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Dr Shyam AshtekarMD (Preventive & Social Medicine)

Nashik 4220131st April 2011

A Public Health Perspective on

Health Sector of Nashik District

Based On A study of Nashik district

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Nashik is said to be part of the ‘golden triangle’ of Pune-Mumbai-Nashik

Has all ingredients –a booming city, rural, tribal, draught prone.

The prestigious Maharashtra University of Health Sciences is in this city.

This district has all types of medical colleges: Modern medicine, Ayurveda, Homeopathy, Unani, Dental, Pharmacy, Nursing etc.

Introduction (1)

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We started with NMC registry data for clinics and hospitals (2009-10), However we had to revise the data after checking other relevant sources.

We obtained figures from various medical associations/members for each category of doctors.

Rates of some typical medical services have been obtained through telephonic enquiries from some hospitals/close sources.

Estimates of pharmacy sales are based on distributors’ average monthly proceeds from reliable sources, and in case of Malegaon from octroi-tax information.

Sources of information (1)

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Findings

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Doctors in the district (1: 634p)

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Consultants and GPs in N city

A) Gen Practitoners

BAMS

Homeopaths#

MBBS

degree not Avialble

BUMS Yunani

B) Dentists

C) Specialists

Ob-Gynec

Child sp

MD Ayurveda

Orthopedic sp

General Surgeons

Radiologists

Eye specialists

gen Physician

Pathologists

Anesthetists

Psychiatrists

ENT sp

Skin specialist

Super specialty

0 200 400 600 800 1000 1200 1400 1600 1800

1622

1250

153

121

91

7

350

1106

200

140

100

87

85

83

80

75

65

65

50

26

25

25

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PG: GP ratio in the district

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Nasik city,Ozar, Devlali

7815, 61%

Malegaon city8917%

15 Rural blocks416232%

Hospital beds by location

Nasik city,Ozar, DevliMalegaon city15 Rural blocks

Hospitals Beds by location

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Govt; 2828; 22%

Mun/ cant ; 716; 6%

Trusts; 1468; 11%

Pvt; 7859; 61%

Hospital- beds by ownership

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0-4

5--

10

11

--2

0

21

-30

31

-40

41

-50

51

-60

61

-70

71

+

81

+

91

+

10

1+

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Nashik city: Pvt & Trust Hospitals by bed capacity

N(units) beds

Pvt & Trust Hospitals in N-city by bed capacity

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Public hospitals

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Public Hospitals

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Dysfunctional SS Shalimar hospital Overcrowded district Hospital, Public hospitals are last option for poor families Specialist scarcity in public hospitals Only 4 anesthetists in 26 Rural Hospitals! Scant C-section services in RH (state data < 10 per yr

per RH)

The Plight of public hospitals

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For all the state Govt facilities-the district has only 96 specialists for over 1600 beds spread in 24RH, 5SDH, 1DH, 1 Super specialty H, and an ESIS hospital.

In contrast, NMC has 67 specialists for 600 beds in the 5 hospitals.

The State Govt needs to look at this generic problem.

Plight of Public Hospitals

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Charitable Hospitals and Bed Allocation

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Public sector; 173.6; 14%

Pvt; 526.5; 42%

Trust Hosp; 27; 2%

Pharma; 536; 42%

Public sectorPvtTrust HospPharma

The Health Sector Economy

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Prices of care in Nashik hospitals

Table3: Fees and rates of various sector in Nasik

ItemPrivate sector charges RSBY offers MVP hospital

(without medicine) Cover up toGP fees (usually includes an injection) 30-50 None

-

PG-Consulting-specialist 200 None

Super specialist consulting fees 500-1000 None

Normal delivery $ 10000-30000 2500 1500

LSCS (Caesarian section)$ 25000-50000 4500 1500

MTP (medical abortion) 2000-4000 500

Appendix surgery 15000-40000 8000 1000

Hernia 10000-25000 8000 1500Hip fracture: surgery with prosthesis 25000-70000 10000

1000-1500

Cataract (Indian lens) 5000-12000 5000 500

Angiography 6000-10000 10000 ?

Heart -Bypass surgery (CABG) 150000-200000 NA

ICU daily charge 2000-5000 300 200

Ventilator 750

Bed charges 500 150

SONOGRPHY# 600 100-250

X-ray chest adult size 250-500 110

Hysterectomy vaginal 25000-50000 10000 2000

Medicine costs As per details 15000 ?

$ in MVP hospital 1&2nd delivery and LSCS are free & there is no separate charge for LSCSHernia in pediatric age group is free*MTP with TL is free in MVP, # obstetric sonography in MVP hospital costs Rs 100

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Rates of private medical services are going up due to many factors-investment in building and technology, increasing competition for patient volume, changing nature of medical practice (more investigations, defensive medicine) and better income of some clients.

Trust hospitals represent a scenario of rates with ‘no capital investment’, which is a potent formula for affordable care for future. PPPs can help.

The equally big public hospital sector can work as a good parallel care-provider, and needs to be looked as such. Can we make it a vibrant system?

On rates of medical services?

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Public Health Perspective

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Do all or most people in need get care : Equity Can all people-the last man –get care: Access Can all people afford it: The price factor Are the services good: Outcomes Is it efficient: Is it worth the rupees spent by clients Does it improve health situation: Decrease in mortality

and morbidity

Public Health Perspective

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Hospitals: Through A Public Health Lens

Public health

perspective

Context

Numbers

Distribution

Quality of care

efficiency

clients’ angle

public: pvt

dichotomy

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If we want to ensure HEALTH CARE FOR ALL/ UNIVERSAL HEALTH CARE- is our hospital sector rightly poised?

Is there a correct mix of pre-hospital and post-hospital care with the hospital sector,

Are there synergies?

Questions to Ask

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Nearly 1 bed for 470 people, satisfies UHC recommendation of 2 beds for 1000 pop.

We do not know about occupancy/utilization rates Is it an oversupply, will it escalate costs?

On Numbers

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This is about various aspects of care given:Appropriate interventions for client needs

Result orientedTimely

Rational & ScientificHumaneEthical

Accountable (procedure audits?)

Quality Issues

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The BNHRA is an underdeveloped/ rudimentary act. Rules & byelaws are awaited.

But many nursing homes may not conform to it, esp the small ones. Infrastructure, HR and transparency are issues in some cases.

Many units may not qualify for medical insurance (<20 beds)

Hospital accreditation system is still not very popular.

BNHRA & Insurance & accreditation

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Rural sector, with 60% population has 32% beds, but this is OK since hospital system is always clustered in urban areas.

Pvt sector is naturally clustered in better off areas Public sector has to compensate or reach out.

Rural-Urban Distribution

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Efficiency is productive utilization of beds We dont know about bed-occupancy We dont know about outcomes We dont know about costs and earnings of various

units- Since most Exp is from private sources, the efficiency

factor is largely invisible, It will be visible and operative only when third party

payment or UHC will come into force.

Efficiency angle

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What does it cost to clients..the price tables is suggestive

Pvt Insurance is still not very large enough, may cover only 20% clients

is the Pvt sector affordable to most clients? There are no local studies

But national studies suggest hardships..one cause of client dissatisfaction

Clients’ angle

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10% doctors are in public sector, 90% in pvt and trust sector

61% Hospitals beds are in Pvt sector 70% specialist positions are vacant in rural hospitals Super-specialty hospital is still largely defunct Govt is instead pushing schemes like Jeevandai, which

buys pvt care for poor clients We need to count Trust Hospitals in a semi-public

sector

Public: Pvt dichotomy

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The Govt floated the scheme, of providing cover to all ‘procedures’. Cover upto 2 lakh annual. operated thru Star Health

established network of corporate hospitals, 50+ bedded private hospitals, government medical colleges, district hospitals and area hospitals

Public-private partnership Focus on Tertiary Care

The Arogyashree experience in AP

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Many hospitals in smaller towns in the state were performing unnecessary hysterectomies to benefit from the scheme.

Normally the insurance company maximizes its profits by closely monitoring the hospital’s practice and claims to limit payouts. In Arogyashri, the insurance company benefits every time bills are paid since they take 20% of the amount paid out.

Counterproductive?

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The Aarogyasri scheme has been revolutionary in placing health on the political map in the state.

It is a major landmark in India’s administrative approach to health and has emerged as a popular scheme among the masses. It has given hope to multitudes where none existed.

However in its current form, the programme is a means to fund corporate hospital profit and distorts the pattern of healthcare in the state. A re-examination of the Aarogyasri programme is urgently necessary, especially in the context of its emergence as a possible model for universal healthcare.

Arogyashree-AP

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The NHS British Model (Beveridge)-The sarkari model (so is Canada, Cuba)

American Model- Private Insurance, Private providers, Health Management Organizations ( insurance and provision by same company)

Bismarck Model: Social Health Insurance wherein social contribution/Cess flows into sickness fund, also fund from Govt. The fund is managed by providers’ collective, everyone gets care

Chinese model: Public health system pyramid, paid post 1979 by users, now converting into social health insurance model, Govt bears small part

Our Desi model: Mixed Health system

Health Sector Models of Other countries

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Has a good Primary sector (gatekeeper) Institutiinal secondary-tertiary health care Universal access-all people get care All conditions are covered Most/All providers participate Payment not at point of service. Both client and

provider are not worrying about payment. Some arrangement of pre or post payment, either through tax or social insurance

Basic principles of a good health system

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The Health Care Pyramid

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12th FY plan wants to increase allocation to health sector from 1.2% to 2.5% of GDP

The states may not be able to improve their allocation UHC by HLEG intends to improve (a)public hospitals (b)

offer cashless care to all clients thru free health cards (c) declare a national health package.

Understanding the UHC angle

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An opportunity, influential doctors can lobby for taking N as a pilot district.

With known limitations, UHC is still a potent tool for offering free health care to all

How it translates in a district is something to see—the HOW’s are very important.

It wants to steer clear of Pvt health insurance, close user fees in public hospitals, PPPs with large hospitals on exclusive terms, contracts with primary care providers, invest in health promotion etc.

Implication of UHC plan to Nashik health sector

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Small units may start closing down due to problems of technology & capital, HR and issues regarding scale of operations. However Gynec, Pediatric units may hold ground no matter how small they are.

Costs and prices of medical care will rise. All super-specialty work may cluster in few units. PPPs may happen under UHC, Jeevandai is an insidious

start.

What can happen to the health sector

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Maharashtra may expand its Jeevandai yojna, with more families under cover, listing more conditions, higher compensation packages. Health Cess may come!

GOI was considering a National Health package, cashless cover (BPL and APL), Free drugs for all, even for private care seekers ( cover for generics and EDL)

New RSBY may appear.

Health Policy news

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Broadly Nashik district spends about 1263 crores—or 2000 Rs per capita on health care thru public, private sources

Theoretically, the district can develop social health insurance model for all including BPL, including public hospitals.

The NMC and ZP and local bodies can experiment in some wards/blocks.

What needs to be done

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• GP will nearly consist of AYUSH doctors, while PG mostly from MM-how do we cope with this legally and academically?

• If GP sector declines what happens to economics of health care? Where is the family doctor?

• Do more patients now go directly to PG-consultants rather than GPs?

The GP-PG issue

• Increasing specialization and deconstruction of medical diagnosis and treatment is unfavorable to holistic health. How do we correct this?

• What is the legal responsibility of a specialist to problems of other organs?

A deconstruct of medical approach.

• Surely some can afford the current costs of care, but definitely not all can pay the rising bills, esp life threatening/terminal chronic illnesses.

• Are Medicines costlier than doctors? Can doctors remedy this problem?

Rising Cost of care

Issues for systemic amends

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•How can medical insurance help families to contain costs? •How can RSBY be available and actually help families?

Insurance & RSBY

•Only select Govt and Municipal hospitals are fully utilized•How do we put other facilities to use?•How to fully activate the Shalimar Super Specialty hospital?

Public Health facilities.

•Are all charitable hospitals fully functional, and fully utilized? •Are all charitable hospitals offering services at affordable and charitable prices?

Charitable hospitals

Issues for systemic corrections (2)

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6. Review prescription practices for rational

therapeutics5. Efficient utilization of pubic & Trust facilities

4. Promote public hospitals & affordable charitable hospitals

3. Expansion of RSBY and Group insurance

2. Programs by NMC/Govt for preventing Diabetes, High BP, IHD,

Develop Open information

sources/campaigns

1. Improve pre & post hospital care, esp home

care and GP sector, AYUSH,

Contours of Affordable health care

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The health Sector Radar

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Wherein capital costs are borne by other sources

Transparent and dedicated management Provides both secondary and tertiary care Owns or links with primary care network

We need more Trust Hospitals in the district

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Thanks