surveyed in 12 villages of 5 blocks in 3 districts i.e. Gumla, Palamau and Singhbhum. In each block 2 remote villages were selected. In one block 2 extra villages were studied, since the population of two selected villages was very small. A questionnaire was administered to the head of the household. The questionnaire dealt with information regarding family composition, marital status, education levels and occupational characteristics of rural households. Details about the diseases suffered and their frequency, type of herbal treatment resorted to, source of knowledge about the herbal medicine, herbal medicine practitioner consulted by the tribal people etc were also collected. All families in the selected villages were covered by the survey. Practitioners of herbal medicine were also interviewed. Information was also gathered about the medicinal herbs available in the area and the types of diseases for the treatment of which herbs were prescribed.

Findings and conclusions: When asked about their preference for different system of treatment i.e. between homeopathy, ayurvedic, allopathic and herbal, out of total 913 households only one household responded in favour of homeopathic treatment, 56.62% were in favour of allopathic, 40.31% favoured herbal medicine, 2.96% favoured ayurvedic system of medicine. Thus, the real choice of rural households was between herbal and allopathic systems of medicines. The main reasons for opting for herbal system of medicine were easy accessibility and effectiveness. The two main sources for procurement of herbal medicine were from the ohja or baidh? [Vaidh] (86.89%) and the forest (82.46%). It was found that the availability of facilities for allopathic treatment has adversely affected the popularity of the herbal system of medicine. It was found that there is a direct relationship between the literacy level of the family and their preference to use allopathy and an inverse relationship between the literacy level of the family and preference to use herbal system. As the literacy ratio of the families increases the percentage of families favouring allopathy increases, while the percentage of families favouring herbal system decreases.
The study revealed that the nature and extent of morbidity was fairly high in remote rural areas and almost each family had some illness to report. This was partly due to poverty and unsanitary condition of rural living. High incidence of malaria among the tribes was also reported. A significant percentage of households depended upon medicinal herbs for treatment of acute and chronic illness, either on the basis of their own knowledge or with advice and guidance from tribal medicine men. The most common diseases, the people suffered from were malaria, cold and cough, fever, typhoid, diahorrea, dysentery and jaundice. Around 44% of the children were suffering from severe malnutrition. Unlike practitioners of allopathy, ayurvedic and homeopathic system, who are registered for practice, the herbal medicine men were neither formally trained nor registered for private practice. The tribals were finding it hard to keep the indigenous healing system alive, because of large-scale destruction of forest.

The study shows that herbal medicine is very popular among tribal people of Ranchi, Gumla, Singhbhum and Palamau districts. Dependence of tribal people on herbal medicine is mainly due to non-availability of modern medical facilities, easy accessibility of herbal medicines, cheap treatment costs, faith of tribals in the healing capacity of the ojhas. An important advantage of herbal medicine is that of population control. There are many herbs, which are used by the tribal people for anti-fertility purpose such as pupraria tuberosa, tithi, annona sqamosa, cassifistula etc. Tribals are concerned about the future of this system of medicine and are interested in their preservation and propagation.

Measures should be undertaken for identification of threatened herbal species with the co-operation of herbal medicine practitioners, conservation of the forest areas where such species are grown, educating people on the methods of collecting herbs for personal use or for commercial purposes. If necessary curbs will have to be imposed on the commercial exploitation of important herbs which may be in danger of becoming extinct on account of over exploitation. Regulating their marketing should also be done. Further, training should be given for practitioners of herbal medicine and they should be educated about the protection and propagation of the important herbs.

29. The State of Medicare Facilities in Agra City (with special reference to medical practitioners)

Author/s: Jincari, Bharat Bhushan
Publication source: Department of Social Work, University of Agra (1992-93)
Year of publication: 1992-93.
States covered: Uttar Pradesh
Social geography: Urban
Data source: Primary
Type of study: Case Study
Type of private sector: Qualified Practitioners.
Issues addressed: Organization of Private Sector, Utilization, Cost of Care.

Objectives: The objective of this study was to understand the state of medicare facilities provided by medical practitioners in the city of Agra. It also examines the emerging trends such as commercialization and malpractice in the Medicare system by exploring the conditions under which these practitioners operate.

Methodology: A quantitative research design was used in which a sample of 25 qualified practitioners were selected out of 870 practitioners from three localities of Agra viz. Shahagany, Kharia and Sadar areas.

Findings and conclusions: The study comes to the conclusion that the lower classes in the city are unable to meet the high cost of medical services prescribed by the medical practitioners. Medical care provided by the private sector has become very commercial and as a result malpractices are common. These practitioners possess an MBBS degree as their academic qualification, and none of them have post graduate degrees. About 50% of them have undergone specialized diploma courses and post graduate diploma courses. More than 50% of practitioners are general practitioners. Respondents with M.D. and M.S. degrees are also practise as general practitioners. More than 75% of the respondents also dispense medicines as their mode of practice. The obvious reason is that dispensing ensures greater patient load and thereby more income. A compounder supports each of these doctors. The compounders are not illiterate but their employment with the doctor is temporary in nature.
Only 32% of the respondents provide their services in their respective clinics. Some of these doctors are permanent employees of the government hospitals. All of them provide first aid facilities at their clinics None of them provides anti rabies or anti toxic treatment, and very few of them provide immunization services. More than 80% of the respondents charge consultation fees below Rs. 35/-, which they perceive as affordable by the patients. None of these practitioners refers his cases to other professionals. These professionals serve mainly lower and lower middle class patients.This study gives some insights into those who practice as qualified general practitioners, and these are mainly MBBS doctors. Their practice is mainly curative and they provide very little preventive input . This study also shows that some government doctors have a private practice. These qualified practitioners cater mainly to the lower middle classes and their role in providing preventive medical care is minimal.

30. Understanding Environmental Health: A Study of Some Villages of Pauri Garhwal

Author/s: Bisht Ramila
Publication source: Unpublished M.Phil Dissertation, Jawaharlal Nehru University, 1993.
Year of publication: 1993
Status covered: Uttar Pradesh
Social geography: Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Private Practitioners, Traditional Practitioners
Issues addressed: Private Sector Utilization

Objectives: The broad aim of this study was to explore the objective and subjective components of environmental health of the Himalayan eco-system. The sub-objectives were: - a) To understand the socio-economic and environmental problems and people's perception about it them b) To understand the process that has led to the present situation. c) To examine the relevance of different developmental approaches that have emerged in relation to the existing realities in this area.

Methodology: This study explores factors determining environmental health in Pauri Garhwal. It is based on a sample of five villages where all households were studied. This was preceeded by a total study of the population consisting of 981 persons.

Findings and conclusions: Though private practitioners were not the primary focus of the study, it throws some interesting light on the utilization patterns and their reasons. The area had its prescribed PHCs and CHCs, however, their distribution was such that it made access difficult for some villages because of the terrain and the distances. As a result private practitioners of a wide range were not uncommon. Of these the Registered Medical Practitioner (RMPS) were the commonest. The reasons (cited for not utilizing the other than distance and terrain) cited were lack of medicine at PHCs, timings of the PHC, the poor attention given by the staff which was often compared and contrasted to the 24 hour availability of the private practitioners. The traditional practitioners still continue to play an important role in these areas and religious healers also practice. As a result the practice of mixing systems of medicine by the people is prevalent in this area. This study documents the presence of a plurality of practitioners in the rural areas of the hilly areas of Uttar Pradesh. The villagers go to these practitioners for primary level care and an important reason for this is the accessibility and availability of these practitioners.

31. Utilization and Impact of Private Healthcare Services in Rajasthan

Author/s: Finch B. Cedric, Rajesh Misra
Publication source: Voluntary Health Association of India (VHAI) and Rajasthan Voluntary Health Association (RVHA), Rajasthan.
Year of publication:
States covered: Rajasthan
Social geography: Urban & Rural
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit, Not- for profit
Issues addressed: Utilisation, Regulation, Costs, Quality

Objectives: To assess the distribution pattern and to present the profile of the private healthcare services in Rajasthan.
To evaluate the changing pattern of the hospitals and the economic burden on the families due to healthcare expenses.
To assess the peoples perception about private healthcare services in Rajasthan.
To assess the socio-economic background of the people visiting private hospitals for treatment.

Methodology: The study area covered five districts of Rajasthan; they were Jaipur, Jodhpur, Udaipur, Ajmer and Bharatpur. The 5 districts cover around 60% of the total private hospitals in Rajasthan. A general survey was conducted in the 5 districts to assess the profile of different hospitals. The researchers tried to select only those hospitals that have multiple facilities and more than 20 indoor beds, but since it was not possible, a total of 25 hospitals with a single facility and some hospitals with less than 20 indoor beds were selected as the sample. One interview schedule was used to assess the profiles of hospitals and a second schedule was used to interview the patients and their attendants. This schedule was designed to collect information about the socio-economic background of the patient, treatment cost, perception of the respondent about health care services and other related information.

Findings and conclusions: A total of 313 patients were surveyed. Of these, three fourths of the patients belonged to the poor economic strata. Around 48.28% of the patients accounted for malaria and 24.14% for tuberculosis. The main reason they went to the private hospital was the better healthcare services there and non-availability of Government health services. It showed that 29.71% of the respondents found the services provided by the private hospitals to be good. It was found that 74.1% visited the private hospital directly to receive healthcare services. Only 21.7% were found to go to public hospitals.
People were not fully convinced or satisfied with the fees charged by the private healthcare services. They found the charges to be high and irrational. Around 44.73% found the charges reasonable, 29.71% found it comparatively high and 14.70% very high. They also felt that unnecessary surgery and tests were on the rise because of this patients had to borrow and take loans. Around 47.28% borrowed money for their treatment, 10.86% took loans. This shows that the major proportion of patients belong to the poor economic strata. Through this study it becomes clear that the private health sector is more accessible and popular with those who can afford it. However, it is found that the private health sector in its present unregulated form does not favour the low-income groups since they suffer from a heavy economic burden due to high treatment costs. The reason the poor are forced to go to the private hospitals is the non-availability of government medical services, better quality of services, easy access. Unless certain minimum reforms are undertaken to ensure good service by the Government, the poor will be forced to go to the private hospitals and get exploited, thus leading to the increase in their economic burden.

32. User Perspective in Urban Tuberculosis Control

Author/s: Rangan Sheela
Publication source: Foundation for Research in Community Health (FRCH), Bombay
Year of publication: 1995
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector:Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, for profit, Not - for profit
Issues addressed: Utilisation,

Objectives: To assess the performance of the T.B control programme from patients' point of view.

Methodology: A sample of 60 T.B patients from Bombay and 196 patients from Pune was selected for the study. The patients from Bombay were registered with the Area TB Centre (ATC) which fell under City Tuberculosis Programme (CTP). The patients from Pune were either taking treatment from the TB clinics run by the corporation or from the district TB centre run by the state government. The data obtained from 61 patients from the Pune City who were followed for a period of nine months was also incorporated wherever required. The data was based on two separate studies carried out in Bombay and Pune

Findings and conclusions: Though TB is considered to be a major disease, the medical help-seeking pattern in case of TB is similar to the pattern in other diseases. In the study area it was observed that after developing the first symptoms of TB such as chest symptoms 62% of the patients were found to be seeking the help of private practitioners. Forty percent of them were diagnosed by the doctor and the treatment was started for 25%. It was found that the private practitioners were the major providers in the diagnosis and treatment of TB. However, due to their high cost the public services were preferred. When the patients were asked to compare between public and private services most of them agreed that given a choice they would prefer going to the private practitioner. The reasons were non-availability of medicines at the TB centers long waiting hours for treatment and check ups, inadequate provision of the information, etc. Despite these difficulties, 25% of the patients were able to complete the treatment.

The National TB Programme offers both diagnosis and treatment free of charge. But many times patients seek other sources of treatment and end up spending extravagantly. In the study the patients had visited average 2.9 sources in Bombay and 2.5 sources in Pune before registering with the TB programme. The average total expenditure of the Bombay sample was Rs. 826/- where as in Pune it was Rs. 325/-. Even registering with programme did not result in cuts of their spending since money was spent on travelling. In the sample, 32% of the patients interviewed were spending Rs. 10 on travelling. When the total cost was not supposed to go above Rs.1500/- even with the private treatment, it was found that some of the patients had spent Rs.1000/- to Rs.7000/- on the treatment. Even after registering with the public services their income on drugs sometimes continued since they were asked by the TB clinics to purchase the drugs from private chemists. The figures revealed by the study are disturbing since 66% of the people in the sample were from the low-income group and their earnings were meager as compared to the expenditures they made on the treatment. E.g. in Bombay, the mean per capita income of the people from the sample was Rs. 238.74.

Defaulter's identification and retrieval are the most important aspects of the National Programme. It is a duty of the health workers to see that the people registered with the TB center complete their treatment. In the study sample from Bombay all the patients had at least once not reported for drug collection. However only one patient was sent a reminder post card and only two were visited personally by the health workers. The problem resided with identifying the patient's address. It was found that 20% of the people had not filled up the address properly in the registration form and 15% of them were not residing at the mentioned address. The health workers however admitted that the follow up was not according to the programme standards due to various administrative and personal reasons. The motivation of the health workers was sometimes a problem, which needed proper attention by the programme manager. The conversations with the patients revealed that 37% of the patients from Bombay were sent back from the clinics due to the non availability of the drugs or were told to come after two or three days. This was in sharp contrast with the argument, which puts all the blame of non-adherence on the patients
The study has concluded that the patients were not fully satisfied with the performance of the TB control Programme as they had difficulties with the treatment they received. The costs of the treatment, the availability of the medicines, follow ups, etc. were the areas where patient's dissatisfaction was registered. By analyzing the performance according to various parameters such as case finding targets, sputum positivity, case holding, etc. from patient's point of view, the study has suggested that the programme managers should look at the problems at various stages of implementation and evolve improvements. This is necessary to make it people oriented.

33. Willingness to participate in Health Insurance

Author/s: Gupta Indrani
Publication source: Paper presented at Health Insurance Conference at Indian Institute of Management, Ahmedabad, 18-19 March, 2000.
Year of publication: 2000
States covered: Delhi
Social geography: Urban
Data source: Primary
Type of study: Cross sectional survey, primary data.
Type of private sector:Issues addressed: Financing, Payment Mechanisms, Insurance

Objectives: The study examined the willingness and ability of individuals to participate in private health insurance programmes.The other aspects that the study examined were the following: What do consumers feel about private health insurance? Are all sections of society willing and able to participate in private health insurance programmes ? Should India have only private insurance or a mix of private and government schemes? What happens to the existing insurance schemes in the event of privatization?

Methodology: A primary study of 504 households in Delhi, representing three distinct economic groups was done. The duration of the study was eight-months.

Findings and conclusions: Preliminary results revealed that the willingness to participate in health insurance schemes differed according to the extent, nature and period of their coverage, premium for adults and children, withdrawal amounts and whether unused funds would be returned in future. Most low and many middle income households considered the premium beyond their reach, while lower income households were wary of private schemes and trusted government schemes. Those in the middle-income group have been unwilling to consider coverage outside what they had at the time of this study (mostly government health schemes). They thought that there was no need for such schemes as they had no major illness. Moreover, they could always borrow when needed. Those who were in favour of the insurance schemes, consider it a good investment, that returns with interest. They also thought that such schemes were not only good for serious illnesses but also provide better treatment.

34. Willingness to Pay for Rural Health Insurance through Community Participation in India

Author/s: Mathiyazhagan K
Publication source: International Journal of Health Planning and Management, vol. 13 (1998), pp.47-67.
Year of publication: 1998
States covered: Karnataka
Social geography: Rural
Data source: Primary
Type of study: Cross sectional
Type of private sector: Private sector in general.
Issues addressed: Willingness to pay, rural health insurance scheme, financing of private health care, consumer choice.

Objectives: To examine the willingness to pay for a viable rural health insurance scheme through community participation in India.

Methodology: Willingness to pay is estimated through Contingent Valuation approach (logit model) by using rural household survey on health from Karnataka state. The sampling was carried out in three stages. The districts were stratified into three groups based on development statistics. Six districts were selected, two from each strata (of low, middle and high income districts). From each district, taluks were stratified into two groups in terms of their accessibility to health services (measured in the form of beds per 1000 populations). One taluk from each group was selected. Thus a total of 12 taluks were selected. From each taluk, one village having a primary health centre and private / non-governmental organization hospital services was selected. This selection was purposive, in the sense that the village was selected to obtain a large community. One or two more villages proximate to the selected village with PHC only were included in the sample. Thus a total of 36 villages were surveyed. From these villages, a sample of 1000 households was covered. These households were allocated in relation to the number of households in each of the villages. Simple systematic sampling was followed in choosing individual households.

Findings and conclusions: The results show that the insurance / savings schemes were popular in rural areas. People have relatively good knowledge especially of life insurance schemes. Most people stated that they were willing to join and pay for the proposed rural health insurance scheme. The main reasons for joining the proposed scheme were (a) poor quality of existing government services and (b) inaccessible and ineffective services in the government sector. The local bodies (Panchayats) have potential for participating in health insurance schemes. If such schemes are followed at Panchayat level, people will have a greater choice of heath care services. The study also validated the use of Contingent Valuation approach using binary responses on willingness to pay for rural health insurance scheme.

35. Women and Health Care in Mumbai – A study of morbidity, utilisation and expenditure on health care in the households of the Metropolis

Author/s: Nandraj S, Neha Madhiwalla, Roopashri Sinha, Amar Jesani
Publication source: Centre for Enquiry into Health & Allied Themes (CEHAT), Mumbai
Year of publication: 1998
States covered: Maharashtra
Social geography: Urban
Data source: Primary
Type of study: Cross Sectional
Type of private sector: Practitioners, Hospitals, Laboratory/investigation, ISM, Unqualified practitioners, For profit
Issues addressed: Utilisation, Financing, Costs, Expenditure

Objectives: To document and analytically understand the perceived morbidity patterns, access and constraints of women to health care facilities and their utilization and expenditures by households on women's health problems with special reference to socio economic differentials.

Methodology: The study was conducted in the 'L' ward of Greater Mumbai City, a congested pocket with residential units as well as small-scale factories and commercial establishments. A stratified random sampling method was used in the five clusters, two slums, two chawls and one apartment block. A household interview schedule was administered in the study area. Since women were the focus of the study, women investigators conducted the interviews and the respondents were all women. The sample consisted of 430 households. A 'probe list' of 14 symptoms, was used to probe for the existence of specific symptoms among women that might otherwise go unreported. Data was collected in July 1996, with a reference period of 1 month for morbidity-related questions and a reference period of 1 year for questions related to pregnancy, delivery, abortion and contraception.

Findings and conclusions: The findings were quite revealing. The monthly prevalence rate of illness worked out to 363 per thousand, (males 169 as compared to 297 for females and when we add those illness with probe for females it goes up to 597 per thousand). Due to the modifications that were made in the methodology, the researchers were able to record a significantly higher burden of morbidity among women. The study attempted to create an environment, which encouraged women to feel, unhindered to speak about their health problems even while a deliberate attempt was being made to elicit information about unreported illness through the probe list. Morbidity by physical environment revealed that the non-slum population, who comprised 41% of the total population, had 31.79% of total morbidity and the morbidity among slum dwellers was 10% higher than that of the total population. Reproductive illnesses form the largest group of problems accounting for 28.2 % of all episodes among females. We found that 127 out of the 167 reproductive episodes reported by women were related to menstruation and child bearing (Menstrual problems, uterine prolapse, low back ache and lower abdomen pain). We found a steady rise in the morbidity rates with age of females.

In terms of utilization the study reveals high non-utilization 32.5% of the illness episodes were not treated. Non-utilization was also found in relation to pregnant women and those who had delivered. Forty-three of the pregnant women did not utilize any facilities. These findings clearly show that Mumbai inspite of some of the best health facilities in the country, people residing within the city were not able to access them. The study found a very high utilization of the private health services and the limited role played by the public sector in the city of Mumbai for provision of health care. 85% of the illness episodes approached the private facility, with public facility accounting for only 10%. Public facilities were mainly utilised by the people in slum areas. The private practitioners mostly treated illnesses such as fever, respiratory and gastro intestinal problems. In case of the reproductive illnesses, about 70% of the facilities utilised were private. Of those pregnant women who utilized health facilities, 57% utilized private facility and only 32% utilized public facilities. With regard to deliveries the public sector accounted for only 30% of the deliveries as compared to the private sector, which accounted for 31.7%.

The average expenditure incurred per capita per episode was Rs. 95.45 working out to Rs. 415.68 per year. In terms of gender difference per episode cost worked out to Rs. 148.56 for males and Rs. 78.59 for females. In 90% of all the illness episodes, the combined expenditure was incurred on the fees paid to the doctor and the purchase of medicines. The expenditure incurred is much higher than what is spent by the government which is just Rs.250 per person in Mumbai city and very much less than the national per capita expenditure of Rs. 90. There was a high expenditure incurred on pregnancy, which works out to Rs. 213.08, Rs. 2428.90 for a Delivery & PNC and Rs. 989 for an abortion. The strong gender bias is very much evident right across the findings of the whole study. Women receive a raw deal both in terms of utilization and the expenditure incurred on their illness and non-illness events. One finds that irrespective of the age, education, occupation, earning status, location of the households there was a wide difference among men and women in terms of utilization.
The study shows that the methodology employed for studies of this nature needs to be sensitive in relation to women's health with emphasis on eliciting information from women with regard to illness that are not perceived as illnesses as such and illnesses relating to reproductive and sexual aspects. In both slum and non-slum areas households were spending less on women's health. The study has brought out these and many other important issues related with women's health, which require proper attention and corrective action. The study has emphasised the need of examination of these issues at a broader level and in a more gender sensitive manner. This study throws up the issue of non-utilization of health services especially women who suffer from various illness and for deliveries even in a premier city such as Mumbai that has more public health facilities compared to other parts of the country. This raises the question that though the services may be available, the access to them is determined by factors operating within the household and outside.

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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))