study of district hospital raisen and sehore an analysis...

Study of district hospital Raisen

and Sehore

– An analysis of out of pocket

expenses

Project Report

Atal Bihari Vajpayee Institute of Good Governance

& Policy Analysis

Project Report

Study of district hospital Raisen and Sehore –

An analysis of out of pocket expenses

Atal Bihari Vajpayee Institute of Good Governance

& Policy Analysis

http://www.aiggpa.mp.gov.in/images/files/pdf/reports/Study%20on%20Status,%20Process%20of%20Appointment%20and%20Performance%20of%20Class%203%20Ministerial%20Staff%20in%20GoMP.pdf#page=1







































Project Team

Under the Guidance of

Shri Madan Mohan Upadhyay, Principal Advisor,

Centre for Social Sector Development, AIGGPA

Project Coordinator

Ms Richa Sharma, Deputy Advisor, State Health Resource Centre (SHRC),

Centre for Social Sector Development, AIGGPA

Research Associate

Mr Vipul Shrivasatava

Index S.No Particulars Page No

Executive Summary

1 Introduction 1

1.1 Introduction to Government supported urban

health care infrastructure in India

1

1.1.1 Primary health care services 1

1.1.2 Secondary health care services 2

1.1.3 Tertiary health care services 3

1.2 Introduction to Out of Pocket Expenditure 4

1.3 Health System Financing 5

1.4 Catastrophic Health Expenditure 6

1.5 Out of pocket expenses on health in India as per

National Health Accounts

7

2 Objectives and methodology 12

2.1 State wise variation of out-of-pocket expenses on

health in India

13

2.2 Objectives of the study 13

2.3 Sampling 14

2.4 Methodology 14

2.5 Limitations of the study 15

3 Findings and analysis of data 16

3.1 District Hospital Raisen 16

3.1.1 Socio economic status of the patients availing

treatment at District hospital Raisen

16

3.1.2 Out of pocket expenses and experiences during

treatment at District hospital Raisen

20

3.2 District Hospital Sehore 27

3.2.1 Socio economic status of the patients availing

treatment at District hospital Sehore

27

3.2.2 Out of pocket expenses and experiences during

treatment at District hospital Sehore

31

4 Recommendations 41

References 44

Annexures

Abbreviations and Acronyms

AIGGPA Atal Bihari Vajpayee Institute of Good Governance

and Policy Analysis

ANM Auxiliary Nurse Midwife

CHE Current Health Expenditures

DES Department of Economics and Statistics

EMAS Emergency Medical Ambulance Service

GDP Gross Domestic Product

GHE Government Health Expenditure

IPD Indoor patients/ admitted patients

JSY Janani Suraksha Yojana

JSSK Janani Shishu Suraksha Karyakram

NFHS National Family Health Survey

NHA National Health Accounts

NHM National Health Mission

NRHM National Rural Health Mission

NUHM National Urban Health Mission

OOPE Out of Pocket Expenses

OPD Out-door patients

PPP Public Private Partnership

RCH Reproductive and Child Health

TB Tuberculosis

THE Total Health Expenditure

WHO World Health Organization

Study of district hospital Raisen and Sehore – An analysis of out of

pocket expenses 2018

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 1

Executive Summary

One of the goals of the recent National Health Policy 2017 is "the attainment of the highest

possible level of health and well-being for all at all ages, through a preventive and promotive

health care orientation in all developmental policies, and universal access to good quality

health care services without anyone having to face financial hardship as a consequence. This

would be achieved through increasing access, improving quality and lowering the cost of

healthcare delivery".

Public health facilities are expected to offer health care services free of cost or at

minimal cost. However, at times people incur a significant expenditure while trying to avail

services from the government healthcare institutions also, which is a cause of concern. When

the poor move out of the domain of availing the benefits of public health they face a lot of

hardship due to ignorance and end up paying a very heavy price in the private health set up

which at times forces them to enter a trap of a high interest loan which affects their life.

Health care out-of-pocket payments may result in a number of households facing

catastrophic payments. Such high expenditure can mean that people have to cut down on

necessities such as food and clothing, or are unable to pay for their children's education. To

address the issue of out-of-pocket expenses several schemes have been followed by the

Government for the benefit of the poor and to minimize the health related expenditure and

suffering to the poor.

As per the Healthy States ,Progressive India report on the ranks of States and Union

Territories the National Family Health Survey (NFHS)-4 data on average out-of-pocket

(OOP) expenditure per delivery in public health facility was considered as a proxy indicator

for overall OOP expenditure. There is significant variation in the average OOP expenditure

per delivery in public health facilities across the States. Given the number of NHM

interventions targeting pregnant women, such as Janani Suraksha Yojana (JSY), Janani

Shishu Suraksha Karyakram (JSSK), and referral transport to ensure free delivery at public

health facilities, the states should aim to reduce such OOP expenditure.




Data is available under NFHS 4 only for average state wise out of pocket expenditure

per delivery in public health facility and not the full range of services provided in the public

health facilities. In light of these circumstances the Department of Health and Family Welfare

, Govt of MP requested Atal Bihari Vajpayee Institute of Good Governance and Policy

Analysis (AIGGPA) to take up a detailed study regarding out-of-pocket expenses at District

hospital Sehore and Raisen covering both indoor and outdoor patients and covering range of

services provided by the hospital. Since both the said district hospitals cater to the health

needs of significant portion of rural population the same were studied to get an understanding

of their needs.

Overall both the said District hospitals worked reasonably well on account of

fulfilling the mandate of the National Health Policy of providing health care while trying to

minimise the cost or financial hardship to the patients. It was found that the facility of the

hospital is mostly used by the people from the low socio-economic background. It was also

found that in some cases the patients had to get the investigation done from outside on

account of delay in the investigation at the hospital and so end up paying money for the same.

In rare cases medicine was purchased from outside especially in case of admitted patients.

Such cases should be minimised. It was found that if the patients end up in the private health

facility then the cost of treatment both direct cost and indirect cost increases exponentially.

The staff of the Government health facility should be sensitive towards the importance of the

service provided by them is on the life of the patients.

The Government of Madhya Pradesh has provided the facility of free transport for

patients under 108 ambulances and for pregnant women and infants under Janani Express.

Majority of the pregnant women who came to the hospital for delivery were able to get the

benefit of Janani Express or 108 ambulances to reach the hospital. Certain instances were

found when the patients paid money even when they availed the facility of government

supported transport the Janani Express and the 108 ambulance even when the facility should

be available free of cost to the patients. Such instances cause dissatisfaction among the

patients and efforts must be done to minimise such instances.

There is high importance of each level of functionary in a government hospital

including doctors, nurses, pharmacists, technicians, cleaner, driver etc needs to be taken into

consideration. Each of the service providers has an important role to play in the smooth

running of the mechanism. Also since the facility of hospital has to function 24 by 7




throughout the year it is important to have a contingency plan for dealing with staff related

issues in case of an emergency. Deficiency of health personnel is not limited to doctors alone.

In the case of district hospital Raisen almost 50 % of the posts lie vacant. Similarly lack of

staff was found at district hospital Sehore also. In light of these circumstances the patients

and services of the hospital suffer. There is shortfall in various categories of paramedical

personnel which is a cause of concern. Thus there is an urgent need to address the staff

related issues.

The referral system is very important for the smooth functioning of the system. It is

essential to strengthen the institutions of PHC and CHC to be able to rationalise the flow of

patients, it was found that majority of the patients came to the district hospitals. This scenario

leads to over load at the district hospital .It is essential that training calendar be developed

and the staff of PHC / CHC visit the district hospital and take training of dealing with basic

health issues. The general population availing the facility of the district hospital must also be

counselled and encouraged to visit the neighbouring health facilities.

The task of making the primary and secondary level health institutions functional

ought to be the utmost priority, such that people can access effective healthcare for common

and easily treatable conditions nearest to their homes. Urgent steps need be taken to provide

working and living conditions in the peripheral areas that will encourage doctors and other

health personnel to be willing for rural service.

How important is the access to medical facility for a common man

Dashrath Manjhi famously known as the Mountain Man who single-handedly carved a

path through a mountain. He gave 22 years of his life to his village and made a

difference in the lives of the people of a small village, in Bihar.

Using only a hammer and chisel, Dashrath Manjhi, a landless farmer, carved a path

through a mountain in the Gehlour Hills, Bihar so that his village could have easier

access to medical facilities. It shortened the distance from 71 Km to 1 Km to the nearest

town for getting medical attention. Dashrath Manjhi's wife Falguni Devi died from lack

of medical care. In the memory of his wife; he carved the path in the Gehlour hills so

that his village could have easier access to medical attention.




Chapter 1

Introduction

Importance of district hospital in India: Every district is expected to have a district

hospital. In the present 3-Tier structured level of care being provided by public health

facilities, the District Hospital (DH) serves at the secondary referral level. The objective of a

district hospital is to provide comprehensive secondary health care services to the people in

the district at an acceptable level of quality and being responsive and sensitive to the needs of

people and referring centres. As the population of a district is variable, the bed strength also

varies depending on the size, terrain and population of the district. There is one district

hospital available in the head quarter of each of the 51 districts of Madhya Pradesh.

1.1 Introduction to Government supported health care infrastructure in

India

The Government supported health care system in India consists of primary, secondary and

tertiary care institutions, manned by medical and paramedical personnel and other staff at

various levels. The district hospital is strategically positioned at the secondary level. Thus it

is essential to have a fair understanding of the various health care facilities at primary,

secondary and tertiary level .The various health care facilities provided by the Government at

various levels is as under:

1.1.1 Primary health care services

The primary health care infrastructure provides the first level of contact between the

population and health care providers. It consists of Sub-health centre and Primary Health

Centre.

Sub-health centre: A Sub-health centre (Sub-centre) is the most peripheral and first point of

contact between the primary health care system and the community. In the field of rural

health, effort is to provide one sub-centre for a population 5000 people in the plains and for

3000 in tribal and hilly areas. However, as the population density in the country is not

uniform, it shall also depend upon the case load of the facility and distance of the

village/habitations which comprise the Sub-centre. A Sub-centre provides interface with the




community at the grass-root level, providing primary health care services. A sub- centre is

generally staffed with a multipurpose worker male and multipurpose worker female.

Primary Health Centre: Primary Health Centre (PHC) serves as a first port of call to a

qualified doctor in the public health sector in rural areas providing a range of curative,

promotive and preventive health care. Primary Health Centre is the cornerstone of rural

health services- a first port of call to a qualified doctor of the public sector in rural areas for

the sick and those who directly report or referred from Sub-Centres for curative, preventive

and promotive health care. A typical Primary Health Centre covers a population of 20,000 in

hilly, tribal or difficult areas and 30,000 population in plain areas with 4-6 indoor/observation

beds. It acts as a referral unit for 6 Sub-centres and refer out cases to CHC (30 bedded

hospital) and higher order public hospitals located at sub-district and district level.

1.1.2 Secondary health care services

Community Health Centre: The secondary level of health care essentially includes

Community Health Centres (CHC), constituting the First Referral Units (FRUs) and the Sub-

district/Sub-divisional Hospital and District Hospitals. The Community Health Centres are

designed to provide referral as well as specialist health care to the rural population. The CHC

were designed to provide referral health care for cases from the Primary Health Centres level

and for cases in need of specialist care approaching the centre directly. 4 PHCs are included

under each CHC thus catering to approximately 80,000 populations in tribal/hilly/desert areas

and approximately 1, 20,000 populations for plain areas. CHC is generally is a 30-bedded

hospital providing specialist care in Medicine, Obstetrics and Gynaecology, Surgery,

Paediatrics, Dental and AYUSH.

Sub-district / Sub-divisional hospital: Sub-district (Sub-divisional) hospitals are below the

district and above the block level (CHC) hospitals and act as First Referral Units for the

Tehsil/Taluk/block population in which they are geographically located. Specialist services

are provided through these Sub district hospitals and they receive referred cases from

neighbouring CHCs, PHCs and SCs. They form an important link between sub-centre, PHC

and CHC on one end and District Hospitals on other end. It also saves the travel time for the

cases needing emergency care and reduces the workload of the district hospital. In some of




the states, each district is subdivided in to two or three sub divisions. A subdivision hospital

caters to about 5-6 lakh persons. In bigger districts the Sub-district hospitals fills the gap

between the block level hospitals and the district hospitals. A sub-district hospital usually has

about 31 to 100 beds.

District Hospital: District Hospital is a hospital at the secondary referral level responsible

for a district. Its objective is to provide comprehensive secondary health care services to the

people in the district at an acceptable level of quality and being responsive and sensitive to

the needs of people and referring centres. Every district is expected to have a district hospital.

District Hospital should be in a position to provide all basic specialty services. District

Hospital also needs to be ready for epidemic and disaster management all the times.

1.1.3 Tertiary health care services

The Government also provides certain tertiary care institutions which provide super-specialty

services for the patients. All hospitals - even those providing secondary or tertiary care also

provide primary health care services to rural and urban population. The urban health facilities

especially the tertiary care institutions cater to both the urban and rural population.

Thus there are several tier of Government facility available for the patients and effort is

done to provide maximum coverage of the facility and provide health care facility at a

nearest location .This is done to ensure that health care facility is available at a

reasonable distance and good functioning of the referral system will help in ensuring

that only cases which need the services of the district hospital actually reach there ,

otherwise this may result in flooding of the district hospitals.




The government health facilities aim to provide health facility at minimum cost to the poor.

Poor health is a common consequence of poverty and vice versa. Poor health leads to poverty

through the inability to work and generate income. For people with low income this is one of

the devastating consequences of falling ill. Sometimes people do not seek treatment until the

disease has affected their daily activities, this could be due to financial reasons or

unavailability of healthcare services. Thus for the poor the nature and the quantum of health

care depends on the cost involved and the source from which the expenditure is financed.

1.2 Introduction to Out of Pocket Expenditure

Households, in general, avail healthcare services from public as well as private health care

facilities, depending on their accessibility, affordability to these facilities and multiple other

factors. In public health institutions, Government incurs expenditure for providing healthcare

infrastructure as well as payment of salaries for medical staff, while in private sector

hospitals, the service providers charge directly from households for their services. Although

the services provided by public health institutions particularly sub centres , primary health

centres, community health centres , sub-district hospitals, district hospitals and other

government hospitals are accessible to the public, mostly free of cost, in practice, there are

various instances, where households have to pay ‘out of pocket expenditure’. These expenses

could be medical as well as non-medical expenditure. Out of Pocket Medical expenditure

Overall coverage of health care facility below the district hospital is as under:

Abbreviations HW (F) =Health Worker (Female). ANM= Nurse Midwifery; HW (M) = Health Worker (Male), ASHA= Accredited Social Health Activists

Source; Adapted From Rural Health Statistics in India (2012) Statistics Division Ministry Of Health and Family Welfare, Government of India.

Primary Health Centre (PHC)

(Average radial distance covered: 6.42 Km)

Population Served: 30,000 (20,000 in tribal/hilly areas) A Referral Unit for 6 Sub Centers 4-6 bedded manned with A Medical Officer In charge and

14 subordinate paramedical staff

Sub centre

(Average radial distance Covered: 2.59 Km)

Population Served: 5,000 (3,000 in tribal/ hilly areas) Most Peripheral Contact Point between Primary Health Care System & Community Manned

With One HW (F) ANM& One HW (M) and 3-5 ASHA Workers

Community Health Centre (CHC)

(Average radial distance covered: 1433 Km)

Population served: 1,20,000 (80, 000 in tribal/hilly areas)

A 30 bedded Hospital/ Referral Unit for 4 PHCs with Specialized services




could be payments towards doctor’s fees, medicine, diagnostics, operations, charges for

blood, ambulance services etc, while non-medical expenditure include money spent towards

travelling expenses, lodging charges of escort, attendant charges, etc.

Out-of-pocket expenditure (OOPE) on healthcare forms a major barrier to health seeking

behaviour. The poor sections do not have any form of financial protection and are forced to

make OOPE when they fall sick. At times, these households have to resort to borrowings or

sell assets to meet this expenditure.

1.3 Health System Financing

Health System consists of all organizations, people and actions whose primary intent is to

promote, restore or maintain health. This includes efforts to influence determinants of health

as well as more direct health-improving activities [1]

.The ultimate goals of a health system

are improving health status, health equity and to make the most efficient use of the available

resources. There are also intermediate goals which to achieve more coverage and better

access to health services without having to compromise on quality and safety. Universal

health coverage means that everyone in the population has access to preventive, curative and

rehabilitative health care at the time they need it and at a cost they can afford [2]

There are four main types of financing for healthcare: Government funded (through

taxes), social insurance (through payroll, taxes or direct contributions) private insurance and

Out-Of-Pocket (OOP). The first three types are pre-paid financing mechanisms and have

some form of risk pooling. There is variation across countries in determining their health

financing mechanism, but it mainly depends on the country’s economic status. The poorer the

country, the more is the dependence on out of pocket payment. The mechanism of fund flow

under health system in India has a complex set of interlink ages mentioned in Annexure –I.

Out-of-Pocket Payment is the most important means of healthcare financing in most

developing countries. It can be divided into direct or indirect costs. Direct costs include

doctor’s consultation fees, medications, tests, procedures, hospital bills etc. Indirect costs

include transport charges to treatment site, daily living cost for accompanying household

members and loss of income due to illness[3]

.

http://www.imedpub.com/scholarly/health-system-journals-articles-ppts-list.php




Often the OOP expenditure poses a colossal burden on poor households. The costs are

frequently high enough and households are unable to recuperate them from existing

resources, and, hence, ultimately slip deeper into poverty. As a result, protecting households

from health expenditure continues to remain as a challenge, particularly for countries with

high levels of poverty. Out-of-Pocket healthcare expenditure remains one of the most typical

means of financing health expenditure around the world and more specifically in developing

countries where access to financial protection provided by health insurance is minimal due to

low income levels by citizens. This situation is made worse by the fact that in some countries,

the burden of out of-pocket spending creates barriers to health care access and use.

1.4 Catastrophic Health Expenditure

Catastrophic health expenditure is not always synonymous with high health-care costs [4].

A

large bill for surgery, for example, might not be catastrophic if a household does not bear the

full cost because the service is provided free or at a subsidised price, or is covered by third-

party insurance. On the other hand, even small costs for common illnesses can be financially

disastrous for poor households with no insurance cover. World Health Organization has used

the following definition of Catastrophic Expenditure .An expenditure is considered as being

catastrophic if a household’s financial contributions to the health system exceed 40% of

income remaining after subsistence needs have been met[5].

The impact of health care

financing systems on the welfare of households, particularly poor households is mainly

regarded as an important issue encountered by policy makers when developing healthcare

systems and insurance mechanisms.

Several studies of Indian villages to determine why households descent into poverty

find that in a majority of cases of decline into poverty, three principal factors are at work:

health expenses, high-interest private debt, and social and customary expenses[6].

Healthcare

access in India is affected with 70:70 paradox; 70 per cent of healthcare expenses are

incurred by people from their pockets, of which 70 per cent is spent on medicines alone,

leading to impoverishment and indebtedness [7].




1.5 Out of pocket expenses on health in India as per National Health

Accounts

Table 1: As per National Health Accounts (NHA) Estimates for India 2014-15

Particulars Amount Remarks

Total Health Expenditure

(THE) for India for the

year 2014-15

Rs. 4,83,259 crores (3.89%

of GDP and Rs. 3,826 per

capita)

Total Health Expenditure

constitutes current and

capital expenditures

incurred by Government

and Private Sources

including External/Donor

funds

Government Health

Expenditure (GHE)

including capital

expenditure for the year

2014-15

Rs. 1,39,949 crores (29 %

of Total Health

Expenditure (1.13% GDP

and Rs. 1,108 per capita)

This amounts to about

3.94% of General

Government Expenditure

in 2014-15

Out of Pocket Expenditure

(OOPE) on health by

households

for the year 2014-15

Rs. 3,02,425 crores (62.6%

of Total Health

Expenditure, 2.4% of GDP,

Rs. 2,394 per capita)

Private Health insurance

expenditure

Rs. 17,755 crores (3.7% of

Total Health Expenditure)

Table 2 : Key Health Financing Indicators for India across National Health Accounts

Rounds

S.No Indicator NHA NHA NHA

2014-15 2013-14 2004-05

1 Total Health Expenditure (THE) as per cent 3.9 4 4.2




of GDP

2

Total Health Expenditure (THE) per capita

(Rs.) 3826 3638 1201

3

Current Health Expenditures (CHE) as % of

Total Health Expenditure 93.4 93 98.9

4

Government Health Expenditure (GHE) % of

Total Health Expenditure 29 28.6 22.5

5

Out of pocket Expenditures (OOPE) as % of

Total Health Expenditure 62.6 64.2 69.4

7

Private Health Insurance Expenditures as %

of of Total Health Expenditure 3.7 3.4 1.6

8

External/Donor Funding for health as % of

Total Health Expenditure 0.7 0.3 2.3

Source: National Health Accounts (NHA) Estimates for India 2014-15

Though there has been a reducing trend of Out of Pocket Expenditure (OOPE) as percentage

of Total Health Expenditure over a period of time, yet OOPE of 62.6 % is still an area of

serious concern.

Private Hospital Vs Government Hospital

As per National Statistical Survey 71st round covering key indicators of social consumption

in India health held during Jan 2014 to June 2014 it was seen that private doctors were the

most important single source of treatment in both the sectors. They accounted for around

50% of the treatments in rural as well as urban areas. In fact, more than 70% (72 per cent in

the rural areas and 79 per cent in the urban areas) spells of ailment were treated in the private

sector (consisting of private doctors, nursing homes, private hospitals, charitable institutions,

etc) [8]

.

To address the issue of Out-of-Pocket Expenses several schemes have been followed by

the Government for the benefit of the poor:




Free Medicines: The Sardar Vallabh Bhai Free Medicine Distribution Scheme has been

implemented since October 2012 in all 1595 health institutions in the state. About 3 lakh

patients are availing its benefit daily. Most required generic medicines are provided 24 x 7

hours to OPD as well as indoor patients in hospitals.

Free Pathology Tests: This measure has been initiated by State Government towards

ensuring better health to people. Objective of the scheme is to provide free pathological test

facility to people in government hospitals. The facility is available right from district

hospitals to sub-health centres. Several categories of pathological tests are provided based on

the level of facilities at the respective health care facility.

Madhya Pradesh Rajya Beemari Sahayta Nidhi: Under the scheme, financial assistance of

Rs. 25,000 up to Rs. 2 lakh is provided to a member of BPL family suffering from identified

and deadly diseases. Under it, financial assistance of Rs. 25,000 up to Rs. 1 lakh is sanctioned

at district level and Rs. 1 lakh to Rs. 2 lakh at division level.

The scheme is targeted for all the BPL families who cannot bear the expenses for serious

diseases that are specified in the scheme. Under the scheme, the beneficiary has to be a

resident of Madhya Pradesh. The eligible people for the scheme get financial aid for the

treatment. The range of the financial aid depends upon the criticality of the disease. However,

there are certain conditions also mentioned in the scheme. The health benefits can also be

availed of from accredited health organizations. The payment in such cases is made through

cheque to the health organizations where the patient is undergoing treatment.

Mukhyamantri Bal Hriday Upchar Yojana: Under the scheme, financial assistance up to

maximum Rs. 1, 00,000 is provided to concerning government and recognized private

hospitals for heart surgery of BPL children from 0 to 15 years of age, who suffer from heart

disease.

Health services being strengthened in rural areas: Village Health Centres have been set

up. Village health register is maintained at these health centres where necessary medical

equipments and medicines are available.




Janani Suraksha Yojana: Janani Suraksha Yojana (JSY) is a safe motherhood intervention.

The scheme focuses on the poor pregnant woman with special dispensation for states having

low institutional delivery rates. All pregnant women delivering in Government health centres

like Sub-centre, PHC/CHC/FRU/general wards of District and state Hospitals or accredited

private institutions are eligible.

Table 3: Incentives under Janani Suraksha Yojana

Category Incentive to be provided to

mother in Rupees

Incentive to be provided to ASHA in

Rupees (per delivery)

Rural area 1400 600

Urban

Area 1000 200

Janani Express: The Janani Express Yojana aims at providing benefit of transportation to all

of the expectant mothers for their institutional deliveries. It benefits them also in emergency

circumstances during pre and post-delivery periods. Besides this, eligible beneficiaries of

Deendayal Antodaya Upchar Yojana and sick infants can also avail the services of Janani

Express for their casual medical treatment under the scheme.

Mamta, Astha and Kayakalp Abhiyans: Mamta, Astha and Kayakalp Abhiyans are being

implemented to effectively monitor all schemes and services of Health Department. Maternal

and child health, vaccination and family welfare programme have been included in mamta

abhiyaan, TB, leprosy, blindness, malaria, dengue, chikanguiniya and swine flu and seasonal

diseases in astha abhiyaan and works of entire infrastructure and development of health

institutions is being done under kayakalp abhiyaan. These include construction of new

buildings, up gradation of old buildings, cleaning, safety, free medicines and pathology tests,

food, transport etc for patients.

Source: http://www.mpinfo.org/MPinfoStatic/english/articles/2013/100813Lekh22.asp,

Department of Public affairs, govt of MP accessed on 10th May 2018

http://www.mpinfo.org/MPinfoStatic/english/articles/2013/100813Lekh22.asp




About 108 ambulance facility: The Government of M.P. is running an ambulance service

project. It is an emergency medical ambulance service (EMAS) which is running across the

state of M.P. and is also popularly known as "108 Ambulance Service". The ambulances are

deployed strategically across MP supported with a fully functional centralized call centre

which receives more than 25,000 calls per day and handling approximately 2500 emergencies

on daily basis. GPS with biometric system has been installed in these ambulances. The

project is being managed under public private partnership (PPP) mode and financials are on

reimbursement basis.

The project aims to provide round the clock pre-hospital emergency transportation care

(ambulance) services across the state. It aims to improve the access to medical & health care,

police and fire service, particularly attending emergency situations relating to pregnant

women, neonates, parents of neonates, infant and children in situations of serious ill health

and all other emergencies in the general population. It covers emergency cases including

pregnancy cases, accidental, unconscious, paralysis, fever, heart attack. Any person in need

of emergency help can dial a toll free number 108 from any landline or mobile set. The

ambulance reaches the site and rushes the victim to the nearest hospital during the transit;

pre-hospital care is to be provided to the patient.

Source: http;//www.nhmmp.gov.in/hc-sanjeevanilexp-background.aspx accessed on 10th

May 2018




Chapter 2

Objectives and Methodology

One of the goals of the recent National Health Policy 2017 is "the attainment of the

highest possible level of health and well-being for all at all ages, through a preventive

and promotive health care orientation in all developmental policies, and universal

access to good quality health care services without anyone having to face financial

hardship as a consequence. This would be achieved through increasing access,

improving quality and lowering the cost of healthcare delivery".

Public health facilities are expected to offer health care services free of cost or at

minimal cost. However, at times people incur a significant expenditure while trying to avail

services from the government healthcare institutions also, which is a cause of concern.

When the poor move out of the domain of availing the benefits of public health they face a

lot of hardship due to ignorance and end up paying a very heavy price in the private health

set up which at times forces them to enter a trap of a high interest loan which affects their

life.

Though numerous schemes are announced by the health department and made

available for the poor, access to them is at times difficult. Proper dissemination of

information about the schemes also remains a challenge. While government has launched

several schemes aimed at mitigating the financial burden on the persons visiting hospitals,

poor have to spend money from their own resources in meeting various other types of

associated expenses. The financial burden of out-of-pocket payments at the time of health

care utilization can lead individuals to spend high amounts compared to their available

incomes, thereby reducing spending on other basic items.

Increasing the availability and use of health services is critical with a view to

improving health systems. However, if health systems financing basically relies on out-of-

pocket payments and financial risk protection measures are missing, unwanted effects may

be observed. Health care out-of-pocket payments may result in a number of households

facing catastrophic payments. Catastrophic payments occur when households need to spend

an important fraction of their net income on health care, some of them being pushed into

poverty and others giving up the care needed. Therefore, it is a major challenge for health




systems to protect households from the risk of impoverishment resulting from health

expenditure, and to ensure that the population receives the needed health services.

2.1 State wise variation of out-of-pocket expenses on health in India

As per the Healthy States ,Progressive India report on the ranks of States and Union

Territories the National Family Health Survey (NFHS)-4 data on average out-of-pocket

(OOP) expenditure per delivery in public health facility was considered as a proxy indicator

for overall OOP expenditure. This data is available only for 2015-16 and hence the indicator

is reported only for the reference year. There is significant variation in the average OOP

expenditure per delivery in public health facilities across the States. The expenditures range

from as low as Rs 471 in Dadra & Nagar Haveli to as high as Rs 10,076 in Manipur. The top

five States and UTs with average expenditure above Rs 6,000 per delivery in a public facility

are Manipur Rs 10,076, Delhi Rs 8,719 West Bengal Rs 7,782 Kerala Rs 6,901 and

Arunachal Pradesh Rs 6,474. The average OOP expenditure per delivery in public health

facility for Madhya Pradesh was found to the lowest among states at Rs 1,387 as per NFHS 4

data [9]

. Given the number of NHM interventions targeting pregnant women, such as Janani

Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), and referral transport to

ensure free delivery at public health facilities, the states should aim to reduce such OOP

expenditure.

Data is available under NFHS 4 only for average state wise out of pocket expenditure per

delivery in public health facility and not the full range of services provided in the public

health facilities. In light of these circumstances the Health department, Govt of Madhya

Pradesh requested Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis

(AIGGPA), Bhopal to take up a detailed study of district hospital Raisen and Sehore with an

analysis of out of pocket expenses including covering both indoor and outdoor patients

covering the range of services provided by the hospital.

2.2 Objectives of the study

1. To identify the nature and the amount spent by the family as out of pocket expenses in

order to avail treatment at District Hospital Raisen and Sehore.




2. To identify the bottlenecks in availing facility of the Government Schemes for IPD and

OPD patients.

3. To identify socio-cultural health practices prevalent in the area that influences the access

and utilization of various health schemes.

4. To map the pattern of patients visiting respective district hospital and to identify the

services this could have been availed at the neighbouring PHC/CHC.

2.3 Sampling

Information was taken from the hospital regarding the number of patients who have availed

the services of District Hospital Raisen and Sehore as out-door patients (OPD) and those who

have been admitted in the hospital for treatment as indoor patients (IPD). For the purpose of

the study it is essential to determine an optimal number of patients to be included in the

sample. The sample size was determined using Slovin’s formula for sampling at 92%

confidence level for outdoor patients and at 90% confidence level for indoor patients. The

sample comprised of 200 outdoor patients and 100 admitted patients covering all the

departments in district hospital Raisen and Sehore respectively.

Table 4: Total number of patients included in the study

Name of the Hospital Particulars Number of Patients

surveyed

District Hospital ,

Raisen

OPD patients surveyed 200

Admitted patients surveyed 100

District Hospital ,

Sehore

OPD patients surveyed 200

Admitted patients surveyed 100

Total number of patients surveyed 600

2.4 Methodology

Both primary and secondary data was used for the purpose of the study. Secondary data was

collected by means of various websites and brochures of various government schemes and

series of interactions with the staff at respective district hospital. Primary data was collected

by means of a detailed questionnaire which was developed based on a series of interactions




with various officers and staff working in the Raisen and Sehore District Hospitals and

concerned officers in the Department of Health and Family Welfare, Govt of MP.

Department of Economics and Statistics, Govt of Madhya Pradesh supported in development

a mobile application for the same. For the purpose of collecting data from the patients in the

form of questionnaire, two field investigators were identified. Since the data was required to

be collected from male as well as female patients; it was essential to hire the services of a

male and a female field investigator for each of the District Hospital. The eligibility criterion

applied was that the field investigators were graduates and competent of interacting with the

patients and entering the data in the mobile application. Interaction with the patient was done

at the time when the patient was returning home after obtaining treatment in case of OPD

patients or after discharge from the hospital in the case of indoor patients.

The questionnaires were pre-tested by means of a pilot test before conducting the study.

Efforts were made to include patients from all the functional departments in the hospital for

the purpose of the study.

2.5 Limitations of the study

The study is mainly based on primary data. There is a risk that because of the presence or

influence of the interviewer in a face-to-face interaction, the interviewer might unknowingly

bring out an untrue response to sensitive questions, e.g. the respondent may craft an answer to

please the interviewer instead of answering truthfully or the interviewer might record a verbal

response incorrectly because the statement is not interpreted correctly. Nevertheless, efforts

were made to minimize the possibility of error since the field investigators, who were

selected for the purpose of the study, were local from the respective district only.




Chapter 3

Findings

3.1 District Hospital Raisen:

The observations of the study are based on the responses received from the respondents

comprising of patients. Almost all patients availing the service of district hospital Raisen

were from Raisen district itself. Against 200 beds sanctioned for the hospital, there are 283

beds available in the hospital. Details of section wise beds is given in Annexure -II

The status of staff position of the district hospital is available in Annexure –III . Almost 50

% of the posts lie vacant.The hospital is facing shoratge of not just doctors but also for

staff nurse, ward boy , pharmasist etc.

Rural /Urban mix of patients: Majority of the inflow of patients were from the rural area (63

%) while only approximately 37 % of the patients who availed the services of the Raisen

district hospital were from urban area.

3.1.1 Socio economic status of the patients availing treatment at District

Hospital Raisen

B.P.L card holders: The Government hospital in a great boon to the patients facing

financial hardship. Majority approximately 60 % of the families surveyed which availed the

facility of Raisen District hospital were B.P.L card holders.

Rural Area

63%

Urban Area

37%

District Hospital Raisen -Pateints from

Rural Area or Urban Area




Age group of the patient: The district hospital covers an entire basket of services dealing

with patients of almost all age groups including infants, children, adults and the aged. Efforts

were made to include patients of all age groups for the purpose of the study. Out of the

patients surveyed, about 15% were less than 10 years of age, 7% were in the age group 10 to

18 years, 70% were more than 18 years of age but less than 60 while approximately 8 %

patients were more than 60 years of age.

Category of patients: About 32% of the respondent patients who availed the services of

Raisen District Hospital were from general category, approximately 17% were from

scheduled caste, and 9% were from scheduled tribe while 42% were from other backward

classes.

15%

7%

70%

8 %

0

10

20

30

40

50

60

70

80

0-10 years >10 years upto

18 years

>18 years upto

60 years

> 60 years

District Hospital Raisen Number of respondent patients

falling in different age groups




Level of education of the head of the household:

Occupation: An effort was done to identify the main source of income of the family of the

patients availing the treatment facilities at the hospital were as under:

Majority of the patient’s family worked as labourers with almost 55 % of the surveyed

families working as labourer. Almost 27% derived their major source of income from

General

32%

Scheduled

Caste

17%

Scheduled

Tribe

9%

Other

Backward

classes

42%

Category of respondent patients who availed

treatment at District Hospital Raisen

Illiterate

28%

Upto 5th

Standard

21%

Upto 8th

Standard

31%

Upto 10th

Standard

12%

Upto 12th

Standard

4%

Graduate

2%

Post

Graduate

2%

Education level of the head of household of the

patients surveyed in District Hospital Raisen




agriculture, 14% of patients surveyed were self employed / had business, almost 3% were in

Government job while 1 % did other work.

Monthly income of the household from all sources: An effort was also done to classify the

families of the patients on the basis of the monthly income of the families. Huge majority

(72%) of the families covered in the survey earned less than Rs 10,000 per month,

approximately 18 % of the families earning income in the range more than Rs 10,000 but less

than Rs 15,000. Only 10 % of the respondents mentioned that their monthly income from all

sources was more than Rs 15,000.

Agriculture

27%

Labourer

55%

Govt. Service

3%

Self employed /

Business

14%

Others

1%

Main source of income for the family of the patients -

District Hospital Raisen

0

10

20

30

40 37

35

18

7 1 0 2

Monthly income from all sources of family of

patients availing facility of District Hospital Raisen

(value in %)




It is a usual perception that Government hospitals are flooded with people and number of

persons accompanying the patient to the hospital is very high. An effort was done to know

how many persons accompanied the patient to the hospital. In 20% of the cases two persons

or more persons were accompanying the patient.

3.1.2 Out of pocket expenses and experiences during treatment at District

hospital Raisen

Mode of transport: Among the admitted patients, about 22 % used the Government

supported transport facility like 108 or Janani express. The government supported facility

was used in cases pertaining to delivery of the baby, accident etc. Majority of the patients

mentioned that they got the government supported facility free of cost; however, in few cases

they mentioned that they had to pay some money for the service. 60 % of the admitted

patients used public transport like bus, tempo etc. 18 % of the patients made their own

arrangement.

Amongst the outdoor patients, 67 % used public transport like bus, tempo etc. 23 % of the

outdoor patients came cycle or by foot. 33 % of the respondents made their own arrangement

for travel to the hospital including two-wheeler or by foot and in rare cases some of the

patients came to the hospital by car.

23

57

19

1

0

10

20

30

40

50

60

70

No

accompanying

person

Patient +1 Patient +2 Patient + 3

Number of persons accompanying the patient to

District Hospital Raisen (value in %)




Cost of travel incurred by the patients: The average cost borne on account of travel by the

indoor patients amounted to Rs 164. Certain instances were found when the patients paid

money even when they availed the facility of government supported transport the Janani

Express and the 108 ambulance even when the facility should be available free of cost to the

patients. Such instances cause dissatisfaction among the patients and efforts must be done to

minimise such instances. The average cost of travel for the outdoor patients was Rs 124.

Note: The information was gathered by means of a questionnaire at the time of discharge from the

hospital .Thus the travel cost as informed by the patient was multiplied by 2 to be able to get the

approximate travel cost involved.

In spite of the fact that some of the admitted patients used the government facility of

108 ambulances or Janani express, the average cost of travel is more in case of admitted

patients than the cost of travel borne by the outdoor patients. This is because the family

bears travel cost on account of visit of attendants of the patient to the hospital in the case of

admitted patients.

Cost of stay in case of admitted pateints : Information was gathered from the admitted

pateints for cost incurred during stay in the hospital for treament.Majority of the attendants of

the patients shared the bed with the patient or slept on the floor.

Amount spent on food during treatment at the hospital: There is a facility of free food for

the admitted patients in the hospital. In spite of the fact that food is provided free of cost the

admitted patients, some expenses are incurred on food for attendants. Also, some amount is

spent on food by outdoor patients and their attendants. An average sum of Rs 228 was spent

for food related expenses in case of admitted patients. The duration of stay of the patients in

case of admitted patients was in the range 1 day to 35 days depending on the nature of the

disease. The average duration of day of the admitted patients in the hospital was 5 days. The

average amount spent on food was Rs 60 per day in case of admitted patients while in case of

outdoor patients they spent an average amount of Rs 7 on food.




Expenses for medicines and investigation:

Medicines: Medicines were provided free of cost in case of majority of the patients.

Investigations: The facility of free investigation was provided to majority of the patients.

Pathological investigation and X-ray etc was done free of cost for the patients .However, one

patient mentioned that he had to get MRI done from outside.

Health care seeking behaviour: The patients were also asked about the treatment taken, if

any course of action taken by them in the past for treatment of the same disease in the past.

About 77 % of the patients either treated the patient at home or did not take any action for

treatment prior to bringing the patient to the district hospital. Approximately 15 % of the

respondents had visited same or other government health facility in the past for treatment of

the same disease. Only 8 % of the patients used the facility of private hospital/ clinic in the

past for the treatment of same disease. The usage of facility of CHC/ PHC was also found to

be very low likewise the usage of jadi-booti or traditional medicine was also found to be low

among the respondents.

The patients who used the private hospital / facility before availing the Govt facility had a

total out of pocket expenditure of Rs 1217.

The respondents were asked about the nearest government health facility for them. Majority

85 % of the respondents mentioned District hospital Sehore to be the nearest Government




supported health facility. 15 % of the respondents mentioned that other health facility was

available close to their residence at average distance of about 10 km, yet they preferred to

come to District hospital for treatment. This shows lack of awareness about the facilities

available at the PHC/CHCs and the need to strengthen the same.

Referral mechanism: Ideally the patient should visit the neighbouring Sub – centre or PHCs

and in case of problem referred to CHC of sub-district hospital. However, it was found only

6% of the patients surveyed were referred to the hospital.

Travel time to reach the hospital: Information was gathered from the respondents regarding

the travel time required to reach the hospital. Almost 83 % of the patients reached the

hospital within one hour, 13 % of the respondents reached took more than one hour but less

than 2 hours to reach the hospital while 4 % of the respondents travelled for more than 2

hours to reach the hospital .Almost all of the indoor patients who used the Govt supported

transport facility like the Janani Express or 108 ambulance were also able to get the vehicle in

1 hour’s time.

Waiting time to show the patient to the doctors: Once the patient reaches the hospital he

/she are required to get the token and then stand in a queue waiting to be seen by the doctor.

About 63% of the respondents mentioned that they waited for almost half an hour to meet the

doctor. About 28% of the patients waited more than 30 minutes but within 1 hour. 4% of the

patients had to wait for more than one hour but less than 2 hours. 4 % of the patients had to

wait more than two hours to show the patient to the doctor.

It is a major complaint by the patients that they were not seen by the doctors in Government

hospital do no not see the patient or listen to their complaint for sufficient duration of time.

The summary of the responses is as under:

Time taken by doctors to see the outdoor patients

(responses value in %)

0-5 minutes 68

5-10 minutes 28

10-30 minutes 1

> 30 minutes 1




The patients who were seen by the doctor for more than 10 minutes mainly comprised of

fracture, accident, cataract procedure etc.

Opinion of patients regarding behaviour or the doctors: Opinion was taken from the

patients regarding on the behaviour of the doctors during the course of the treatment

approximately 20 % of the outdoor patients and indoor patients found the behaviour of the

doctor to be good or very good, while almost 80 % of the patients were of the view that the

behaviour of doctors was average.

Opinion of patients regarding behaviour of the staff: 15 % of the indoor patients were of

the view that the behaviour of staff was good while 10 % of the outdoor patients found the

behaviour of the staff to be good or very good. 85 % of the indoor patients and 90 % of the

outdoor patients were of the view that the behaviour of staff was average.

Facility of drinking water in the hospital: The admitted patients and the outdoor patients

were asked to give their opinion in the facility of drinking water in the hospital. Almost 21 %

of the patients were of the view that the facility of drinking water was good, almost 63 %

found the same to be average .Approximately 16 % of the patients felt that the facility of

drinking water in the hospital was bad or very bad.

0

10

20

30

40

50

60

70

Very good Good Average Bad Very Bad

0

23

58

16

3 0

20

67

10

3

Opinion of patients about facilty of drinking water

at Raisen District Hospital (value in percent)

Admitted Patients Outdoor Patients




Facility of toilets in the hospital: Almost 48 % of the admitted patients were of the view

that the facility of toilets in the hospital was bad or very bad while 53 % of outdoor patients

who mentioned that the facility of toilets was bad or very bad.

Response of admitted patient for certain facilities availed by them exclusively: The

admitted patients were asked about the quality of food, the response of the patients on the

same is as under. 21 % of the admitted patients found the food served to them as good, 79 %

felt that the food was average.

The admitted patients were asked to rate the stay facility for the attendants at the hospital. 74

% of the patients said that the facility for stay for the attendants in the hospital was either bad

or very bad. 24 % of the indoor patients found the stay facility to be average, only 2 % of the

respondents found the stay arrangement to be good.

The patients were asked if they would like to come back to the hospital if they faced any

medical problem. This is an indicator of overall satisfaction from the services of the hospital.

Almost all the patients mentioned that they would like to come back to the hospital in case of

health related problems .However it must be kept in mind that majority of the patients who

availed the facility of the district hospital Raisen were found to be from the relatively poor

community also the education level of the families of the patient was also found to be not

very high. Considering the cost of treatment to be much higher in the private institutions

which has also been validated by the means of the study, it seems that the patients did not

have many other options.

Private Hospital Vs Government Hospital

The respondents were asked if they availed the facility of treatment in private hospital / clinic

during the last one year, 40 % of the respondents mentioned that they availed the facility of

private hospital / clinic during the last one year.

The respondents were asked about the average monthly expenses on medicines for common

problems like cough, cold, fever etc which they at time purchase directly from the chemist at




times based on the prescription given by the doctor much earlier or based on advice from the

chemist, friends, relatives etc. On an average the patients spent Rs 728 per annum on

purchase of medicines from common household health related problems. This is another

aspect of out-of –pocket expenses on health which generally gets ignored.

The patients were asked about any other specific complains that they had or any

suggestion they had to make improvement in the facility at the hospital. The major

complaints and suggestions were:

Shortage of beds in the hospital

Need for better arrangement for the attendants

The overall out of pocket expenses for patients who availed the facility of District hospital

Raisen was found to be very low as compared with the out-of-pocket expenses incurred by

the patient in the private facility.

Particulars Amount spent by patients availing facility of

district hospital Raisen ( amount in rupees)

Indoor patients Outdoor patients

Transport 164 124

Food related

expenses

228 7

Stay facility 0 0

Pathological

investigation

0 0

Investigation X-

ray, scan , other

investigation

0 6

Medicines 0 0

Total 392 137

The average cost of treatment in private hospital for the same disease among the

patients of Raisen district was found to be Rs 1217.




3.2 Findings of District Hospital Sehore:

District Hospital Sehore pattern of patients: The observation of the study is based on the

responses received from the respondents comprising of patients. Almost 97 % of patients

surveyed were from Sehore district itself. However, some patients from neighbouring

districts like Raisen, Ujjain, Shajapur, Dewas etc also availed the facility of treatment at

District Hospital Sehore. Against 200 beds sanctioned for the hospital, there are 260 beds

available in the hospital. The detail of staff posted in the hospital is available in Annexure –

IV.

3.2.1 Socio economic status of the patients availing treatment at District

hospital Sehore

Rural /Urban mix of patients: Majority of the inflow of patients were from the rural area

(69 %) while only approximately 31 % of the patients who availed the services of the Sehore

district hospital were from urban area.

B.P.L card holders: Approximately 53% of the families surveyed which availed the facility

of Sehore District Hospital were B.P.L card holders.

Age group of the patient: The hospital provides a range of facilities for patients of all age

groups. About 18% of the patients covered under the study were less than 10 years of age, 8

% were more than ten years but less than 18 years of age, and about 65% were in the age

group 18-60 years while approximately 9% patients were more than 60 years of age. The

range of facilities available in the hospital includes delivery, paediatrics, nutrition

rehabilitation centre, surgery, ophthalmology, medicine, ENT, gynaecology, urology, dental

etc. There is facility of OPD for outdoor patients and for admission of the patients. The

average duration of stay in case of admitted patients was 5 days with a minimum duration of

stay at the hospital for 1 day while the maximum duration of stay for the admitted patients

covered under the survey was 14 days.




Category of patients: Almost 12% of the respondent patients who availed the services of

Sehore District Hospital were from general category, approximately 9% were from scheduled

caste, and 15% were from scheduled tribe while 64% were from other backward classes.

Level of education of the head of the household: In 39 % of the cases the head of the

household was either illiterate or had completed primary education. In 15 % of the cases the

head of household was educated up to middle school. 25 % and 11% had completed high

18%

8%

65%

9 %

0

10

20

30

40

50

60

70

0-10 years >10 years upto

18 years

>18 years upto

60 years

> 60 years

District Hospital Sehore -number of respondent

patients falling in different age groups

General

12%

Scheduled

Caste

9%

Scheduled

Tribe

15% Other

Backward

classes

64%

Category of respondent patients who availed

treatment at District Hospital Sehore

mailto:school.@5




school and higher secondary school respectively. Only in 10 % of the cases the head of the

house hold were either graduate or post–graduate.

Occupation: Information was gathered on the main source of income of the family of the

patient availing the treatment facilities at district hospital Sehore. Majority of the patient’s

family worked as labourers with almost 51% of the surveyed families working as labourer.

Almost 24% derived their major source of income from agriculture, 16% of patients surveyed

were self employed / had business, almost 4% were in government job while 5 % did other

work like plumber, tailor, driver etc.

Illiterate

22%

Upto 5th

Standard

17%

Upto 8th

Standard

15%

Upto 10th

Standard

25%

Upto 12th

Standard

11%

Graduate

9%

Post Graduate

1%

Education level of the head of household of the patients

surveyed in District Hospital Sehore




Monthly income of the household from all sources: Information was also gathered and

classification was done on the basis of the monthly income of the families. Majority (56%) of

the families earned less than Rs 5,000 per month while 27% of the families had monthly

income in the range Rs 5,000 to Rs 10,000 approximately 6% of the families earning income

in the range Rs 10,000 to Rs 15,000. Only 11% of the families covered under survey earned

more than Rs 15,000 per month.

Agriculture

24%

Labourer

51%

Govt. Service

4%

Self employed /

Business

16%

Others

5%

Main source of income for the family of the patients

who availed treatment at District Hospital Sehore

0

10

20

30

40

50

60 56

27

6 5 2 3 1

Monthly income from all sources of family of pateints visiting

District Hospital Sehore(value in %)




It is a usual perception that Government hospitals are flooded with people and a numbers of

persons accompanying the patient to the hospital are very high. The respondents were asked

about the number of persons accompanying the patient to the hospital .In 17% of the cases

there more than two persons were accompanying the patient.

3.2.2 Out of pocket expenses and experiences during treatment at District

hospital Sehore

Mode of transport: Among the admitted patients, about 25% used the Government

supported transport facility like 108 or Janani express. The government supported facility

was used in the cases pertaining to delivery of the baby, accident etc. Majority of the patients

mentioned that they got the government supported facility free of cost; however, in few cases

they mentioned that they had to pay some money for the service. Almost all the patients who

availed the service of Janani Express / 108 ambulances received the same within 1 hour of

calling the ambulance. 23% of the admitted patients used public transport like bus, tempo etc.

48% of the patients made their own arrangement including two -wheeler or car. 4 % of the

patients came on foot.

Amongst the outdoor patients, 24% used public transport like bus, tempo etc. 23% of the

outdoor patients came cycle or by foot. 53% of the respondents made their own arrangement

0

20

40

60

80

19

64

12 4 1

Number of persons accompanying the patient to

District Hospital Sehore (value in percentage)




for travel to the hospital including two-wheeler and in rare cases some of the patients came to

the hospital by car.

Cost of travel incurred by the patients: The average cost borne on account of travel by the

indoor patients amounted to Rs 356, it was observed that few of the patients came from

neighbouring district Shajapur and had to incur a cost of Rs 3,000 on account of travel to the

hospital. Certain instances were found when the patients paid money even when they availed

the facility of government supported transport the Janani Express and the 108 ambulance

even when the facility should be available free of cost to the patients. Such instances cause

dissatisfaction among the patients and efforts must be done to minimise such instances. The

average cost of travel for the outdoor patients was Rs 78.

Note: The information was gathered by means of a questionnaire at the time of discharge

from the hospital .Thus the travel cost as informed by the patient was multiplied by 2 to be

able to get the approximate travel cost involved.

In spite of the fact that some of the admitted patients used the government facility of

108 ambulances or Janani express, the average cost of travel is more in case of admitted

patients than the cost of travel borne by the outdoor patients on account of certain cases were

the patient had to spent higher amount as travel cost in case of emergency. The family also

bears travel cost on account of visit of attendants of the patient to the hospital in the case of

admitted patients.

0

100

200

300

400

Admitted patients Outdoor patients

356

78

Cost of travel in rupees -for pateints who availed the

facility of treatment at District Hospital Sehore




Cost of stay in case of admitted pateints : Inforamtion was gathered from the admitted

pateints for cost incurred during stay in the hospital for treament.Majority of the attendants of

the patients shared the bed with the patient or slept on the floor.Few respondents mentioned

paying amount in the range Rs 50 to Rs 200 on account of stay.

Amounts spent on food during treatment at the hospital: There is a facility of free food

for the admitted patients in the hospital. The food being served to the patients was also

observed. In spite of the fact that food is provided free of cost the admitted patients, some

expenses are incurred on food for attendants. Also, some amount is spent on food by outdoor

patients and their attendants. An average sum of Rs 313 was spent for food related expenses

in case of admitted patients. The average duration of stay in case of admitted patients was 5

days with a minimum duration of stay at the hospital for 1 day while the maximum duration

of stay for the admitted patients covered under the survey was 14 days. The admitted patients

spent Rs 56 per day on an average on account of food during stay at the hospital .While in

case of outdoor patients they spent an average amount of Rs 9 on food.




Expenses for medicines and investigation:

Medicines: Medicines were provided free of cost in case of majority of the patients,

however, purchase of medicine was reported in few cases since the medicine was not

available in the hospital.

Investigations: The facility of free investigation was provided to majority of the patients.

Some patients reported that paid money for pathological investigations and x-ray .The reason

reported for the same were: delay in investigation or it was informed by the doctor that the

investigation needs to be done form outside the district hospital. Efforts must be done to

minimise such cost to the extent possible.

CT scan machine is available in the district hospital Sehore on a PPP mode. The BPL patients

are not charged any amount for the scan facility. There is a rate list applicable for the scan

facility of the APL patients. It was observed that CT scan was being done free of cost for the

BPL patients.

0

50

100

150

200

250

300

Admitted Patients Outdoor Patients

313

9

Average cost of food in rupees availing treatment at

District Hopsital Sehore




Health care seeking behaviour: The patients were also asked about the treatment taken, if

any course of action taken by them in the past for treatment of the same disease in the past.

About 50 % of the patients either treated the patient at home or did not take any action for

treatment prior to bringing the patient to the district hospital. The patients availing the facility

of district hospital Sehore showed higher faith in the Govt supported facility as

approximately 40 % of the respondents had visited same or other government hospital in the

past for treatment of the same disease. Only 7 % of the patients used the facility of private

hospital/ clinic in the past for the treatment of same disease. The usage of facility of CHC/

PHC was also found to be very low likewise the usage of jadi-booti or traditional medicine

was also found to be low among the respondents.

The respondents were asked about the nearest government health facility for them. Majority

86 % of the respondents mentioned District hospital Sehore to be the nearest Government

supported health facility. 14 % of the respondents mentioned that other health facility was

available close to their residence at average distance of about 9 km, yet they preferred to

come to District hospital for treatment. This shows lack of awareness about the facilities

available at the PHC/CHCs and the need to strengthen the same.




Note: The patients who used the private hospital / facility before availing the Govt facility

had a total out of pocket expenditure of Rs 2566.

Referral mechanism: Ideally the patient should visit the neighbouring Sub – centre or PHCs

and in case of problem referred to CHC of sub-district hospital. However, it was found only

2% of the patients surveyed were referred to the hospital.

Travel time to reach the hospital: Information was gathered from the respondents regarding

the travel time required to reach the hospital. Almost 94 % of the patients reached the

hospital within one hour, 6 % of the respondents reached took more than one hour to reach

the hospital while in case of 1 % of the respondents it took them more that 2 hours to reach

the hospital .Almost all of the indoor patients who used the Govt supported transport facility

like the Janani Express or 108 ambulance were also able to get the vehicle in 1 hour’s time.

Treatment at

home only

12%

No action

taken prior to

this

38%

Used Jadi-

booti

1%

Private

clinic/hospita

l

7%

Same/other

Government

hospital

40%

PHC / CHC

2%

Action taken for treatment of same disease

prior to bringing the pateint to district hospital




Waiting time to show the patient to the doctors: Once the patient reaches the hospital he

/she have do the registration and then stand in a queue waiting to be seen by the doctor.

About 73% of the respondents mentioned that they waited for almost half an hour to meet the

doctor. About 25% of the patients waited more than 30 minutes but within 1 hour. 2% of the

patients had to wait for more than one hour but less than 2 hours.

It is a major complaint by the patients that they were not seen by the doctors in Government

hospital do no not see the patient or listen to their complaint for sufficient duration of time.

The summary of the responses is as under:

Time taken by doctors to see the outdoor patients

(responses value in %)

0-5 minutes 62

5-10 minutes 26

10-30 minutes 9

> 30 minutes 3

Opinion of patients regarding behaviour or the doctors: Opinion was taken from the

patients regarding on the behaviour of the doctors during the course of the treatment

approximately 70 % of the outdoor patients and indoor patients found the behaviour of the

doctor to be good or very good, while almost 30 % of the patients were of the view that the

behaviour of doctors was average.

upto 1 hour

94%

1 hour to 2

hours

6%

more than 2

hours

1%

Travel time to reach Distrct Hospital- Sehore




Opinion of patients regarding behaviour of the staff: 72 % of the indoor patients were of

the view that the behaviour of staff was good or very good approximately while 68 % of the

outdoor patients found the behaviour of the staff to be good or very good. Almost 30 % of the

patients were of the view that the behaviour of staff was average.

Major portion of the Sehore district hospital was renovated in the recent past. Some

construction work was still going on at the time of data collection.

Facility of drinking water in the hospital: The admitted patients and the outdoor patients

were asked to give their opinion in the facility of drinking water in the hospital. 66 % of the

indoor patients and 63 % of the outdoor patients were of the view that the facility of drinking

water was very good or good in the hospital .Approximately 35 % of the patients felt that the

facility of drinking water in the hospital was average or bad.

Facility of toilets in the hospital: The admitted patients stay and use the facility of toilets in

the hospital for a longer duration of time. 67 % of the admitted patients were of the view that

the facility of toilets in the hospital was good or very good while 62 % of outdoor patients

who mentioned that the facility of toilets was good or very good.

Response of admitted patient for certain facilities availed by them exclusively: The

admitted patients were asked about the quality of food, the response of the patients on the

same is as under. 15 % of the admitted patients found the food served to them as very good,

61 % felt that the food was good while 24 % of the admitted patients found the quality of

food to be average.

The admitted patients were also asked to give their opinion on the facility of stay for the

attendants, 66 % of the responded found the facility to be good, 32 % found it to be average

while 2 % of the respondents mentioned that the facility of stay was bad.




The patients were asked if they would like to come back to the hospital if they faced any

medical problem. This is an indicator of overall satisfaction from the services of the hospital.

Almost all the patients mentioned that they would like to come back to the hospital in case of

health related problems .However it must be kept in mind that majority of the patients who

availed the facility of the District hospital Sehore were found to be from the relatively poor

community also the education level of the families of the patient was also found to be not

very high. Considering the cost of treatment to be much higher in the private institutions

which has also been validated by the means of the study, it seems that the patients did not

have many other options.

The respondents were asked if they availed the facility of treatment in private hospital / clinic

during the last one year, 53 % of the respondents mentioned that they availed the facility of

private hospital / clinic during the last one year.

The respondents were asked about the average monthly expenses on medicines for common

problems like cough, cold, fever etc which they at time purchase directly from the chemist at

times based on the prescription given by the doctor much earlier or based on advice from the

chemist, friends, relatives etc. On an average the patients spent Rs 745 per annum on

purchase of medicines from common household health related problems. This is another

aspect of out-of –pocket expenses on health which generally gets ignored.

The patients were asked about any other specific complaints that they had or any

suggestion they had to make improvement in the facility at the hospital. The major

complaints and suggestions were: ‘ilaj time se kiya jaye’ which is an indicator of the

time spent by the patients and their attendants during the course of the treatment.

Patients also complained about the excess time taken for the investigations, lack of

cleanliness in the toilets and scarcity of staff in the hospital.




The overall out of pocket expenses for patients who availed the facility of district

hospital Sehore was found to be low as compared with the out-of-pocket expenses

incurred by the patients in the private facility.

Particulars Amount spent by patients availing facility of

district hospital Sehore ( amount in rupees)

Indoor patients Outdoor patients

Transport 356 78

Food related

expenses

313 9

Stay facility 5 0

Pathological

investigation

66 2

Investigation X-

ray, scan , other

investigation

80 20

Medicines 87 0

Total 907 106

The average cost of treatment in private hospital by patients of Sehore district for the

same disease was found to be Rs 2566.




Chapter 4

Recommendations

Overall the district hospitals seems to have worked reasonably well on account of fulfilling

the mandate of the National Health Policy of providing health care while trying to minimise

the cost or financial hardship to the patients. The following recommendations are made based

on the feedback received from the patients and the findings of the study:

1. Minimise cost of treatment to the patient: Health problem in the family coupled with

expenditure on account of treatment is a great cause for concern especially to the poor. It was

found that the facility of the hospital is mostly used by the people from the low socio-

economic background. It was found that in some cases the patients had to get the

investigation done from outside on account of delay in the investigation at the hospital and so

end up paying money for the same. In rase cases medicine was purchased from outside

especially in case of admitted patients. Such cases should be minimised. It was found that if

the patients end up in the private health facility then the cost of treatment both direct cost and

indirect cost increases exponentially. The staff of the Government health facility should be

sensitive towards the importance of the service provided by them is on the life of the patients.

2. Improved awareness and availability of transport for the patients to the hospital: The

Government of Madhya Pradesh has provided the facility of free transport for patients under

108 ambulances and for pregnant women and infants under Janani Express. Majority of the

pregnant women who came to the hospital for delivery were able to get the benefit of Janani

Express or 108 ambulances to reach the hospital. Certain instances were found when the

patients paid money even when they availed the facility of government supported transport

the Janani Express and the 108 ambulance even when the facility should be available free of

cost to the patients. Such instances cause dissatisfaction among the patients and efforts must

be done to minimise such instances.

3. Staffing in the hospitals: There is high importance of each level of functionary in a

government hospital including doctors, nurses, pharmacists, technicians, cleaner, driver etc

needs to be taken into consideration. Each of the service providers has an important role to

play in the smooth running of the mechanism. Also since the facility of hospital has to

function 24 by 7 throughout the year it is important to have a contingency plan for dealing

with staff related issues in case of an emergency. Deficiency of health personnel is not




limited to doctors alone. In the case of district hospital Raisen almost 50 % of the posts lie

vacant. Similarly lack of staff was found at district hospital Sehore also. In light of these

circumstances the patients and services of the hospital suffer. There is shortfall in various

categories of paramedical personnel which is a cause of concern. Thus there is an urgent need

to address the staff related issues.

4. Attitude of the doctor and staff towards the patients: Opinion was taken from the

patients regarding on the behaviour of the doctors and staff during the course of the treatment

, in almost while 30 % of the patients who availed the facility of district hospital Sehore felt

that the attitude of the doctors and the staff members towards the patients was average or bad

.It is proposed that a short training on soft skills and sensitivity to the needs of the patient be

organised for staff in the hospital.

5. Cleanliness and facility of toilets: There is a high risk of spread of infection if the hospital

premises are not kept clean. Maintenance of the hygiene and cleanliness of health facilities

and the toilets helps in reducing the risk of Hospital Acquired Infections (HAI). Maintaining

cleanliness in a health care facility differs from the conventional cleaning. The admitted

patients stay and use the facility of toilets in the hospital for a longer duration of time. 33 %

of the admitted patients for District hospital Sehore were of the view that the facility of toilets

in the hospital was bad or very bad as compared to 30 % of outdoor patients for District

hospital Sehore who mentioned that the facility of toilets was bad or very bad .Thus, there is

a the need to ensure that the toilets are functional and cleaned regularly in a phased manner

round the clock in the hospital.

Based on the responses from the patients it is known that the condition of toilets in

District Hospital Raisen was even worse with 48 % of the admitted patients and 53 % of

the outdoor patients stating that the facility of toilets in the hospital was bad or very

bad . This issue needs to be addressed immediately.

6. Facility of drinking water: The facility for drinking water is a very important for the

smooth functioning of the hospital. Approximately 35 % of the patients who availed the

facility of district hospital Sehore said that the facility of drinking water was either average or

bad. There is a need to ensure regular supply of clean drinking water in the hospital.




The facility of drinking water was not very good at District Hospital Raisen was not very

good with almost 63 % of the respondents stating that the facility of drinking water was

average and 16 % of the patients felt that the facility of drinking water in the hospital was

bad or very bad. This is an area of concern and it is proposed that immediate action be taken

to improve the facility of drinking water in the hospital.

7. Increased use of information technologies: One of the common problems reported by the

patients was delay in investigations. A number of modern technologies have become

available over the years to improve the functioning of public hospitals. The guiding principle

for their use should be that these technologies should be used to maximize the patient

welfare, rather than for curtailing patient services. Diagnostic equipment, like auto analyzers

that are now available, have replaced the manual diagnostic processes and can be deployed to

do laboratory investigations round the clock without necessarily having to deploy larger

manpower as was necessary with manual processes.

8. Strengthening the referral mechanism: The referral system is very important for the

smooth functioning of the system. It is essential to strengthen the institutions of PHC and

CHC to be able to rationalise the flow of patients, it was found that majority of the patients

came to the district hospitals. This scenario leads to over load at the district hospital .It is

essential that training calendar be developed and the staff of PHC / CHC visit the district

hospital and take training of dealing with basic health issues. The general population availing

the facility of the district hospital must also be counselled and encouraged to visit the

neighbouring health facilities.

The task of making the primary and secondary level health institutions functional ought to be

the utmost priority, such that people can access effective healthcare for common and easily

treatable conditions nearest to their homes. Urgent steps need be taken to provide working

and living conditions in the peripheral areas that will encourage doctors and other health

personnel to be willing for rural service. Family hostels should be built in the nearby urban

centres to house the families of doctors and other medical personnel, while they are posted in

remote areas. It may be noted that such steps are taken in the case of defence personnel , if

comparable status is given to health care professionals if will go a long way in improving the

health scenario.




References:

http://www.mpinfo.org/MPinfoStatic/english/articles/2013/100813Lekh22.asp,

Department of Public affairs, govt of MP accessed on 10th May 2018 and brochures on the

government schemes

National Health Accounts Estimates of India 2014-15 -

https://mohfw.gov.in/sites/default/files/National%20Health%20Accounts%20Estimates%20Report%2

02014-15.pdf

Vikas Bajpai, the Challenges Confronting Public Hospitals in India, Their Origins, and Possible

Solutions, Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New

Delhi, India, Advances in Public Health Volume 2014 (2014), Article ID 898502

Nicholas Otieno Okello and Dr. Agnes Njeru- Factors Affecting Out-Of-Pocket Medical Expenditure

Among Out Patients in Hospitals in Nairobi County- International Journal of Scientific and Research

Publications, Volume 5, Issue 6, June 2015

Footnotes:

1. Xu K (2004) Distribution of health payments and catastrophic expenditures. World Health Organization.

2. Carrin G, James C, Evans D (2005) Achieving universal health coverage: Developing the health financing

system. World Health Organization, Geneva.

3. Puteh SEW, Almualm Y. Catastrophic Health Expenditure among Developing Countries. Health Syst

Policy Res. 2017, 4:1. doi:10.21767/2254-9137.100069.

4. Wyszewianski L. Financially catastrophic and high-cost cases:definitions, distinctions, and their implication

for policy formulation.Inquiry1986; 23:382–94

5. http://www.who.int/health_financing/documents/lancet-catastrophic_expenditure.pdf accessed on

21/08/2018.

6. Krishna, Anirudh, M Kapila, M. Porwal and V. Singh. Why Growth is not enough: Household Poverty

Dynamics in Northeast Gujarat, India. Journal of Development Studies, Vol. 41, No. 7. October 2005

7. Golechha M (2015) Healthcare agenda for the Indian government. Indian J Med Res 141:151-153.

8. Key indicators of Social Consumption in India Health, Ministry of Statistics and Programme

Implementation, National Sample Survey Office, NSS round 71.

9. Healthy States, Progressive India report on the ranks of States and Union Territories, Ministry of Health and

Family Welfare, Govt of India, Niti Aayog and the World Bank.

http://www.mpinfo.org/MPinfoStatic/english/articles/2013/100813Lekh22.asp

https://mohfw.gov.in/sites/default/files/National%20Health%20Accounts%20Estimates%20Report%202014-15.pdf

https://mohfw.gov.in/sites/default/files/National%20Health%20Accounts%20Estimates%20Report%202014-15.pdf

http://www.who.int/health_financing/documents/lancet-catastrophic_expenditure.pdf%20accessed%20on%2021/08/2018

http://www.who.int/health_financing/documents/lancet-catastrophic_expenditure.pdf%20accessed%20on%2021/08/2018

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418149/

Financial flow of funds in health system Annexure I

Find flow

to NPISH

Fund flow to Government

Health Facilities

Taxes Payments

OOPE

NHM fund

flow

Premiums

Fund Flow

to

Private

Facilities

ULB- Urban Local Bodies; RLB- Rural Bodies

NPISH- Non- Profit Institutions Serving Households (NGOs) OCMs- Other Central Ministries);DH – District Hospital;SDH – Sub District Hospital

CHC- Community Health centre; PHC- Primary Health Centre; SC- Sub-centre

ESIC- Employees State Insurance corporation

ECHS- Ex- Servicemen Contributory Health Scheme

CGHS- Central Government employee Health Scheme

OOPE- Out of pocket Expenditure; DoHFM- Department of Health and Family Welfare

NHM- National Health Mission

Source : National Health Accounts Guidelines for India 2016 , National Health Accounts Technical Secretariat , National Health System Resouce

Centre , Ministry of Health and Family Welfare , Govt of India

Union

Government

G

State

Governments

nt ULBs/RLBs Enterprises-

Public & Private

NPISH

(NGOS)

External

Donors

Households

ssssolds

OCMS

MMS

MoHFW

hawk

State DoHFW State Other

Depts.

State/District

Societies ESIC

Trusts for Schemes

on social

protection/NPISH

Private Health

Insurance

OOPE

Government

health insurance

Government Health facilities (Center of Excellence, Medical College

Hospitals, all public health facilities including Hospitals/ Dispensaries of

ULB, Defense, ESI, ECHS, Railways, CGHS)

Private Health Facilities

(Private Hospitals/ clinics, Enterprises Hospitals/

Clinics, NPISH Hospitals/Clinics)

(

Households

(as a source of finance and consumer of healthcare services and goods)

Rev

en

ues

of

Hea

lth

-

care

Fin

anci

ng

Sch

emes

(FS

)

Hea

lth

care

Fin

anci

ng

Sch

emes

– (

HF)

Pro

vid

ers-

(HP

)

46

Annexure – II

Strength of ward wise beds in Raisen District Hospital

ftyk fpfdRlky; jk;lsu es orZeku esa iyaxks dh la[;k

1 esy okMZ 85

2 Qhesy okMZ 58

3 cPpk okMZ 17

4 ,u +vkj +lh +okMZ 10

5 ,l +,u +lh +;w +okMZ 22

6 vkbZ +lh +;w +okMZ 4

7 izk;osV okMZ 4

8 ih +ih +okMZ 55

9 eerk okMZ 10

Lokbu ¶yw 4

esu vksVh ,y +Vh +Vh + 4

10 vkbZ okMZ 10

;ksx 283

47

Annexure-III

jk;lsu ftyk vLirky& laoxZ ds Lohd̀r dk;Zjr ,oa fjDr inksa dh tkudkjh

Ø + in dk uke Lohd̀r in dk;Zjr in fjDr in

1 mi izca/kd 1 0 1

2 esMhdy fo'ks"kK 5 1 4

3 us= jksx fo'ks"kK 2 1 1

4 'kY; fØ;k fo'ks"kK 2 1 1

5 L=h jksx fo'ks"kK 4 2 2

6 f'k'kq jksx fo'ks"kK 7 2 5

7 fu'psruk fo'ks"kK 4 1 3

8 jsfM;ksykftLV 2 1 1

9 vfLFk jksx 3 1 2

10 iSFkkykftLV 2 2 0

11 ukd dku xyk fo'ks"kK 2 0 2

12 nar jksx fo'ks"kK 1 0 1

13 {k; jksx fo'ks"kK 1 0 1

14 esMhdy vkWQhlj 28 8 20

15 nar 'kY; fpfdRld 2 2 0

16 vk;q"k fpfdRld 1 0 1

17 izk'kkldh; vf/kdjh 1 0 1

18 , +,l +vks + 1 0 1

19 eq[; fyfid 1 1 0

20 ys[kkiky 3 2 1

21 dsf'k;j 1 0 1

22 lgk;d xzsM&2 2 1 1

23 lgk;d xzsM&3 3 4 -1

24 LvhoMZ 1 0 1

25 ck;ksdsfeLV 1 1 0

48

26 ySc VsDuhf'k;u 15 8 7

27 jsfM;ksxzkQj 5 3 2

28 us= lgk;d 3 2 1

29 QkekZflLV xzsM 2 8 1 7

30 Msªlj 8 8 0

31 ySc lgk;d 1 1 0

32 MkdZ#e lgk;d 3 2 1

33 osDlhusVj 1 0 1

34 bysDVªhf'k;u 1 0 1

35 okgu pkyd 2 1 1

36 esVªu 7 0 5

37 uflZx flLVj 4 0 2

38 LVkQ ulZ 115 69 46

39 , +,u +,e 3 2 1

40 nkbZ 4 4 0

41 Hk̀R; 12 10 2

42 pkSdhnkj 1 1 0

43 Dqd 1 0 1

44 Dyhuj 2 0 2

45 MkdZ#e vVsaMsV 3 1 2

46 vks +Vh +vVsaMsaV 10 0 10

47 vk;k 2 2 0

48 ysc vVsMsaV 6 2 4

49 okMZ ok; 25 7 18

50 Lohij 7 9 -2

51 okMZ ck; lafonk 20 0 20

52 dEI;wVj vkWijsVj lafonk 4 0 4

53

okgu pkyd lafonk ij 4

0

4

Total 358 164 194

49

Annexure –IV

Status of staff at district hospital Sehore

study of district hospital raisen and sehore an analysis...

Documents