Technical due diligence District : Gajapati
1 DISCLAIMER
1. The purpose of this document is to provide interested persons with information that may be useful to them in the preparation and submission of their bids for the projects. The document includes statements which reflect various assumptions and assessments arrived at by the Government of Odisha and IFC for the projects. Such assumptions, assessments and statements do not purport to contain all the information that such persons may require. The information contained in the document may not be appropriate for all persons and it is not possible for the Government of Odisha and IFC, its employees, its consultants or advisors to consider the investment objectives, financial situation and particular needs of each party who reads the document. The assumptions, assessments, statements and information contained in the document may not be complete, accurate, adequate or correct. Each person should, therefore, conduct its own investigations and analysis and should check the accuracy, adequacy, correctness, reliability and completeness of the assumptions, assessments, statements and information contained in the document and obtain independent advice from appropriate sources. The Government of Odisha and IFC accept no responsibility for the accuracy or otherwise for any interpretation expressed in the document.
2. The Government of Odisha and IFC, its consultants, employees and advisors make no representation or warranty and will have no liability to any person under any law, statute, rules or regulations or tort, or otherwise for any loss, damage, cost or expense which may arise from or be incurred or suffered on account of anything contained in the document or otherwise, including the accuracy, adequacy, correctness, completeness or reliability of the document and any assessment, assumption, statement or information contained in the document or deemed to form part of the document or arising from it in any way.
3. The Government of Odisha and IFC, its consultants, employees and advisors also accept no liability of any nature, whether resulting from negligence or otherwise, howsoever caused arising from reliance of any person upon the content of this document.
4. The Government of Odisha and/or IFC may, in its absolute discretion, update, amend or supplement the information, assessment or assumptions contained in this document.
5. The issue of this document does not imply that the Government of Odisha is bound to award the projects to any bidder.
2 SUMMARY
• The district of Gajapati has 31 government health care facilities and 4 private hospitals with a bed strength of 463 beds only. • Among the other public health facilities CHC’s share the highest percentage of OP consultations (52%) whereas DHH share the highest percentage IP admissions (49%). • DHH Gajapati has a higher than optimum BOR which is 121.1% indicating the need for additional bed strength in the district to meet the rising demand of healthcare services. • OP to IP conversion has been higher than industry standards at DHH. For the FY 2015-16 the OP to IP conversion rate was 15%. • Considering data for FY 2015-16, surgeries performed at the district are mostly minor surgeries (64%). • For FY 2015-16 data indicate under utilization of OT at DHH with not more than 3 surgeries per OT per day. High IP load and lack of beds at DHH explains patients preference for surgery and unofficial referrals from DHH to private hospitals and nursing homes. • Total rate of C-sections in the district account for more than 15% of total institutional deliveries making it an area of concern. ▪ Overall Lab tests accounts for majority (93%) of total diagnostics at the studied facilities, whereas CT- Scan facility is not available at any of the healthcare facilities in the district. ▪ It can be inferred that at secondary care level only 30% of the existing demand is being met for OPD and 20% for IPD.
3 SUMMARY
▪ Considering the WHO norm of 3.5 beds per 1000 population, the district has a shortfall of 4775 beds (i.e. a gap of 78.3% beds). ▪ Considering the WHO norm of 1 doctor per 1000 population, the district has a shortfall of 550 doctors. ▪ Considering the WHO norm of 2 nurses per 1000 population, the district has a shortfall of 1198 nurses. ▪ For gaps under service facilities, when compared with IPHS for district hospitals, major gaps are in the areas of Diagnostics and Specialty OPDs. ▪ As per population survey response, majority of the respondents choose govt hospital over private for health care services. ▪ Availibility of comprehensive services under one roof holds the prime reason for choosing govt hospital over private. Proximity of residence and reputation of private practioner is the only reason for people choosing a private facility. ▪ While Majority of the respondents depend on savings for their healthcare spending only 10% of the patients surveyed had health insurance as a primary source of health related costs, indicating a need for insurance coverage awareness among the population. ▪ All the surveyed physicians indicated that patients from the district travel to other districts / cities for availing tertiary level healthcare, of which majority ailments pertain to cardiology and Joint replacement surgeries followed by oncology, neurology and urology.
4 SECTION 1: PROJECT SNAPSHOT
5 PROJECT BACKGROUND
▪ As a part of a broader health sector enhancement program, the Government of Odisha (GoO), wants to strengthen and enlarge the private health sector facilities and promote the participation of quality private health providers across all the 30 districts in the state to enhance the health infrastructure in the state by structuring and implementing the rollout of low cost hospitals across the state in a PPP model which will offer decent quality care at affordable prices.
▪ The project will look at the entire state as a whole and based on detailed financial, fiscal, logistics and operational due diligence a network will be developed with recommendations on the number, size, type and locations of the hospitals.
6 SECTION 2: METHODOLOGY FOR TECHNICAL AND MARKET DUE DILIGENCE
7 TECHNICAL DUE DILIGENCE
Demand & Supply Assessment Paying Capacity Assessment
• Assessment of district level demand for health services, • Assessment of patient profile – APL through primary research such as surveys, interviews of & BPL patient/ doctor and review of available clinical data at • Prevailing market rates, CGHS and hospitals and MIS data from NHM various industry empanelled rates • No. of patients referred outside •Assessment of existing clinical services, infrastructure Odisha for secondary and high and resources secondary care • Additional sources such as Centre & • Capacity Utilisation Assessment of existing capacity State’s healthcare support schemes including OPD and IPD Numbers, bed occupancy, average – RSBY, BKKY, ESIS etc length of stay, OT utilisation, major and minor surgeries and other clinical procedures
Assessment of Gap in Health Facilities with respect to existing and future demand
8 METHODOLOGY
•Secondary data survey: based on information available over public domain •Primary data survey: Onsite healthcare facility assessment, data collection from government offices, interviews with hospital administrators, clinicians and Step 1 general population
•Preliminary assessment to cover the functional feasibility of developing a Step 2 hospital along with the mapping of road and rail connectivity.
•Correlation of primary and secondary data that is already collected from districts and state •Data analysis the overall state and each of the 30 districts. Step 3 •Presentation on the findings of the market assessment to Government of Odisha.
9 SECTION 3: DISTRICT PROFILE
10 DEMOGRAPHIC PROFILE
Particulars Odisha Gajapati District HQ Town (Parlakhemundi) Total Population 4,19,74,218 577,817
Urban 16.6% 12.23% population Decadal population 14.05% 11.37% growth rate Mean household 4.35 4.50 size
BPL households* 44,08,070 75,081
BPL Population* 1,91,75,105 337,551
BPL % 46% 58.00%
• Gajapati is the 16th district in terms of size and 28th in terms of population. • Gajapati is the 13th urbanized district in state having only 12.23 percent of its population living in urban areas. • Gajapati has 2nd rank in terms of sex ratio in the state.
Source : 11 Census of India – 2011, Odisha * RSBY status 2015-16, Odisha HEALTH INDICATORS
Key Health Indicators
District Odisha India
297
230
178
82 79 61 59 55 44 30 39 31 20.2 19.8 22.2 7.8 8.2 7.1
Maternal Mortality Neonatal Morality Rate Infant Mortality Rate Under 5 Mortality Rate Crude Birth Rate Crude Death Rate Ratio*
* Maternal Mortality Ratio is of Central Division
Source : Annual Health Survey Report 2011-12
12 SECTION 4: SUPPLY ASSESSMENT
13 BEDS AVAILABILITY
Number of Number of Facility type facilities beds
District Headquarters 1 111 Hospital Share of Beds at Govt. & Pvt. Hospitals in the district Sub-divisional 0 0 hospitals Community Health 8 176 Govt. Centers Beds 35% Primary Health Pvt. Beds 21 6 Centers & IDH 65%
Other hospitals / Area 1 6 Hospital Private Hospitals 6 164
Total 37 463
Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM, DHS & DMET Odisha
14 ABOUT DISTRICT HEADQUARTERS HOSPITAL,GAJAPATI
Total number of Sanctioned 111 beds Functional 111 Service specialties Internal medicine, General surgery, Gynecology and obstetrics, Pediatrics, Ophthalmology, ENT, Dentistry Emergency Diagnostic facilities X-ray, USG, ECG Operating rooms and 2 major and 1 minor OT, 3 Labour tables Labour tables
Other clinical facilities Pharmacy
Outsourced Support Laundry, Dietary, Biomedical facilities waste management, Security, Housekeeping
15 Major Private Healthcare Facilities
Private Facilities Beds Serango Christian Eye Hospital, Paralakhemundi 40 Seramga Christian Hospital, Paralakhemundi 50 Ravi Nursing Home 30 V. V. Laxminurshing Home, paralakhemundi 16 Laxmi Nursing Home 14
16 OPD Consultation & IPD Admission
OPD Consultations IPD Consultations 160,000 16,000 140,000 14,000 120,000 12,000 100,000 10,000 80,000 8,000 60,000 6,000 40,000 4,000 20,000 2,000 0 0 DHH CHC Pvt.Hosp.1RR Ravi Pvt.Hosp.2VVL DHH CHC Pvt.Hosp.1RR Ravi Pvt.Hosp.2VVL 2013-14 72,196 121,558 19,357 17,735 2013-14 12,180 8,458 1,742 1,127 2014-15 84,098 130,570 22,368 18,127 2014-15 13,440 9,186 1,967 1,371 2015-16 89,929 146,330 23,129 21,046 2015-16 13,265 10,340 1,995 1,522
▪ OPD consultations have consistently increased Facility wise share of OPDs (FY Facility wise share of IPDs (FY over the years at both public and private 2015-16) 2015-16) healthcare facilities. ▪ During FY 2015-16, per day OP consultations at DHH was 300 and on an average per day OPD per Pvt. Pvt. Pvt. CHC was 60. Hosp.2 Hosp.2 Pvt. Hosp.1 ▪ OP consultations at Pvt. Hosp.1 and Pvt. Hosp.2 8% 6% Hosp.1 DHH 7% for FY 2015-16 was 77 and 70 respectively. 8% DHH 32% ▪ IP admissions have consistently increased over the 49% years at the private facilities and CHC’s, with on CHC an average 4 IP admisiions per day per CHC in the CHC 38% FY 2015-16. IP admissions per day at DHH was 44, 52% 7 at Pvt. Hosp.1 and 5 at Pvt. Hosp.2. ▪ CHC’s in the district share the highest percentage of OP consultations (52%) whereas DHH share the highest percentage IP admissions (49%) among the studied facilities in the district. Source: Primary data from DHH & Pvt hospital & Secondary data from NHM Odisha 17 BED UTILIZATION
OPD to IPD Conversion ▪ OP to IP conversion has been higher than industry 2013-14 2014-15 2015-16 standards at the DHH. This is due to the availibility of all services and renowned specialties at one place. 17% Low pricing of services is also another crucial factor 16%15% for the same 9% 9% 9% 7% 7% 7% 6% 8% 7%
DHH CHC RRPvt.Hosp.1 Ravi Pvt.Hosp.2VVL
Bed Occupancy Rate (FY-2015-16) ▪ BOR at DHH is much above the optimum level of 80%, indicating the need for additional bed strength 121.1% in the district to meet the rising demand of healthcare services,
69.5% 54.7%
DHH RRPvt.Hosp.1 Ravi Pvt.Hosp.2VVL Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM Odisha
18 GENERAL SURGERIES
Facility Name Major Minor TOTAL
DHH 1,135 782 1,917
CHC 162 1,934 2,096 ▪ Considering data for FY 2015-16 Surgeries Pvt. Hosp.1 306 116 422 performed at the district are majorly minor surgeries.
Pvt. Hosp.2 100 146 246 ▪ For the FY 2015-16, of all the surgeries performed at DHH, only 59% comprise of major surgeries. TOTAL 1,703 2,978 4,681 ▪ Of the total surgeries for FY 2015-16 , 48% of the surgeries was conducted at CHC, however 92 % of these surgeries were minor in nature. Overall proportion of Major & Minor Surgeries (FY 2015-16) ▪ Private hospitals together accounts for only 14% of the total surgeries in the FY 2015-16
Major 36%
Minor 64%
Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM Odisha
19 OT UTILIZATION
Procedure per Name of Number of Total number Procedures per Number of OT Surgeries per surgeon per Facility surgeon of procedures day in the facility OT per day day DHH 7 2,901 9.7 1.4 3 3.2 CHC 25 2,096 7.0 0.3 8 0.9 Pvt. Hosp.1 2 678 2.3 1.1 2 1.1 Pvt. Hosp.2 1 314 1.0 1.0 1 1.0
IPD to Surgery Conversion (FY-2015- ▪ Data indicate under utilization of OT at DHH with 16) around 3 surgeries per OT per day.
34% ▪ The IP to surgery conversion at Pvt. Hosp.1 is highest. Overload of surgical cases at DHH, explains the patient preference for surgery and unofficial 22% 20% 21% referrals from DHH to Pvt. Hosp.1 for surgery.
.
Pvt.Hosp.1 Pvt.Hosp.2 DHH CHC RR Ravi VVL
Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM Odisha
20 INSTITUTIONAL DELIVERIES
2013-14 2014-15 2014-15 Name of Normal C - Normal C - C - Normal Facility Deliver Sectio Deliver Sectio Section Delivery y n y n DHH 2,370 1,011 2,682 1,210 2,539 984 323,27 CHC 0 3,310 0 3,083 0 4 ▪ Total rate of C-section account in the district is more Pvt. Hosp.1 115 193 132 238 156 256 than the industry standard of <15%.
Pvt. Hosp.2 0 44 0 47 0 68 ▪ In 2015–16, DHH performed 10 deliveries per day 325,7 (@ 7normal and 3 C-section). Sub Total 1,248 6,124 1,495 5,778 1,308 59 ▪ 75 % of the total C-sections during FY 2015-16 has been carried out at DHH. C-section at the private Category of Institutional Deliveries facilities comprise of 25%, whereas all deliveries (FY 2015-16) conducted at Pvt. Hosp.2 were C-section.
C - Section 18% Normal Delivery 82%
Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM and DHS Odisha
21 DIAGNOSTICS PROCEDURES
Diagnostic X Ray USG ECG CT ScanLab Tests Test DHH 4,094 1,705 161 0 56,524 ▪ Overall Lab tests accounts for majority (9\3%) of total CHC NA NA NA 0 69,707 diagnostics.
▪ X-ray and USG constitute of only 4% and 2% of the total Pvt. Hosp.1 3,768 2,009 NA 0 30,148 diagnostic procedures conducted at the district which is far below industry standards. Pvt. Hosp.2 NA NA NA 0 9,057 ▪ Data indicate majority of the diagnostic procedures are NA: Data not available conducted at CHC (39%), however all of these tests are laboratory tests. Facility wise total diagnostics ▪ CT Scan facility is not available at any of the public 69,707 health facilities in the district. 62,484
35,925
9,057
Pvt.Hosp.1 Pvt.Hosp.2 DHH CHC RR Ravi VVL Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM Odisha
22 ECONOMIC SEGMENT & MODE OF PAYMENT
Economic Segment of Patients
DHH Pvt.Hosp.1 Pvt Hosp.2 APL - APL - APL - APL - High APL - High APL - Middle High income Middle income Middle income income 2% income 5% income 10% 5% APL - 15% 15% APL - Low APL - Low Income Low BPL BPL Income BPL 28% Income 60% 60% 20% 60% 20%
Mode of Payment by Patients to the Hospital
DHH Pvt.Hosp.1 Pvt.Hosp.2
BKKY RSBY 2% Free 5% RSBY Free RSBY 5% 20% 20% 10%
Cash Cash Cash 73% 80% 85%
Note: estimations given above are based on discussion with ADMO Medical and Hospital Manager 23 SECTION 5: CATCHMENT AREA & REFERRALS
24 CATCHMENT OF DHH
Distance Catchment Name of the Population from district Type block HQ Primary Parlakhemundi 69,447 - Gosani 54,133 20 Kashinagara 51,414 27 Guma 79,520 29 Secondary Rayagada 70,886 33 Nuagada 54,696 55 R. Udaigiri 64,123 63 Mohana 133,598 100
Significant number of patients also come to DHH Parlakhemundi to seek secondary care health services from Pathapatanam tehsil of Srikakulum District of Andhra Pradesh
District Headquarters Hospital Block Headquarters
25 SOURCE OF PATIENT INFLOW
DHH Pvt.Hosp 1
From within the district town From within the 10% 30% 30% district town From the district other than the 70% 60% district town From the district other than the Other districts district town
Pvt. Hosp. 2
From within the 40% district town 60% From the district other than the district town
Source: estimations given above are based on discussion with Management of concerned hospitals
26 POINTS OF REFERRAL
311km 5h30m
MKCG Berhampur SCB, Sishubhawan, Cancer Hospital 118km & AHRC in Cuttack 2h12m Various Pvt. Hospitals in Vizag (Seven hills & Care Hospital)
185km 3h50m 27 Top specialties of referral from DHH to other district
No. of patients Specialty reffered Top 5 specialties for which patients are referred out of district (Monthly) General Surgery 73 18% 18% Orthopedics 72 11% 11% General/Internal 10% 9% TOP 5 45 medicine 6% 5% 5% SPECIALTIES 4% 4% Gynaecology and 44 obstetrics
Cardiology 40 Others
Urology/Nephrology 35 Cancer
ogy Neurology
Cardiology Gastro
Gastro Orthopedics medicine
23 obstetrics Neonataology
enterology/surgery enterology/sur…
General Surgery General
Urology/Nephrol General/Internal OTHER Neonataology 20 and Gynaecology SPECIALTIES TOP 5 SPECIALTIES OTHER SPECIALTIES Neurology 15 Cancer 15 ▪ Other than institutional referrals people also visit health care facilities in Others 20 Vishakhapattanam and Bhubaneswar in want of better quality of care. Total referral per month 402 ▪ Top 5 specialties of referrals accounts close to 68% of total referrals.
Source: Interviews from ADMO (Med.), Specialist Physicians and General Physicians.
28 CONNECTIVITY & TRANSPORT
▪ Nearest railway station : The nearest operational Major Railway Station is Palasa, which is 43 km away. Parlakhemundi is connected to Naupada railway junction on the main East Coast railway line from Kolkata to Chennai by 90 km long (Gunpur to Naupada) 1676mm broad gauge line.
▪ Road ways: Paralakhemundi is connected to other parts of Odisha by the State Highway No.04 which connects Berhampur at one end and Rayagada on the other. The town is well connected to Bhubaneswar,Brahmapur, Rayagada, Jeypore, Gunupu Visakhapatnam, Srikakulam, Palasa, Bhawanipatna, Nabrangpur, Cuttack, Vijayanagaram, Rourkela, etc. by road.
▪ Airport : The nearest Airport is the Visakhapatnam Airport, which is at a distance of 156 km.
▪ Nearest government referral centre: MKCG Medical College Berhampur (118 km).
29 SECTION 6: DEMAND-SUPPLY-GAP ASSESSMENT
30 DEMAND - OPD and IPD
▪ Out Patients: As per NSSO 60th round data, the estimates of spells of ailment in Odisha population and percentage of the spells of aliment seeking non-institutional treatment i.e., ambulatory care, applied to the catchment population gives estimates of OP demand in the population. The PAP (proportion of ailing person) per 1000 population in 15 days is 77 for Odisha and spells of ailments treated during 15 days is 76%.
▪ Percentage of specialty mix for OPD is derived from morbidity rate of NSSO data 2004-05, 60th Round, increased by a factor of 1.5 to develop a conservative estimate of patient need.
▪ Further the OP estimates has been extrapolated to include the load of estimated pregnant women in a population, to cover ANC visits as OPD in health facilities.
▪ In patient: For the FY 2015-16, OP to IP conversion rate for 30 DHHs in Odisha has been 15%. Hence for the calculation purpose OP to IP conversion rate is taken on an average to be at 15%.
▪ Diagnostics: Diagnostics demand is extrapolated as per industry standards.
▪ Population: Projected population for 2016 has been considered for estimation of OPD and IPD demand
▪ * Other specialties include: Skin & VD, Psychiatry and Dental
31 Demand – Supply – Gap of OPD consultations
Department/ Estimated % Estimated Actual Estimated Gap assessment of OPD specialty Specialties of OPD demand Supply Gap mix
Gen Med 22 203,086 71,742 131,344 Estimated Demand Actual Suppy
OBG 14 129,237 37,962 91,275 Gen Med Pediatrics 12 110,774 32,870 77,904 OBG Gen. Surgery 11 101,543 34,785 66,758 Paediatrics Orthopedic 9 83,081 22,528 60,552 Gen. Surgery ENT 7 64,618 16,538 48,080 Orthopaedic
Ophthalmology 7 64,618 16,538 48,080 ENT Others 18 166,162 47,470 118,692 Opthalmology specialties Others specialties TOTAL 100% 923,120 280,434 642,686
Total OPD Gap 70%
Source : -NSSO 60th Round data 32 -Journal: the cost of universal healthcare in India – A model based estimate, 2012 Demand – Supply – Gap of IPD admissions
Estimated IPD Gap assessment of IPD specialty mix Department/ demand (@ Actual Estimated Specialties 15% OP-IP Supply Gap Estimated Demand Actual Supply conversion) Gen Med 30,463 6,700 23,763 Gen Med
OBG 19,386 4,415 14,971 OBG
Pediatrics 16,616 2,597 14,020 Paediatrics Gen. Surgery 15,231 3,733 11,499 Gen. Surgery Orthopedic 12,462 2,124 10,338 Orthopaedic ENT 9,693 1,652 8,040 ENT Ophthalmology 9,693 1,652 8,040 Others Opthalmology 24,924 4,249 20,675 specialties Others specialties TOTAL 138,468 27,122 111,346
Total IPD Gap 80%
Source : -NSSO 60th Round data 33 -Journal: the cost of universal healthcare in India – A model based estimate, 2012 Demand – Supply – Gap of Diagnostics (OPD+IPD)
Key Demand OPD Demand IPD Total Total Actual diagnostics Estimated Estimated Total % of Estimated Total % of Estimated Supply services Demand Gap OPD Demand IPD Demand
X Ray 15% 138,468 50% 69,234 207,702 3,768 203,934
USG 20% 184,624 35% 48,464 233,088 3,714 229,374
ECG 10% 92,312 60% 83,081 175,393 161 175,232
CT Scan 2% 18,462 5% 6,923 25,386 0 25,386
Lab Tests (number of 60% 553,872* 100% 138,468** 692,340 165,436 526,904 patients)
* Considering industry standards 60% of OPD patients undergo at least 2 tests per patient. Hence, demand number of OPD lab tests would be 1,107,744 tests.
** Considering industry standards 100% of IPD patients undergo at least 5 lab tests per patient. Hence, demand number of IPD lab test would be 692,340
34 GAP - HOSPITAL BEDS
Hospital beds available in the district
Primary Community Sub district District Other Private Total Bed health health centers Hospital hospital Hospital Hospital strength centers & IDH 21 8 0 01 1 6 6 beds 176 beds 0 beds 111 beds 6 beds 164 beds 463
Gap in bed availibility The district of Gajapati has 31 public and 6 private health care facilities with a total bed 2140 strength of 463 beds only. 2500 Considering the WHO norm of 3.5 beds per 1000 2000 population, the district with a population of 1500 6,11,421 has a shortfall of 1677 beds (i.e. a gap of 463 78.3% beds). 1000
500
0 Beds available Beds required as per WHO norm * Source : Bed Strength, DHS Odisha and Clinical Establishment, DMET Odisha
35 GAP – DOCTORS AND NURSES
Gap in doctors availibility Gap in nurses availibility
611 1223 700 1400 600 1200 500 1000 400 800 300 61 600 200 25 100 400 0 200 Doctors available Doctors required as 0 per WHO norm Nurses available Nurses required
As per primary and secondary data collected There are ▪ There are 91 sanctioned positions for doctors, of which ▪ 30 positions are vacant. only 25 nurses posted in the district. (14 nursing sister and 10 staff nurse, 1 Asst Matron). ▪ Considering the WHO norm of 1 doctor per 1000 population, the district has a shortfall of 550 doctors ▪ Considering the WHO norm of 2 nurses per 1000 population, the district has a shortfall of 1,198nurses.
* Source : Staff position list received from DHH Phulbani and * Source : District wise Incumbency list , DHS Odisha nursing staff list from directorate of nursing, Odisha.
36 SERVICE AVAILIBILITY AND GAPS
Diagnostic Facility Clinical Facility
Name of facility IPHS Requirement Available Name of facility IPHS Available 500 M.A X-ray machine 1 0 Requirement 300 M.A. X-ray machine 1 1 General OPD 1 1 100 M.A. X-ray machine 1 0 Speciality OPD 8-10 3 60 M.A. X-ray machine (Mobile) 1 1 Major OT 2 1 Dental X-ray machine 1 0 Emergency OT 1 0 USG with colour doppler 3 1 Ophthalmology/ ENT OT 1 0 ECG computerized 1 1 Minor OT 1 1 ECG ordinary 2 1 Gyneaecology OT 1 0 TMT 1 1 Labour Table 11 4 A Scan 1 1 Pharmacy 1 1 B Scan 1 0 Blood Bank 1 1 Audiometry 1 1 Ambulance (BLS) 1 4 PFT 1 0 Bronchoscope 1 0 Haematology lab 1 1 When compared with IPHS for district hospitals, major gaps are in the areas of Biochemistry lab 1 1 Diagnostics and Specialty OPDs Microbiology lab 1 0 Histopathology lab 1 0
Immunology and Serology lab 1 0 Source : IPHS for District Hospital, Equipment norms 101– 200 bedded
37 SECTION 7: FINDINGS OF GENERAL POPULATION SURVEY
38 HEALTH SEEKING BEHAVIOUR
Do you visit a doctor / health facility whenever Why, Not always? someone is sick in your family? 67%
Not 33% always 30% Yes 0% always 70% The doctor/hospital Visiting a The clinical condition is far from my doctor/hospital is is always not that residence expensive serious
The district displays a good health seeking behavior, where 70% of families visit a hospital when someone is sick at home.
First choice of healthcare facility Which, government / private hospital? 67% 40%
30%
20%
10% 17% 17%
Private Physician Govt Hospital Private hospital Others(Quack / DHH Gajapati Murti Nursing Home Dr. Ravi Nursing clinic Pharmacist) Home HEALTH SEEKING BEHAVIOUR
Reasons for choosing a hospital
75%
67%
50% 50%
33% 25%
0% 0% 0% 0% 0% 0% 0% 0% 0%
My Preferred doctor I have been visiting The facility is large I knew about the The facility is practices there the facility for a long and most services reputation of the proximate to my time offered under one facility for its quality residence roof of care
Govt. Pvt. Pvt.Physician clinic
While preference for doctors is the major factor that influences the decision making of a person in choosing a private hospital as well as private physician clinic. Other than that people also opine proximity of the facility and reputation of the doctors to choose Private Health care facility. The reasons for choosing government hospital are spread, with long time preference ,large infrastructure and with service availability.
It is critical to note that no respondent has opined about cost of healthcare, indicating that people are willing to spend for good quality healthcare. HEALTH SEEKING BEHAVIOUR
Distance travelled to access healthcare from government and private hospitals
120%
100% 100% 100%
80% 67%
60%
40% 33%
20%
0% 0% 0% < 5km 5.1-10km
Govt. Pvt. Pvt. Physician clinic
Patients travel longer distances to access better quality of care both for private hospitals and private clinics. REGULAR MEDICATION BEHAVIOUR
Does any member of your family take regular medications?
No 40% Yes 60% The findings indicate a high prevalence of chronic diseases requiring continued treatment.
Conditions for which patients take On an average 1 persons per family take regular medications regular medication for some prolonged ailment.
50%
33%
17%
Diabetes Hypertension/heart problem Others(Asthama) OP HEALTH SEEKING BEHAVIOUR AND SPEND Frequency of hospital visit
60%
20% 20%
40% of the respondent families were consulting a health facility at least <6 visits/year 7-12 visits/year >12 visits/year once in two months.
Common specialties of consultation The top specialties include a mix of 33% secondary and tertiary care specialties 20% 17%
7% 7% 3% 3% 3% 3% 3% 0% 0% 0% 0% 0% AVERAGE OP SPEND (Rs)
Average OP spend at government and private hospitals (Rs)
400 358 350 300 300
250 200 200 183 183 167
150 100 100 73 63 50 35 15 5 0 0 0 0 0 0 Registration0 Consultation Diagnostic tests Medicines Any minor Travel to health porcedure facility
Govt. Pvt Pvt. Physician clinic
The average outpatient spend in a government hospital is Rs. 264/-, while the same at a private hospital is Rs. 615/- and at a private physician clinic the spend is Rs 771/-. However it should be noted that travel to a private healthcare facility is an escalating factor that infers to lack of better private hospitals in the district. IP ADMISSIONS
There was atleast one hospital admission in the family in the last one year
70%
30% The survey indicates a moderate morbidity rate, wherein, nearly 30% of the families had one hospital admission in the last one year. Yes No
Place of admission The patients had chosen government hospitals for admissions. 100%
0%
Government hospital Private hospital IP ADMISSIONS
Reason for getting admitted in a government hospital
35% 33% 33% 33%
30%
25%
20%
15%
10%
5% 0% 0% 0% 0% 0% 0% 0% 0% 0% Referred by I have been The hospitalI knew about The hospital Only this Brought in Low pricing The staff in The hospital It is a a doctor / visiting this is large and the is proximate hospital an of services this hospital is clean network hospital hospital for a most reputation of to my provides the emergency and free behaves when hospital in long time services this hospital residence services in medicines well when compared my health offered the region compared with other insurance / under one with other hospitals corporate roof hospitals tie-up
The reasons for choosing a hospital for admission are limited to only few options. The top reason for choosing a government hospital is the large infrastructure , service availability , long time preference ,emergency admission and referrals from Other Govt. Hospital, private hospital & private physician . This evidently indicates that DHH Gajapati is the largest hospital in the district. Due to lack of private hospitals, people tend to visit DHH. IP ADMISSIONS
Specialty of admission 67%
33%
replacement
Orthopedics/joint General Medicine
All the government hospital admissions were related to secondary specialties such as General Medicine and Orthopedic. IP ADMISSIONS
Amount spent during admission Informal charges paid in a government 67% hospital
33% Yes 0% 0% 0% 0% 33%
No 67%
Source of health related costs 33% of patients admitted at government hospital
80% claims to have paid informal charges. The average informal charges paid is Rs. 1020/-
Only 10 % of the surveyed population is having health insurance as their primary source of health related costs which indicates lack of awareness 10% 10% among individuals. 0%
From savings Loan from Sold assets Health family/friends insurance SECTION 8: FINDINGS OF INPATIENT SURVEY
49 HEALTH SEEKING BEHAVIOUR
Have you consulted/visited any other doctor 60% of the patients had visited a local government /hospital before coming to this hospital,in this hospital before visiting the hospital. instance and for this ailment?
It is important that the proposed low cost hospitals develop an integrated referral network to refer patients No requiring higher level of secondary care. 40%
Yes Similar to the general population and outpatients, the 60% respondents display a good health seeking behaviour.
Which hospital did you consult? Do you visit a doctor / health facility whenever someone is sick in your family? 100% 100%
0% 0% 0% 0% 0% A private A private A local govt. District Others practitioner hospital hospital hospital Yes always Not always EPISODE OF CARE
Speciality of the ailment of admission Frequency of hospital visit before this admission 40% 60% 20% 20% 20%
20% 20%
0% General General Surgery Gynaecology Paediatrics and Medicine and obstetrics neonataology This is the first 2-6 visits 7-12 visits >12 visits
Reason for choosing this hospital
60%
40%
0% 0% 0% 0% 0% 0% 0% 0% 0%
Referred by a I have been visiting The hospital is large I knew about the The hospital is Only this hospital Brought in an Low pricing of The staff in this The hospital is clean It is a network doctor/hospital this hospital for a and most services reputation of this proximate to my provides the services emergency services and free hospital behaves well when compared with hospital in my health long time offered under one hospital residence in the locality/district medicines when compared with other hospitals insurance/corporate roof other hospitals tie-up
On a random sample, it could be observed that majority of the admissions were in the common secondary care specialties. However, these admissions pertain directly to the service availability in the hospital. It is imperative to note that the reasons for admission are limited to few options with no mention of cost. EXTERNAL REFERRALS
Did you have to visit any other hospital/diagnostic center for any diagnostic test?
80%
20% of the admitted patients had to get their diagnostic tests done from an external diagnostic center. Confirmation of Test reports ,long queue at 20% diagnostic department and unavailability of services at DHH are the main reasons for referrals.
Yes No Similarly 80% of patients had to buy medicines from an external pharmacy. Did you have to buy any medicine from an external pharmacy? The above inferences indicate the need for more 80% facilities in the district hospital. Also there is a need to improve the pharmacy stock availability in the hospital. However improving pharmacy stock may be challenging as the procurement is centralized through the government. 20%
Yes No SECTION 9: FINDINGS OF OUTPATIENT SURVEY
53 HEALTH SEEKING BEHAVIOUR
Do you visit a doctor / health facility whenever Why, Not always? someone is sick in your family? 100%
Not always 20%
Yes 0% 0% always 80% The doctor/hospital Visiting a The clinical condition is far from my doctor/hospital is is always not that residence expensive serious
Have you consulted /visited any other doctor First choice of healthcare facility /hospital before coming to this hospital,in this instance and for this ailment? 100%
80%
20% 0% 0% 0% 0%
A private A private A local govt. District Others Yes No practitioner hospital hospital hospital
The people display good health seeking behavior, however, in the absence of a private hospital, the patients visit the nearest government hospital for their immediate health needs.
54 EPISODE OF CARE AND CHOICE OF PROVIDER Why do I choose this hospital?
60%
20% 20%
0% 0% 0% 0% 0% 0% 0% 0%
hospital
emergency
residence
time
Broughtin an
medicines
tie-up
Referredby a
doctor/hospital
Thehospital is
Low pricing Lowpricing of
proximateto my
I knew I about the
reputationthis of
servicesand free
inmy health
otherhospitals
otherhospitals
Thein staff this
Only hospital this
andmost services
Thehospital clean is
I have I been visiting
inthe locality/district whencompared with
whencompared with
insurance/corporate
providesthe services
Thehospital large is
hospitalbehaves well
thishospital for long a
It It network a is hospital offered underone roof
Specialty of consultation This survey indicates that patients are 40% coming mostly for Obstetric and Gynaecology followed by general medicine , general 20% 20% 20% surgery , Paediatric and Neonatology.
Personal preference for long time ,large infrastructure, service availability are the General Medicine General Surgery Gynaecology and Paediatrics and obstetrics neonataology main reason for choosing health care facility.
55 EPISODE OF CARE AND CHOICE OF PROVIDER
Did you get to meet the specialist doctor pertaining to Did you have to buy any medicine from an your specialty during today's consultation? external pharmacy outside the hospital? 45% 40% 40% 70% 40% 60% 35% 60% 30% 50% 25% 40% 20% 40% 20% 15% 30% 10% 20% 5% 10% 0% Yes No Don't know 0% Yes No
Did you have to visit any other In the absence of higher specialties, most patients are hospital/diagnostic center for any diagnostic consulted through general medicine clinic. This is test? evident from 40% of patients saying that they did not 70% 60% get to meet the doctor pertaining to their suffering. 60%
50% 40% 40 % of respondents had to avail diagnostic tests from 40% external centers. 30% 20% 60% of patients had to buy medicines from outside 10% indicating the need for better formulary and supply 0% 0% chain mechanism. Yes No I was not prescribed
56 FINANCING FOR HEALTHCARE
Amount spent on visit to the hospital
106 88 88
20
4 0 Patients tend to spend mostly on travel to health facility , diagnostic tests and medicines Registration Consultation Diagnostic Medicines Any minor Travel to tests porcedure health especially as they had to purchase them from Average (Rs) facility external facilities.
Source of health related costs This indicates that people are ready to purchase healthcare if services are available. 100%
0% 0% 0% 0%
From savings Loan from Sold assets Health Others family/friends insurance
57 SECTION 10: FINDINGS OF PHYSICIAN’S SURVEY
58 COMMON SPECIALTIES OF CONSULTATION BY GENERAL PHYSICIANS
22% 22%
13% 13% 13%
9%
4% 4%
0% 0% 0% 0% 0% 0%
59 ECONOMIC AND GEOGRAPHIC STRATIFICATION OF PATIENTS
General physician survey Specialist physician survey
Economic class of patients Economic class of patients
49% 52% 46% 41%
5% 7%
Upper economic Middle economic Low economic class class class Upper economic class Middle economic class Low economic class
Geographic classification of patients Geographic classification of patients 65% 55%
36%
21% 14% 9%
From within the From the district From adjacent town/city other than the districts From within the From the district other From adjacent districts town/city town/city than the town/city
60 REASONS FOR PHYSICIANS TO REFER PATIENTS TO A PRIVATE HOSPITAL
Reasons to refer a patient to a particular hospital
27% 27% 27% 27%
20% 20%
13%
7% 7% 7% 7% 7% 7%
0% 0% 0%
Your professional Proximity to your Hospital that Low pricing of Availability of Availability of Good Good clinical affiliation with patient's updates you on services/price known/reputed comprehensive infrastructure and serice quality the residence the progonosis of discounts to your physicians in the treatment high end facilities hospital/referral your patient patients hospital facilities and fee from the capability to hospital handle complications
General Physician Specialist Physician
61 SPECIALTIES OF CARE FOR WHICH PATIENTS TRAVEL TO OTHER CITIES
SPECIALTIES OF CARE FOR WHICH PATIENTS TRAVEL TO OTHER CITIES
20% 18% 16% 14% 12%
8%
4% 4% 2% 2% 2%
The above are averages of the responses from both general and specialist physicians. All the surveyed physicians indicated that patients from the district go to other districts / cities for availing healthcare. Most physicians responded that the district has sufficient Gynaecology and Obstetric and Pediatric services.
62 SPECIALTIES THAT A NEW HOSPITAL SHOULD FOCUS
All the surveyed physicians indicated the need for a new hospital in the district and they opined that the hospital should focus on the following specialties The percentages is the physicians who responded with yes for a specialty. SPECIALTIES THAT A NEW HOSPITAL SHOULD FOCUS
General Physician Specialist Physician
26%
20%
16% 16% 16% 16%
12% 12% 11%
8% 8%
5% 5% 5% 5% 5% 5% 4% 4%
0% 0% 0%
Cardiology / Pulmonology Neurology / Gastro Cancer Urology Nephrology Orthopaedics Gynaecology ENT Pediatrics cardiac / Thoracic Neuro enterology / & Obstetrics and surgery Surgery Surgery surgery neonatalogy
63 FACILITIES RECOMMENDED BY THE PHYSICIANS
Specialities General Physician Specialist Physician ECHO,ECG,TMT,Holter,Cath ECHO,ECG,TMT,Holter,Cath Cardiology / cardiac surgery Lab,CCU,Cardiac Ot Lab,CCU,Cardiac Ot Pulmonology / Thoracic Surgery PFT/Spirometry, Bronchoscopy EEG, EMG, Specialized Neuro Neurology / Neuro Surgery EEG, EMG OT USG, Endoscopy, Colonoscopy, Endoscopy, colonoscopy, ERCP, Gastro enterology / surgery ERCP Leproscopy Chemotherapy, Chemotherapy, Radiotheraphy, Cancer Radiotheraphy, Mammography, Mammography, Surgical Oncology Surgical Oncology Nephrology Dialysis & other diagnostics Dialysis Orthopaedics BMD, Joint Replacement OT BMD, Joint Replacement OT USG, Management of High risk Gynaecology & Obstetrics cases Ophthalmology Adenoidectomy, Adenoidectomy, ENT Audiometry/BERA,Tonsillectomy, Audiometry/BERA,Tonsillecto Septoplasty my, Septoplasty Pediatrics Specialized Procedures Pediatrics and neonatalogy & Neonatology
The physicians opined that any hospital proposed should focus on the above facilities for the corresponding specialties.
64 THANK YOU
65