ACHUTHA liE4ON174TR: FOR r 31; •:13E STUOIEI Sree Clitr i , • z. nor tAedica I S.' 7 nt': THIAIJVAIIANT0APUBOA. 1 A. MiA Structure and Functioning of In Patient Health Care Institutions in Thiruvananthapuram Taluk, Kerala

Sonia Andrews

Dissertation submitted in partial fulfillment of the requirement for the award of the degree of Master of Public Health

Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram Kerala (India) June 2003 Declaration

I hereby certify that, the work embodied in this dissertation entitled, "Structure and

Functioning of In-Patient Health Care Institutions in Thirovananthapuram Taluk,

Kerala", is the result of original research and has not been submitted for any degree in any other University or Institution.

Thiruvananthapuram, Kerala JZia)/111- Date: c2/0 _ Sonia Andrews Certificate

Certified that the dissertation titled, "Structure and Functioning of In-Patient Health

Care Institutions in Thiruvananthapurarn Taluk, Kerala" is a bonafide record of original research work undertaken by Ms Sonia Andrews, in partial fulfillment of the

requirement for the award of the Master of Public Health degree under our guidance and

supervision.

CS'61-ck[ Co-Guide Guide

Dr. V. Raman Kutty Dr. D. Varatharaj an Executive Director Associate Professor Health Action by People Achutha Menon Centre for Health Thiruvananthapuram Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapu rarn A cknowledgentent

I hereby place on record my sincere thanks and gratitude to my guide Dr. D. Varatharajan

for his Lruidanee and help. I owe my indebtedness to my co-guide Dr. V. Raman Kutty for valuable discussions. suggestions and directions.

I profusely thank all my teachers, Dr. K.R. Thankappan, Dr S. Sarma and Dr V. Mohanan

Nair for their interest in my work, Dr. Amar Jesani who has been a great source of

inspiration and encouragement and Dr Sundari Ravindran who has gone through the draft

and provided valuable suggestions.

I thank all the authorities of the hospitals I visited in connection with my fieldwork and

also the patients who cooperated well with me during the interview sections.

A word of special thanks to Dr Alphonse Ligori of Jubilee Hospital,

Thiruvananthapuram, for his help and kindness.

I sincerely thank all my colleagues for their help and encouragement during my study.

I have no words to thank my parents who cared so much for me and my work.

I thank every one at AMCHSS for the excellent academic environment provided. As a

student of Economics, I must state that I have received genuine help and encouragement

from all the members of the faculty of AMCHSS which made me stand in good stead and

confidence to carry out the present work.

Sonia Andrews CONTENTS

Page No CHAPTER 1: INTRODUCTION 1.1 Background 1 1.2 Kerala Scenario 1.3 This Study 3 CHAPTER 2: METHODOLOGY 2.1 Conceptual Basis 6 2.2 Design 6 2.3 Area 6 2.4 Participants 7 2.5 Period 7 2.6 Stage-la. Listing of Institutions 8 2.7 Stage-1b. Background Characteristics of Institutions 8 2.8 Stage-2 Functioning of Non-government Institutions 10 2.9 Concepts and Definitions 14 CHAPTER 3: RESULTS 3.1 In-patient Care Institutions in Thiruvananthapuram Taluk 18 3.2 Types of Non-government Institutions 20 3.3 System of Medicine 20 3.4 Range of Specialties 21 3.5 Year of Establishment 24 3.6 Registration Status 25 3.7 Selection of Institutions for Second Stage 25 3.8 Physician Payment Mechanisms 27 3.9 Charging of Patients 30 3.10 Facilities Available 30 3.11 Contracting out 31 3.12 Reasons for Choosing to Work in an Institution 32 3.13 Reasons for Choosing an Institution to Seek Care 33 Page No

3.14 Sources of Financing care 36 CHAPTER 4: ANALYSIS AND CONCLUSIONS 4.1 Existence of Non-government Sector 37 4.2 Specialties Offered 39 4.3 Mixed Practice 40 4.4 Registration Status 41 4.5 Efficiency Indicators 41 4.6 Physician Payment Mechanism 42 4.7 Contracting out 44 4.8 Conclusions 45 References 47 Annexure 1.Facilities Available 50 2.Checklists and Interview Schedules 54 Abstract

India has a complex, pluralistic and dynamic health system. The non-government sector plays a major role in it. The growth of this sector has been diagnostically visible mainly since the mid 1970s. The dearth of studies relevant to the nature and function of this sector has left it unaccounted for and unplanned.

It is in this context the present work attempts to study the structure and functioning of in- patient facilities in Thiruvananthapuram taluk expecting to pave way for a wider perspective on the Kerala scenario; explicating points relevant to organization/typology, functional dynamics and client profile.

The study was carried out in two stages. Stage-1 included a collection of basic information on all in-patient facilities in the taluk by a telephonic survey. The stage-1 findings were used for stage-2 sampling. A detailed study of the selected number of in- patient facilities was done in stage-2. It involved information on specialties, stair, doctor payment mechanism, efficiency indicators etc. Staff interviews and in-patient exit surveys were also carried out. A schedule for these purposes was formulated and used.

The work draws close discussion on a number of pertinent issues related to size, management pattern and function, distribution and its impact, specialties and facilities, co-existence of different systems of medicine, establishment details, registration status, efficiency indicators, personnel profile, payment mechanism, partnerships and charging patterns of in-patient facilities in the taluk.

Results indicated that sole proprietorship was the dominant pattern of ownership within the non-government sector while public and private limited institutions offering maximum range of specialties. The study found that there existed a high concentration of inpatient facilities in corporation area. Both government and non-government institutions existed in limited number in panchayat area but the non-government sector had a dominant presence even in rural areas.

Efficiency indicators were better in government institutions. Government institutions had higher bed occupancy, turnover and average length of stay. Single physician payment mechanism existed in most of the non-government institutions with salary and incentive- based mechanisms existing in almost equal proportion. Panchayati raj institutions did not have any knowledge and control over the existence of non-government inpatient care institutions in their own areas even though some of the non-government institutions were registered with them. Chapter 1

Introduction

1.1. Background

The way health care is organized and the extend of resources allocated for it influences the availability and accessibility of resources, quality of care, cost of treatment and people's satisfaction. The evolution of Indian health care system after independence was based on Bhore Committee recommendations and revolved around the public health care sector. Private sector was basically promoted at least officially as a supplementary system to public sector. Private investment on the hospitals and other health care infrastructure was not thought to be profitable during the 1940s. As a result, only about 8% of all medical institutions in the provinces (states) were maintained wholly by private agencies in the early 1940s; the share of private hospital bed capacity was about 13%) However, the situation changed after independence and about 60% of all hospitals and 40% of hospital beds are now in the private sector: Private sector also accounts for 80% of the registered allopathic doctors.2 Hence, from a 'government dominated one, Indian health care system has evolved into private and public comprising of allopathic and other systems of medicine.

Health expenditure in India in 2001 was estimated as 5.2% of the GDP, of which only about 17% was accounted by government; the rest was private out-of-pocket expenditure.3 Government contribution to total health expenditure is weak in India compared to countries such as China arid Sri Lanka; worse still, government share is coming down from 25% in 1991 to 17% in 2001.3 Its share in GDP too came down from

1.3% in 1990 to 0.9% in 1999. 3 Under the constitution, health is a shared responsibility of the central and state governments and the states were responsible for this decline too. 2

States' fiscal allocations are known to be static and therefore, any improvement in this

front could be termed as 'ambitious'.

On the other hand, private health care expenditure in India has grown at the rate of 12.5%

per annum since 1960-61.4 Growth of private hospitals took place during the late 1970s

and early 1980s and gained momentum in the late 1980s and 1990s. The growth was

linked to developments in the international as well as national scenes. The factors such as

New Economic Policy, influx of medical technology, growing deficits of the public sector

hospitals and rising middle class, rising demand for medical services, reduction in the

budgetary support and lack of employment in the public sector, ease to obtain funds for

setting up of health care institutions, have contributed to its large scale growth.4'5 The

mid 1980s also showed a change in the structure of the private sector in medical care with the rise of corporate medical care as against the single owner or partner managed private institutions, which existed until the 1980s.5

1.2. Kerala Scenario

The state of Kerala with a relatively high achievement in the field of health care falls generally in line with the above-cited pan Indian situation. Kerala has a long history of organized health care and now the private hospitals in the state surpass government facilities in the density of beds, employment of personnel and in the provision of high- tech methods of diagnosis and therapy. Private sector controls 82.3% of institutions,

57.7% of beds and 85.7% of doctors.6 Also, about 0.3% of institutions, 2.2% of beds and

0.7% of doctors are in the cooperative sector. 36.9% of private health care institutions practice modern medicine, 37.3% ayurvedic, 24% homeopathy and 1.8% other systems of medicine such as sidha and unani.6 3

Health expenditure by Kerala government has consistently been around 13-15% of the total development expenditure.' This is one among the higher values for government expenditure on health by states in India. However, as a share of state's domestic product

(SDP), total government expenditure on health in recent years is consistently below 1.5%, which is not high. Out-of-pocket expenditure from the consumers contributes a large share to the total health spending in the state. The growing expenditure on salaries forced the public sector to cut back the supplies.'

In Kerala, the period from the early 1960s to the mid 1980s was characterized by great growth and expansion of the government health services. The number of beds and institutions increased sharply. The major growth phase of facilities in the government sector was before 1986, after which it slowed considerably. Fiscal crisis and growing revenue deficits and decline in government spending, rising disposable incomes, lack of barriers to opening a private hospital, high demand for health care and ageing of population have contributed to the growth of non-government sector in the state.8

1.3. This study

Institutions in the private sector are heterogeneous in nature with different sizes of operation. Their growth has been unplanned, unregulated and without any accountability.

Past plans, policies and reports focused little on this sector. Only in Maharashtra and

Delhi, there is some legislation for private hospitals/nursing homes; Delhi has Delhi

Nursing Home Registration Act (DNHRA) enacted in 1993. The Bureau of Indian

Standards (815) has laid down standards for hospitals ranging from 30 to 250 beds. The

standards, which are laid down, are applicable to both private and public sectors.

National Institute of Health and Family Welfare (NIHFW) has laid down standards but

largely for 50 and more than 50 bedded hospitals and that too only for equipment. Most 4 of the standards lay down by HIS, NIHFW etc are meant for relatively larger hospitals

located in major urban areas.9 However, the standards laid out so far fall short of the requirements by miles. It virtually means that one of the largest private health sectors in the world, providing care to 70% Indian population, still remains unregulated. On the other hand, basic requirements and guidelines are laid down for government hospitals.

Ilealth policies in India haven't paid much attention to the private sector, the most crucial sector in Indian health care system. Moreover, a near total lack of regulation resulted in

uneven categorization of this sector. State governments have not been able to evolve an appropriate regulatory mechanism (including designing physical standards for various

categories of hospitals, accreditation system and a redressal system for patients) in spite

of the persuasion of the Government of India. A major reason for their failure lies in the

lack of understanding of how the private hospital market functions.

In the absence of standard guidelines for growth, private health care institutions have

grown significantly and almost erratically during the post independence era. But there is

dearth of studies to describe its structure, Characteristics and functioning. The large

presence of private sector in Kerala necessitates the need to focus more attention on the

services provided privately. While some studies existed in the past, not much information

is available in relation to Kerala. It is in this context, the present work attempted to study

the structure and functioning of non-government in-patient health care facilities in a taluk

in Kerala. However, the basic framework of the study allowed for a detailed analysis of

in-patient care in its entirety, not just in relation to one sector/system in isolation.

However, in-depth analysis was provided only with respect to the non-government sector

within the overall context of in-patient care. Understanding of the structure and

functioning of the non-government sector in a small area, it is hoped, would ultimately

lead to larger understanding of in-patient care provision and contribute towards attempts 5 to evolve a system, which is efficient, equitable and affordable to all sections of the people.

Aim

The overall aim of this study was to understand the nature, spread and functioning of the non-government in-patient health care institutions in Thiruvananthapuram taluk of

Kerala.

Objectives

Specific objectives of the study were:

1. To capture the organization/typology of non-government in-patient facilities

Typology included the system of medicine (like allopathy or ayurveda), and the type of

management (sole proprietorship, partnership, trust etc). Details relevant to size,

distribution and establishment (year and ownership of premises) and range of specialties

were included. •

2. To understand their functional dynamics

The aim here was to analyze the functioning of non-government in-patient health care

facilities in relation, but not necessarily restricted, to physician payment mechanism,

charging of patients/clients and efficiency parameters.

3. To analyse their client profile

The aim was to know the health care seeking behaviour of the clients as to where do they

go for in-patient care, for kind of ailments, the referral system, sources of financing etc. 6

Chapter 2

Methodology

2.1. Conceptual basis

The basic premise of this study was that the non-government sector plays a significant role in in-patient care provision. The presence of this sector was assumed to vary across geographic divisions (corporation and panchayat), across types of medicine (allopathic, ayurvedic, homeopathy, sidha, unani and others), and ownership types (trust, charity, sole proprietorship, private and public limited company etc.). This, in essence, provides the conceptual framework for this study. The listing and final selection of institutions for the two stages of study were done on this basis.

2.2. Design

Exploratory and Cross sectional survey.

2.3. Area

The study was conducted in Thiruvananthapuram taluk (with an approximate population of 1 million) of the Thiruvananthapuram district. Districts in Kerala were ranked

according to the mix of the institutions and Thiruvananthapuram district was selected

since it had a mix of different systems/sectors of health care institutions (Table-I).

Thiruvananthapuram taluk, which is one of the four in the district, was chosen because it

includes both city corporation and panchayat areas. The city corporation has a population

of 0.67 million while the panchayat area includes 10 panchayats and a total population of

0.33 million.10 7

Table 1. Government and non-government institutions in the state. 24*' 6**

SL Districts Non-Government* Government** No AL AY H 0 1. Thiruvananthapuram 431 232 221 46 115 2. Kollam 369 397 230 11 88 3. Pathanamthitta 257 187 167 17 64 4. Alappuzha 367 346 328 9 90 5. Kottayam 474 501 440 17 85 6. Idukki 239 180 123 13 63 7. Ernakulam 542 406 444 25 117 8. Thrissur 288 455 171 30 122 9. Palakkad 180 452 105 23 112 10 Malappuram 237 554 165 23 123 11 Kozhikode 372 549 366 42 96 12 Wynad III 63 54 5 40 13 Kannur 264 391 260 16 106 14 Kasarakode 157 209 44 13 60

Allopathy — AL, A — Ayurveda, II — Homeopathy, 0 — others,

The term 'institution' has been used for in-patient facility throughout the paper. Non-

government institutions included both for-profit and not-for-profit institutions.

2.4. Participants

All health care institutions with in-patient facilities (with functioning beds) were included

in the study. In addition to the collection of basic details about the institutions, the study

also included interviews of doctors, nurses, other staff and clients. In addition, experts

such as lawyers and health system analysts were contacted at different points of time.

2.5. Period

While actual initiation of the study dates back to September 2002, data collection was

undertaken during the three months starting from I6th December 2002 - 10th March 2003.

In all, there were two stages of data collection — one at the taluk level and the other at the

institution level. 8

2.6. Stage-la. Listing of institutions

The list (including name, address and telephone numbers) of the non-government in-

patient facilities in the taluk was collected from various sources such as:

• Professional Association Directories (QPMPA- Qualified Private Medical

Practitioners Association for allopathy, and AMAI-Ayurveda Medical

Association of India)

• Corporation Office

• Panchayat offices

• Telephone directory

• Newspaper & TV advertisements

• Web sites and Internet searching

• Personal contacts

• Telephone enquiry services

The list of government hospitals was obtained from Directorate of Health Services,"

Directorate of Ayurveda and Indian Systems of Medicine and the Directorate of •

Homeopathy.

2.7. Stage-lb. Background characteristics of institutions

Once the telephone numbers and the addresses of the institutions were obtained during

the earlier stage, telephonic enquiries were made to the institutions (using a check list) to

collect basic details of the institutions such as

• Location of the hospital (corporation or panchayat)

• Bed strength 9

• System of medicine

• Ownership pattern (government or non-government)

• Type of management

• Year of establishment

• Ownership of premises

• Specialties available

• Registration status (the authority where it is registered)

Few institutions were not willing to give the information over the phone. In those cases,

websites. advertisements (Newspaper, telephone directory & TV) personal visits and

contacts were used to get the information. In some cases only partial information were

given through telephone enquiries because they were either reluctant or ignorant. Thus it

had to be supplemented by other methods similar as above. Few institutions in some of

the panchayats could not be contacted over by phone and in those cases the details were

collected from panchayat register by personal examination. The location (corporation or

the panchayat), bed strength. the ownership pattern and the type of management were

very important as the second stage of the study was based on it. An effort was made to

gather other information as stated in the previous paragraph to get additional details of the

institutions in the taluk. One institution was not interested in giving any details or in being

part of the study so it was also excluded from the study. One institution being closed

down during the study was also excluded. In some cases several calls had to be made to a

single institution for getting information. In the case of the government institutions the

location and bed strength were available from their respective Directorates. But they

were again contacted over phone to get other inlbrmation. Although the official data on a

few government institutions have stated the availability of in-patient facility, it was later

found out. on personal visits or enquiry, that the in-patient facility was nil or not

is 10

functional due to various reasons. So they had to be excluded from the study.

The areas in the taluk (both corporation and panchayat) were ascertained by collecting the

list of the wards in the corporation and the panchayats. The institutions outside the taluk and the ones with no in-patient facility were excluded from the study.

A pilot study' was done in an allopathic in-patient facility. The first stage of the study was

done between December] 6th 2002 and January IV' 2003.

2.8 Stage-2. Functioning of non-government institutions

Figure-1 provides the schematic description of the selection of institutions for the study:

The in-patient facilities in the taluk are described as those, which exist in the corporation

and panchayat area. This again is distributed as non-government and government sector.

Again, the institutions in different systems of medicine (allopathy, ayurveda and others),

which belong to different sectors, are included. Then the non-government institutions are

classified according to the existing management patterns. Finally the institutions are

classified according to their bed strengths. The details collected from the institutions

during the second stage included:

• Number of doctors, qualification, specialties

• Payment mechanism of doctors

• Institution admissions and annual OP

• Average length of stay of patients

• Average bed occupancy rate

• Facilities available (diagnostic and other services) 11

• Charging/fee schedule for patients

• Staff other than doctors

• Contracting/renting/hiring of hospital and hospitality services

• Number of accident/medico legal cases attended 12

Figure-1. Selection of institutions

In-Patient facilities

Corporation Panchayat

Government Non-government Government Non-government

AL AY 0 AL AY 0 AL AY 0 AL AY 0

P11

Bed Strength

A L-Allopathy, AY-Ayurveda, 0-Others (Homeopathy, Siddha, Naturopathy and

Orthopathy)

S-Sole Proprietorship, T-Trust, C-Charity, P-Partnership, PV-Private Limited Company,

PU-Publie Limited Company

A facility checklist was used to collect information from the institutions. A separate list was prepared for the ayurveda and other systems of medicine for collecting the range of services and facilities available.

The study also included an interview with the staff members and an in-patient exit survey.

The staff members comprised of doctors of different specialties and different categories of nurses. The details collected using an interview schedule included 13

• The reason for choosing to work in a particular institution

• The working hours and their work pattern

• Payment mechanism (used to cross check with the details given by the institution

authorities)

In the case of in-patient exit survey, patients being discharged on a particular day were interviewed in the institution. In some cases patients were interviewed from outside the institution also whenever discharged patients were not available in the institution after several visits. This was done by collecting the phone numbers of patients from the institutions and contacting them afterwards. The interview was again done using an interview schedule. The details collected included

• The illness for which treatment was sought

• The reasons for coming to the particular institution

• The sources of finance for patient getting treated

• The length of stay (to cross check the information given by the authorities)

The data on in-patient and staff interview were analysed using SPSS statistical program.

A pilot study was also done in an ayurveda and allopathic facility. The second stage of the

study was conducted between January 11th, 2002 and March 10th 2003.

Selection of institutions for the second stage

For selecting the sample of institutions, first, the facilities were distributed according to

their location in corporation and panchayat area, non-government and government sector,

allopathy, ayurveda, and other systems of medicine. Then in the case of non-government

institutions, the institutions were divided according to their bed strength and management 14 pattern. The bed strength were divided into six categories: less than or equal to 10, 11-25,

26-50, 51-100, 101-200 and more than 200. This kind of categorization was done to include institutions from different bed strength groups. The management patterns of the non-government institutions were divided into six categories namely sole proprietorship, trust, charity, partnership, private limited company and public limited company. From each group of institutions, one institution was chosen from each set of five institutions. If the total number of institutions were less than five in some cases then also one institution was chosen. In some cases this pattern was not strictly practiced in order to include

certain special categories in the list. In the case of government institutions, it was grouped

according to their bed strength (same as above) and ownership pattern namely center and

state.

2.9. Concepts and definitions

Details concerning the types of non-government institutions were collected from law

books, websites, past studies'2 and personal consultation. This section provides the

description and definition concerning different type of non-government institutions,

measures and indicators used in the study, and physician payment mechanisms.

Sole proprietorship

Institutions in this category are owned by an individual (physician or non physician) and

the owners have unlimited liability.

Trust

Assets belonging to an individual or group are placed in the custody of trustees, who

depending on the type of trust may actually manage them for the benefit of the owners. 15

These institutions get some tax concessions since they can only re deploy their profits and cannot distribute it among partners.

Charity (charitable society)

Those registered under the Travancore—Cochin Literary, Scientific and Charitable

Societies Registration Act, 1955 (Act XII of 1955). The society can be formed by a group of 7 or more persons and it should be for any literary scientific or charitable purpose. Upon dissolution, no member receives profit. None of the members would be liable for any of the liabilities incurred by the society.

Partnership

Those institutions, which have two or more, but fewer than 20 partners. They have unlimited liabilities. Profits are shared between partners.

Private limited Company

Institutions in this category have more than 20 but less than 50 partners. They have

limited liability. Profits are shared with shareholders. The company cannot invite the public to purchase its shares and debentures.

Public limited Company

The minimum number of members required to form a public limited company is 7 and

there is no maximum limit on members. It can raise resources from the public through

issue of shares. The profits are shared with shareholders and they have limited liability.

They need not be listed in stock markets. 16

Admissions

Number of people who got admitted to these inpatient facilities during the year.

Bed occupancy rate

Percentage of beds occupied by patients at the time of the study. The bed occupancy rate

was either taken from the institution record or calculated using the occupancy in a

particular day.

Bed turnover rate

Average number of in-patients per bed during one year.

OP per bed day

Outpatient strength in a day divided by bed strength

Bed utilization rate

Bed turn over rate x length of stay

365

• Bed Nurse ratio

Bed strength divided by number of nurses

Bed Doctor ratio

Bed strength divided by number of doctors

Doctor Nurse ratio

Number of doctors divided by number of nurses 17

Salaried

Health care professionals are paid a fixed amount for predetermined hours of work. The remuneration is fixed according to qualification and years of work. Salary does not depend on the number of patient visits, number of cases, severity of cases etc. The physicians who receive monthly salary or daily wage/daily honorariums are included in this group

Incentive-based

This includes three categories — fee for service, case-based payment and profit sharing.

The physicians who receive a case based payment. fee-for-service, a share of profit or a

combination of these are included in this category.

Fee-for-service. Physicians are paid, according to the number of patient they see, a

percentage of the consultation fee collected from their patients, the consultation fee and

certain amount per patient admitted to the institution by the doctor who are solo

practitioners but attached with an institution.

Case-based. The physicians are paid, a procedure fee, a fixed charge per case, a

percentage of professional charges collected from the patients and a percentage of the total

discharged amount in the case of patients admitted to the institution by the doctor who are

solo practitioners but attached with an institution.

Profit sharing. Owners of sole proprietorship institutions. and partners and shareholders

in the partnership and public/private limited company share the profit.

Mixed group

Physicians receive a combination of salaried and incentive based payment. 18

Chapter 3

Results

This chapter reports the results pertaining to all the stages of the study. A total of 103

institutions (both government and non-government) were included in the first stage while

21 non-government institutions were selected for stage-2.

Table-2. In-patient care institutions in Thirnvananthapuram taluk - ownership,

location, system and bed size

Bed Government Non-government Total

size Corporation Panchayat Corporation 1 Panchayat n= area area area area

AL AY 0 AL AY 0 AL AY 0 AL AY 0 103

< 25 1 - - 2 1 - 20 9 1 9 3 1 47

26 to 100 6 1 2 2 - - 15 3 1 - 1 - 31

101to200 2 I - - - - 6' - - 1 - - 10

> 200 10 1 - - - - 4 - - - - - 15

Total 19 3 2 4 1 - 45 12 2 10 4 1 103

AL-Allopathy, AY— ayurveda, 0 — Others

3.1. Inpatient care institutions in Thiruvananthapuram taluk

Ownership, geographic location, system of medicine and bed size of the institutions

included in this study is given in Table-2. As indicated by Table-2, 79.7% (59 out of 74)

of non-government institutions were located in the corporation area; corporation area also

had 82.8% (24 out of 29) government institutions. Panchayat area had less number of

government and non-government institutions in all systems of medicine. Percentage of 19 non-government institutions was more compared to government in the panchayat area.

74.3% (55 out of 74) of institutions in the non-government sector and 79.3% (23 out of

29) of government institutions provided allopathic care. Also the non-government sector

dominated in all the systems of medicine. 58.1% (43/74) non-government institutions

had bed strength of 25 or less whereas it was only 13.8% (4/29) in the government sector.

Only 5.4% (4/74) of non-government institutions had bed strength more than 200 whereas

it was 37.9 (11/29) in government sector. None of the non-government ayurveda and

other systems of medicine had bed strength more than 100.

There were 10,964 beds in the taluk when beds in all systems of medicine were added up

(Table-3). Non-government-government ratio of beds in the taluk was 1:1.84. Over 90%

(3,495 out of 3,864) of non-government beds were in allopathy. It was 89.04% (6322 out

of 7100) in the case of government sector. 90.4% (3492/3864) of non-government bed

facilities existed in the corporation area. In government sector it was 98.02%

(6960/7100). The panchayat had more number of non-government beds (almost 3 times)

compared to government beds. This was true of all systems of medicine.

Table-3. Distribution of beds in different systems of medicine

Number of Location Government beds Non-government beds

AL AY 0 AL AY 0 beds (n=103)

55 10,452 (95.3) Corporation 6202 558 200 3214 223 20 512 (4.7) Panchayat 120 20 0 281 71

75 10,964 (100) Total 6322 578 200 3495 294

AL-Allopathy, AY — Ayurveda, 0 — others 20

3.2. Types of non-government institutions

The Type of management of the non-government 113 facilities in the taluk can be divided into 6 categories - sole proprietorship, trust, charity, partnership, private and public limited companies. There were 74 non-government institutions. The categories of institutions and the bed size are given in Table-4. A vast majority (58.1%) of non- government institutions had a bed size below 25. There were no charity institutions with more than 25 beds. Out of the 14 partnership institutions, 85.7% had bed strength of 50 or less. 66.7% of the private limited companies had 50 or less number of beds. Both public limited companies had more than 200 beds.

3.3. System of medicine

Nineteen out of 74 non-government institutions practiced non-allopathic system of

medicine (Table-5). Average bed size of sole proprietorship institutions was less than

others except in other systems of medicine. Average bed size was the highest in public

limited company. The bed sizes of trust and partnership institutions were almost similar.

There existed wide variations in the bed strengths of sole proprietorship, trust, partnership

and private limited company. 21

Table 4. Types of non-government institutions and their bed size (n — 74)

Ownership Pattern Bed Strength Total (%)

< 25 26-100 101-200 >200

Sole proprietorship 24 8 1 - 33 (44.6)

Trust 4 1 3 - 8 (10.8)

Charity 8 - - - 8 (10.8)

Partnership 4 9 1 - 14 (18.9)'

Private Limited Company 3 3 1 2 9 (12.2)

Public Limited Company - - - 2 2 (2.7)

Total 43 21 6 4 74 (100)

3.4. Range of specialties

Information concerning the existence of various specialties in the non-government

allopathic institutions are provided in Table-6. The table also includes the specialties

existing in government institutions for comparative purpose. Majority of the institutions

provided general medicine and obstetrics and gynecology specialties. Table-7 brings out

the range of specialties offered in non-government institutions. As it can be seen, public

and private limited institutions offered maximum range of specialties.

Only government ayurvedic institutions had specialty care. Different clinical (12

specialties which can be broadly defined as general medicine, pediatrics, surgery, eye,

maternity, toxicology, geriatrics and infertility exists) and non-clinical (there are about 6

non-clinical specialties which can be defined broadly as pharmacology, basic principles,

pathology and physiology) specialties existed. However, all non-government institutions 22 did not have specialties and catered to all kinds of health problems. Other systems of medicine had no specialty as such.

Table 5. System of medicine practiced by non-government institutions (n = 74)

Management category Number of institutions Average bed size

AL A Y 0 AL AY 0

Sole proprietorship 24 7 2 31.04 12.7 27.5

Charity 7 1 0 42.4 15 0

Trust 7 0 1 66.1 0 20

Partnership 8 6 0 63.1 24.7 0

Private limited co 7 2 0 122.9 21 0

Public limited co 2 0 0 312.5 0 0

AL-Allopathy, AY— Ayurveda, 0 — Others 23

Table- 6. Specialties in government and non-government allopathic institutions

Specialty No. of institutions Non- Government Total government (%) General Medicine 37 6 43 (55) Obstetrics and gynecology 35 5 40 (51) Pediatrics 29 5 34 (44) General surgery 25 6 31 (40) Anesthesia 17 5 22 (28) ENT 19 6 25 (32) Ophthalmology 13 6 19 (24) Orthopedics 14 4 18 (23) Dermatology 15 3 18 (23) Dental 12 5 17 (22) Casualty/emergency services 11 6 17 (22) Radiology 9 5 14 (18) Psychiatry/counseling/psychology 9 4 13 (16.7) Urology 11 I 12 (15) Cardiology 8 3 11 (14) Neurology and neurosurgery 6 2 8 (10.3) Pathology 3 5 8 (10.3) Plastic surgery 7 1 8 (10.3) Cardio thoracic surgery 6 2 8 (10.3) Chest and respiratory medicine 5 3 8 (10.3) Nephrology 5 I 6 (7.7) Physical medicine & Rehab 3 3 6 (7.7) Gastroenterology 2 1 3 (3.8) 24

Table 7. Range, of specialties in non-government and government allopathic

institutions

Average number of Ownership services (range) Non-government Sole Proprietorship 3.75 (1-19) Trust 6.7 (1-16) Charity 4.1 (1-13) Partnership 7.1 (1-19) Private limited company 12.6 (5-21) Public limited company 24.5 (14-35) Government 6.9 (1-29)

3.5. Year of establishment

Although the study included 74 non-government inpatient facilities, information

concerning the year of establishment was not available in 3 institutions. Information

about the other 71 institutions are given in Table-8. More than 50% of the non-

government inpatient care institutions were es tablished during the 1990s.

Table 8. Year of establishment = 71)

Year of establishment Number of institutions (%) 1960 and before 5 (7) 1961-80 11 (15.5) 1981-90 18 (25.4) 1991-2000 31 (43.7) 2001 and above 6 (8.4)

Out of 29 government inpatient care facilities (all systems of medicine) in the taluk

information about the year of establishment could be collected from only 26 institutions.

All these institutions were established before 1990 and IP facility in three institutions

started after 1990. 25

Majority (88%) of government and non-government institutions were functioning in their own premises. Others functioned in rented or leased premises. Those non-government institutions, which worked on rented/leased premises, 75%, belonged to ayurveda and other systems of medicine. None of the facilities in the Panchayat area worked on rented premises. All the government institutions for which information was available were functioning in their own premises.

3.6. Registration status

Sixty-six out of seventy four non-government institutions reported that they had some sort of registration or license either with the corporation or with a panchayat. This was

verified from the corporation and panchayat registers too. Some felt that since the doctors

employed by them were already registered, there was no separate need to register the

institution. Some also reported that they were registered with certain professional

organizations. Some institutions are found to be ignorant about the very process of

registration itself.

3.7. Selection of institutions for second stage

As mentioned earlier, 20% (21 institutions) of the institutions were included for the

second stage of the study. Table-9 describes the selection method adopted. The 20% norm

was enforced on each category of institutions as far as possible but it was waived

wherever there too small number of institutions. Adjustments were made to the selection

to this extent in order to include as much variety of institutions. 26

Table 9. Selection of institutions for the second stage

Location, system of medicine & Total number Number of ownership pattern (%) and institutions selected Non-government allopathic facilities in 45 (43.7) 8 the corporation area Government allopathic facilities in the 19 (18.4) 3 corporation area Non-government allopathic facilities in 10 (9.7) 2 the panchayat area Government allopathic facilities in the 4 (3.9) 1 panchayat area Non-government ayurvedic facilities in 12 (11.7) 1 the corporation area Government ayurvedic facilities in the 3 (2.9) 1 corporation area Non-government ayurvedic facilities in 4 (3.9) 1 the panchayat area Government ayurvedic facilities in the 1 (1) 1 panchayat area Non-government other systems of 2 (2) 2 medicine facilities in the corporation area Government other systems of medicine 2 (2) 1 facilities in the corporation area Non-government other systems of 1 (1) - medicine facilities in the panchayat area Total number of institutions ' 103 21

Two institutions (one non-government and one government) were not willing to participate in the second stage, so they were excluded from the study. There was a change in the management pattern reported over phone in the first stage and when detailed study was done in stage two. Questions regarding quality of services were asked during the in- patient exit survey but could not get reliable answers. Interview of patients inside the institution and some times in front of a staff member could be a reason for it. Some institutions also did not allow interviewing their staff.

Efficiency indicators such as bed occupancy rate, bed turn over rate, bed utilization rate, average length of stay and outpatient strength per bed are given in Table-10. As the table 27 indicates, average bed occupancy rate, average bed turn over rate, length of stay, bed utilization rate and OP per bed day were less in non-government sector when compared to government in all systems of medicine. The range was also too wide for non-government sector. Bed-doctor and bed-nurse ratios are given in Table-11. The doctor nurse ratio is more in the non-government sector. Some of the Ayurveda institutions do not have a special category of staff called nurses.

3.8. Physician payment mechanisms

Details of the payment mechanism of 181 doctors from the non-government facilities

were obtained from the sample of 21 facilities belonging to different systems of medicine.

Out of 181 doctors, 34 belonged to ayurveda and other systems of medicine. The non-

government sector followed different kinds of payment mechanism. It included monthly

salary, daily wage, fee-for-service, case-based-payment, hourly wage, and profit sharing.

All these mechanisms either existed alone or in combination. All the government

institutions follow a fixed monthly salary payment mechanism. Results concerning

physician payment mechanism are provided in Table-12 and Table-13. Physician

payment mechanism was not influenced by bed size because it remained more or less

uniform for all the sizes. 28

Table-10. Efficiency of non-government and government institutions (N = 21)

Alloppyathy Ayurveda Others Efficiency NG NG(range) G (range) G (range) indicators NG(range) G (range) (range) 47.9 75.53 86.7 100 28 65 Average bed occupancy rate(%) (3.93-90) (69.8-80.3) (80-100) (100) (26-30) (65) 20.6 25.8 15.4 43 7.16 17.83 Average bed turn over rate (3.16-42.5) (17.03-3.6) (4.86-5.63) (10.93-5) (6-8.33) (17-83) 5.6 7.25 18.7 33 14.5 34 Average length of stay (no. of days) (4-10) (6-8) (14 -21) (21-45) (14-15) (34) 28.7 59.9 52.3 283 25.5 166 Bed utilization rate (%) (2.4-56.9) (27.9-73.7) (27.9-89.9) (27.9-431) (24.6-31.9) (166) 0.8 2.6 0.37 10.2 0.69 0.79 OP per bed day (0.034-2) (0.12-8.56) (0.03-1.04) (0.43-20) (0.05-1.33) (0.79)

Table 11. Bed doctor, bed nurse and doctor nurse ratio in allopathy

Government (n=4)

Avg Bed Strength Bed Nurse ratio Bed Doctor ratio Doctor Nurse ratio

(range) (range) (range) (range)

281.8 (16-747) 3.5 (1.1-5.3) 6.2 (4-11.1) 0.65 (0.2-1.3)

Non-Government (n=10)

Avg Bed Strength Bed Nurse Ratio Bed Doctor ratio Doctor Nurse ratio

(range) (range) (range) (range)

84.4 (10-350) 4.7 (1.9-15) 6.9 (1.7-23.3) 1.4 (0.2-6) 29

Table 12. Physician payment mechanisms in non-government sector (n = 181)

Payment mechanism Number of doctors

Monthly salary 77 (42.5%) Fee-for-service + Case based 32 (17.7%) Case based payment 17 (9.4%) Daily wage/daily honorarium 15 (8.3%) 10 (5.5%) Profit sharing 9 (5%) Fee-for-service Fee-for-service + daily visit charge 6 (3.3%) Fixed salary + case based 4 (2.2%) Fixed salary + fee-for-service 4 (2.2%) Fee-for-service + hourly wage 2 (1.1%) Fixed salary + fee-for-service + case based 2 (1.1%) Fixed salary + profit sharing 1 (0.6%) Fixed salary + fee-for-service + profit sharing 1 (0.6%) Voluntary 1 (0.6%)

Table 13. Payment mechanisms among doctors in different management patterns

Mixed Total Management pattern Salaried Incentive (%) (%) based (%) (%) 12 (18.8) 64 (100) Sole proprietorship 25 (39.1) 27 (42.1) 5 (19,2) 26 (100) Trust 11 (42.3) 10 (38.5) 2 (16.7) 12 (100) Charity 8 (66.6) 2 (16.7) .. 18 (100) Partnership 10 (55.6) 8 (44.4) 2 (5.6) 36 (100) Private limited company 8 (22.2) 26(72.2) 1(4) 25 (100) Public limited company 15 (60) 9 (36)

More than 50% of the doctors in charitable (66.6%), partnership (55.6%) and public

limited company (60%) institutions are salaried. Thus salaried payment is the highest in

all categories except in private limited companies and sole proprietorship. Out of 181

doctors, 23 worked in facilities located in panchayat areas. Monthly salary (9 doctors) is

again the most important payment mechanism. Fee-for-service (5), case based payment

(3), profit sharing (4) and others (2) are the other mechanisms followed. Mixed pay

patterns is rarely (2/23) seen in the panchayat area. 30

Retired doctors from the medical college and the government service are employed by most of the non-government institutions. It was also applicable to nurses.

3.9. Charging of patients

Some of the non-government allopathic theilities have fixed registration fee and it was different from the consultation fee. Some of the hospitals did not have a registration fee.

Fixed consultation charge existed in all institutions except in one. Different types of

rooms had different fixed charges. In one of the hospitals, doctors' fee and nursing care

charges were also included in the room rent. Although fixed, rates were not publicized in

most cases. Some of the institutions informed that they would tell the amount if the

people asked. Some informed that the rates were publicized but the researcher was not

able to find any publicized rate there.

All except one of the non-government ayurveda and other systems of medicine did not

have a consultation charge but there was a fixed charge for the medicines. In one

institution, there was a fixed consultation charge but people rarely followed it and it was

true in the case of room charges also. In the case of other institutions, room charges,

different for different types, were also fixed. None of the charges were publicized in the

institutions but some of the rates were there in their websites. There were also fixed

charges for laboratory and other tests.

3.10. Facilities available

In addition to the number of specialties, the study also tried to find out the number and

range of facilities available in both government and non-government sectors. The average

number of facilities and its range are given in Table-14. As indicated, non-government

allopathic and non-allopathic institutions had more facilities compared to that of 31 government in the groups where comparison could be made. List of facilities in the

allopathic and other systems of medicine are given in the annexure.

Table 14- Facilities available in government (G) and non-government (NG) sectors

lied strength Number of facilities

Allopathic (n=14) Non-allopathic (n=7) NG G NG G 5 9 (3-12) 6 8.5 (1-16) 4 26-100 19.3 (16-24) - 14 (11-17) 6 101-200 34 20 - - >200 3 I 30 (26-34) - 23 3.11. Contracting out

Contracting out of clinical and non-clinical services existed in the non-government and

government sectors. Canteens worked on a contract basis (some cases to the highest

bidder) in many in-patient facilities in non-government and government institutions.

Authorities provided the menu to the contractor and they had to serve the food at a rate

fixed by the authorities. in some cases, the institution provided water and electricity so

that the contractor served food to the patients at subsidized rates. In some other cases,

items supplied to the kitchen were contracted out. Employees' society ran the canteen in

one case. Security guards cleaners, drivers, medical stores, telephone booths, laundry

work, stitching and rodent system are the other categories that were contracted out.

Lab in some non-government institutions worked in a contract basis and a percentage of

the collection from each case went to the institution. In some other institutions, room

space for ultrasound scan and dentistry was rented out. In yet other cases, the ultrasound

facility worked on a mutually arranged basis where the institution gives space, utilizes the service and gains a percentage of the amount collected. Some institutions/ doctors do not 32 have inpatient facilities and if their patients get admitted to an institution with the facility then the institution with the facility would get the room rent and the nursing care charges.

This is a mutual arrangement between them. In some cases physiotherapists works in a contract basis. They bring their equipments in some cases and in others the institution provides it. Yoga classes are also conducted in a similar manner in some cases. At times consultants are hired from other institutions if needed. The government also gives aid or salary to the staff in the non-government institutions for family welfare programmes. The

Central Government Health Scheme (CGHS) has entered into contract with 6 non-

government modern medicine institutions in the district for provkiing specialized and

general-purpose treatment for the central government health scheme beneficiaries. Three

of those institutions are included in the study.

3.12. Reasons for choosing to work in an institution

Thirty-six doctors and 19 other staff members (12 nurses and 7 others) of the chosen

institutions were interviewed. Eighteen of 36 doctors had an undergraduate degree while

the rest had diploma, post graduation or other higher degrees in addition. Nurses were

either diploma holders, ANMs or with no formal qualification. 47 (85.5%) staff were

involved in IP care, 43 (78.2%) were involved in OP care, 26 (47.3%) were involved in

supervision, 14 (25.5%) involved in office work and 21 (38.2%) were involved in other

activities. Relatively more time was spent on OP care.

Table-15 reports why the stall chose to work in a particular institution. While majority of

those employed in government sector chose to work there because it had higher job

security, those employed in non-government had prestige and good infrastructure in

mind. Some of the non-government staff was employed there because of ownership while

a significant proportion chose non-government sector, as there was no other alternative. 33

Ownership means that the doctor either owned the institution or she/he was a partner or shareholder. The ownership reason was not applicable in the case of nursing staff.

Convenience mostly refers to the nearness to house.

Table 15. Reasons for choosing to work in a particular institution

Reason Government (n= 17) Non—government (n=38) (7.9%) Job security 9 (52.9%) 3 (47.4%) Good infrastructure, prestige 4 (23.5%) 18 Lack of alternatives 3 (17.6%) 9 (23.7%) 12 (31.6%) Ownership - (7.9%) Convenience 3 (17.6%) 3

3.13. Reasons for choosing an institution to seek care

Hundred in-patients (46 males and 54 females) from the sample institutions were

interviewed. 47 of the patients were from the government facilities and rest from non-

government facilities. Among the 100 patients, 71 sought allopathic care, 19 sought

ayurveda and 10 went for other systems of medicine. Over two-third (69 %) was aged

above 31 years while 50 % earned a monthly income of not more than Rs. 500/-. 49% had

high school education.

Reasons for choosing a particular institution for seeking care are provided in Table-16

and Table-17. Special treatment included super specialty services or post partum

sterilization. The reasons cited for choosing a government and a non-government

institution were entirely different. The major health problem being treated in the ayurveda

(non-government and government) institutions are orthopedic problems and among the

patients with orthopedic problems, 91.7% went to ayurvedic institutions. The patients

visited the other systems of medicine and ayurveda as they could not get cured by the

earlier system they followed for treatment. For obstetrics & gynaecology services and

surgical problems, patients visited modern medicine facilities (government and non- 34 government). The non-government sector shows a lead here since some of the institutions selected were exclusive maternity care / surgery facilities. Such institutions in the government sector were not included in the sample. Also more than 80% visited allopathic (government and non-government) facilities for illnesses like hypertension, diabetes, cardiac problems, fever, UTI, asthma, allergy and cough. In some cases the government facilities shows an increase in the number of patient treated in the case of specific diseases like cardiac and neurological problems since there were institutions, which specializes in these problems while it was absent in the non-government sector.

Table 16. Reasons for seeking care from a particular institution (n = 100)

Reason Government Non-government

A NA A NA .. Emergency 2 - 6

Good care 4 5 10 4

Prefer the system/institution for 5 12 1 8 various reasons

Special treatment/facility available 10 - 3 - only here

Doctor/staff/authorities known 2 - 12

Good doctor - 2 10 1

Cheap/free care 6 4 - -

Insured 7 - .. -

Nearness to home 4 2 7

A-allopathy, NA-non-alloputhy 35

Table 17. Choice of institution reported by patients (n=100) for various illnesses

Illness Government Non-government

Allopathy Ayurveda Others Allopathy Ayurveda Others

- - Obstetrics& 1 - - 16

Gynecology 1 1 Hypertention, Diabetics 13 - 1 3 and cardiac problems* - 1 Fever, UT!, Cough 5 - 7 - Asthma& allergy 6 - 2 4 - - - Surgical reasons** 1 - - 9 - Orthopedic reasons*** 1 7 - - 4 2 Neurological reasons # 5 3 - 1 1 2 Others ii# 0 2 2 1 I 6 Total 32 12 5 41 7

The total does not add to 100 as multiple illness were reported

* Includes cardiac surgeries ** Excludes cardiac and O&G surgeries

*** Spontilosis, body pain, arthritis, hand pain, leg fracture, leg problem, joint pain, disc

problem, sprain, backache, achilitis (only one fracture case was there and it was treated

in allopathic facility)

# Paralysis, Paraplegia, nerve weakness, Parkinsonism, dizziness

## Body swelling, diarrhea, stomachache, psoriasis, eyesight problem, jaundice, general

weakness. 36

3.14. Sources of financing care

An overwhelming majority of patients used past savings for seeking inpatient care from

both government and non-government institutions (Table-18). However, the proportion

was much higher among those who sought care from non-government sector. Other

sources were borrowings with and without interest, insurance/reimbursement and distress

selling ofassets.

Table 18. Sources of financing (n = 97)

Source Government Non-government

Past savings 22 (48.9%) 43 (82.7%)

Borrowing from friends/relatives (no interest) 13 (28.9%) 7 (13.5%)

Borrowing from others with interest 5 (11.1%) 5 ((9.6%)

Selling of assets 1 (2.2%) -

Insurance, social security 6 (13.3%) -

Office reimbursement 4 (8.9%) 3 (5.8%) 37

Chapter 4

Analysis and conclusions

4.1. Existence of non-government sector

The present study found that 71.8% of institutions and 35.2% of beds were in the non- government sector. The figures for India are 60% and 40% and for Kerala are 82.3% and

57.7%.6 In other words, the proportion of institutions in the taluk is higher than the national average but the proportion of beds is lower than the national and state averages.

It means that non-government sector in the taluk are smaller in size and 58.1% of them had a bed size of 25 or less. This goes with the results obtained by other studies in India 1. 14 too 13' Nevertheless, comparison of number of institutions could be misleading because this study has not included the outpatient facilities in the taluk and hence, the proportions are not strictly comparable.

Earlier studies have shown that majority of small hospitals were proprietary and the big hospitals were mostly trusts or corporate.' Declining employment opportunities in the government sector, high salaries for better experienced in the private sector, and easy availability of loans for setting up institutions were cited as reasons for establishing small

institutions.5 Many doctors who retire from the government service also start institutions

for self-employment.

The present study showed that 50% of institutions in the taluk with less than 50 beds

belong to sole proprietorship or charity group. Overall, 44.6% of the institutions belong to sole proprietorship. These institutions are dominated by individual or family controlled enterprises. Allopathic, ayurveda and other systems of medicine institutions established

between 1961 and 1980 mostly had sole proprietorship, partnership or trusts and were mostly owned by doctors. 38

There is also a declining interest in philanthropy by profession as can be seen from the fact that only 22% are trusts or charities (Table-4). 50% of the existing charitable institutions were established on or before 1960. Also it is found that the institutions established on or before 1960 were charitable institutions run by religious or social groups and practiced allopathy.

In the taluk, there is a clear concentration of non-government in-patient facilities in the corporation area. In present study found that 79.9% of non-government institutions and

90.4% of beds existed in the corporation area. This is the pattern observed in many

countries and states too.14. 15' 16, 12' 18

However, in this study, non-government sector also had relatively more proportion

(72.7%) of beds in panchayat areas too compared to government sector. Bed population

ratio was 1.13 per 1,000 population in the case of non-government sector and was 0.42 in

the case of government institutions. High utilization of non-government hospitals in rural

Kerala was reported by other studies.5 Patients with high socio-economic status seem to

have a preference for private hospitals indicating that the hospital sector is moving

towards a two-tiered system with access to the private sector based upon ability to pay 19.20

In Kerala, the government sector has only 25% of its beds located in rural areas while

private sector has 53% of their beds in rural areas. The private sector has greater number

of hospitals and since a large percentage of them has in-patient facilities (45.66% 1995

survey) and ensures that adequate in-patient facilities are available in rural areas. While

the government deploys 64% of their health staff in urban areas, the private sector

deploys 50% of their staff in rural areas.15' 21 Even while the private sector has, to some 39 extent, corrected the inequity in government provided health services, they too appear to have avoided some of the underserved areas.15. 21

The period from the early 1960's to the mid 1980's was characterized by great growth and expansion of the government health services. The number of beds and institutions increased sharply. The major growth phase of facilities in the government sector was before 1986, after which it slowed considerably.8 Non-government in-patient care institutions in the taluk grew after the 1970s, especially during the 1990s (52.2% of institutions established after 1990). All the non-government institutions established before

1960 were charitable institutions run by religious or social groups and practiced allopathic care.

Experiences in countries such as Sri Lanka, Thailand and Papua New Guinea have shown

that the private health sector is expanding at the expense and detriment of public health

care services, whereby government health care facilities are deprived of specialists whose

training has been through public resources. Rapid private growth and income differential

between the public and private sectors serve to pull both doctors and nurses into the

private sector. 20

88% of non-government facilities functioned in their own premises. This has been shown

by other studies as wel1.1' 12 In other words, rented premise is not an attractive option for

the health care institutions, especially the inpatient facilities.

4.2 Specialties offered

The results of this study indicated that general medicine, obstetrics and gynaecology,

pediatrics and general surgery were the widely offered specialties in the non-government

institutions. This is true in other states of India as well as has been suggested in the earlier 40

studies.I2' 22' 23 Specialties like cardiology and neurology were found to be less in number.

Anesthesia existed in 30.9 % of the institutions. There were non-governmental

institutions exclusively meant for surgery, maternity and pediatrics, infertility and eye.

The road traffic accident related trauma is on the increase in the state but

casualty/emergency services are available in only 17 institutions. In those 17, i 1 are in

the private sector. Orthopedics specialty is present in 25.5% of the non-government

institutions. Most of the non-government allopathic institutions did not admit accident or

medico legal cases. It was also true for many of the government and non-government

institutions practicing ayurveda or other systems of medicine. Nevertheless, only certain

special kind of accident cases comes to ayurveda and other systems of medicine. Most of

the non-government institutions (allopathic), which has surgery specialty, performed both

minor and major surgery. Ayurvedic institutions (both government and non-government)

too performed minor surgeries. Ayurvedic physicians performed them. Dental specialty

and physiotherapy existed in some of the ayurvedic institutions.

Making available a wide range services within one institution can be a non-price strategy

used by the hospitals to attract patients in a competitive market situation. Majority of

institutions with higher bed strength or the public and private limited companies offered a

larger range of specialties. Existence of wide range of facilities in bigger in-patient

facilities can also be a non-price tactics.

4.3 Mixed practice

Some of the other system of medicine facilities had doctors with allopathic or ayurvedic

degree. Ayurveda institutions (both government and non government) had doctors,

facilities and therapies of allopathic systems of medicine. Some of the non-government

ayurvedic institutions had allopathy consultants. Some of the other systems of medicine- 41 trained physicians also practiced ayurveda (they have learned it by tradition) in non- government institution. None of the non-government allopathic institutions employed doctors trained in other systems of medicine whereas this is common in other parts of

India.9

4.4 Registration status

The present study showed that 66 out of 74 non-government institutions had some kind of

registration. An earlier study showed that 50% of the health care institutions are

unregistered.24 There exists a rule to register the health care institutions with the

respective panchayat or corporation area for the non-government sector by paying a

certain fee fixed according to the bed strength and renews it every year. But this is not

strictly enforced. Some of the panchayats kept record of the hospitals in their area and

registration has been done but majority of the panchayats in the taluk did not have any

details about the institutions under them. Thus the panchayati raj institutions do not seem

to have any link with the non-government hospital sector.

4.5 Efficiency indicators

Average length of stay was found to be high in government allopathic sector and

government and non-government ayurvedic sector. It was low in the non-government

allopathic sector. Bed occupancy rate too was low in the non-government institutions and

showed a larger variation across institutions. It varied between 4% and 90%. Similar

trend of lower occupancy rate was observed by another study in Thiruvananthapuram 19 city. While ti ts i obvious that the institutions with a low occupancy rate of 4% may not

survive long, low average occupancy rate in general makes one believe that the non-

government sector breaks even faster than the optimum utilization would suggest. In

other words, patients who accessed the non-government sector paid much higher price 42 than the full employment level. Length of stay, bed occupancy rate and bed utilization rate were high in the ayurvedic institutions.

4.6 Physician payment mechanism

The doctor's availability was more than the nurses in many of the cases. For modern medicine facilities, doctors are more than nurses in institutions with bed strength of 50 or less. Overemphasis on outpatients when compared to in-patients can be a possible reason for it. This was verified from the fact that they had higher OP per bed day.

Visiting consultants constituted a major component. of the health care professionals; majority of them were anesthetists. Visiting consultants visited the hospital on a particular day or whenever they were called. There was yet another category of visiting consultants who were solo practitioners and were 'attached' to a particular institution. They came to the institution only when their private patients required in-patient care.

In the present study, 75.7% (28/37) of the junior doctors and those with undergraduate degree, 29.4% (5/17) of the general surgery specialists, '58.3% (14/24) of obstetrics and gynecologists, 35.7% (5/14) of pediatricians. 36.4% (4/11) of general physicians and

physicians working in a small institution (with single or few specialties) received fixed

monthly salary.

A combination of fee-for-service and case-based mechanism existed in the case of gynecology and surgery specialties. Case-based payment was made to visiting consultants, anesthetists (who come on call), and doctors attached to a particular hospital and brings in in-patients. Fee-for-service also existed for the visiting consultants and for

those who 'came' with the patients. Profit sharing was the mode of payment in the case of 43

partners, owners and shareholders. Daily rates were applicable to some of the junior

doctors and specialists.

Over 70 % of doctors received a single type of payment. Monthly salary, daily rate, and

profit sharing constituted 88 % of all payments made to the doctors in ayurveda and other

systems of medicine. Salary and incentive-based payments shared the payments equally.

Doctors also shared the receipts towards the use of diagnostic facilities. Mixed payments

were non-existent in ayurvedic sector. The present study found that many ayurvedic

practitioners working in the government service practiced in other non-government health

facilities, which in fact goes against the existing rule in Kerala. Physicians employed in

the public sector in Kerala are not allowed to work for private sector facilities but are

allowed to do consultancy practice after office hours at the residence.

The most dominant provider payment system in India is fee-for-service.? Salary, fee-for-

service, case-based payment, daily charge, flat rate, capitation and global budget are

different kinds of payment mechanisms that exist in the world.25 A combination of the

payment mechanisms is also seen in many countries.26

Outpatient charges in most of the non-government allopathic institutions were found to be

similar. Hence, non-government institutions appear to be using non-price strategies to raise their revenues and profits. The Central Government Health Scheme (CGHS) clearance for institutions is seen as a part of the competitive strategy, where institutions compete for institutional payers of care. The non-government institutions also told that they would give concession to some poor patients. 44

4.7 Contracting out

There is growing interest in low and middle-income countries in the scope for increasing the efficiency of publicly—financed health services by contracting with private-sector enterprises to run whole facilities, provide particular services, or supply non-clinical services such as catering and cleaning.27 Different services that are contracted out are clinical services (hospital facility, primary care facility, specific specialty or primary care service, specific diagnostic and surgical procedures, public health activity and laboratory

tests), non-clinical services (pharmacy, catering, laundry, cleaning, maintenance of

equipment and building and security) and functions (personnel recruitment and

employment, management, printing / photocopying, building design and construction,

computing and purchasing).

The extent of contracting between the public sector and the commercial sector is

relatively limited. Contracting for clinical services was particularly limited.28 South

Africa has several rural hospitals owned and managed by for-profit companies and

contracted by the province to provide a district hospital service. It also exists in

Zimbabwe and Papua New Guinea to an extent. Contracting for non-clinical services is 28 more common. It exists in Mexico, Bombay, Thailand, and Papua New Guinea. In

India, the CGI-IS and Employee State Insurance Scheme (ESIS) contract with hospitals to

provide health to the insured at a fixed schedule of charges or, in the case of ESIS and a

trust hospital whose facilities are entirely at the disposal of ESIS, a global budget.`'

Some form of contracting existed in both government and non-government sectors in the

study area too. While contracting was restricted to non-clinical services in government

institutions, it was both clinical and non-clinical in the case of non-government sector. 45

Canteen, laboratory, kitchen inputs, security guards, cleaners, drivers, medical stores, telephone booths, laundry work, stitching and rodent system were some of the categories where contracting existed.

4.8 Conclusions

The present study tried to provide an in-patient health facility scape of the

Thiruvananthapuram taluk. Although the study included both government and non- government sectors, the focus of the study was on non-government institutions. The study brought out the existence of a mix of non-government institutions in the taluk. Although allopathic system was the dominant one, non-government sector also practiced ayurveda, sidha, and unclassified system of medicine. Sole proprietorship was the dominant pattern

of ownership within the non-government sector while public and private limited

institutions offering maximum range of specialties. The study found that there existed a

high concentration of inpatient facilities in corporation area. Both government and non-

government institutions existed in limited number in panchayat area but the non-

government sector had a dominant presence there.,

Efficiency indicators were better in government institutions. Government institutions had

higher bed occupancy, turnover and average length of stay. Lower occupancy rate in non-

government institutions is a matter of concern in the sense that they may be fixing a price

much higher than the full employment rate. Single physician payment mechanism existed

in most of the non-government institutions with salary and incentive-based mechanisms

existing in almost equal proportion.

Panchayati raj institutions did not have any knowledge and control over the existence of

non-government inpatient care institutions in their own areas even though some of the

non-government institutions were registered with them. 46

The present study may have a weakness in its potentiality for generalization. But then, the strength of the work, obviously, is derived from its attempt to probe deep into the varied and complex aspects of the non-government health sector, generally conceived as difficult to be explored exhaustively. 47

References

I. Mahapatra P. et al. Structure and Dynamics of Private Health Sector- Implications for

India's Health Policy, Institute of Health Systems, Hyderabad, 2002.

2. Bhat R. Characteristics of Private Medical Practice in India: A Provider Perspective,

Health Policy and Planning, 14 (1): 26-37,0UP, 1999.

3. Government of India. National Health Policy 2002, Ministry of Health and Family

Welfare, New Delhi, 2002.

4.Bhat R. Regulation of the Private Health Sector in India, International Journal of Health

Planning and Management, 1996.

5.Baru RV. Private health care in India: Social characteristics and trends, Sage

Publication India Private Limited, New Delhi, 1998.

6. Varatharajan D etal. Idle capacity in resource strapped government hospitals in Kerala,

Achutha Menon Centre for Health Science Studies, Trivandrum, 2002.

7. Kutty V. R, Panikkar P. G. K. Impact of Fiscal Crisis on Government Health

Expenditure in Kerala, Research Report, Achutha Menon Centre for Health Science

Studies, Trivandrum, 1995.

8. Kutty V.R. Historical Analysis of the Development of Health Care Facilities in Kerala

State, India, Health Policy and Planning, 15 (1): 103-109, OUP, 2000.

9. Nandraj S and Duggal R. Physical Standards in the Private Health Sector: A Case

Study of Rural Maharashtra, Centre for Enquiry into Health and Allied Themes, 1997,

10. Government of Kerala. Panchayat level Statistics- Thiruvananthapuram district,

Department of Economics and Statistics, 1996.

11. Government of Kerala. Government Allopathic Medical Institutions — Kerala 2001

Thiruvaananthpuram: Directorate of Health Services, Health Information cell, 2001. 48

12. Muraleedharan V. R. Characteristics and Structure of Private Hospital Sector in Urban

India: A Study of Madras City, Small Applid Research Paper 5, Partnerships for I lealth

Reform, Abt Associates Inc, Bethesda, Maryland, March 1999.

13. Peters D.H etal. Better Health Systems for India's Poor Findings, Analysis, and

Options, Human Development Network, Health, Nutrition, and Population Series, The

World Bank Washington D.C, 2002.

14. M E Khan(ed). Paying for India's health care, Sage Publications, New Delhi, 1993.

15. Kannan K.P et.al. Health and development in rural Kerala, Kerala Sastra Sahitya

Parishad, 1991

16. Nittayaramphong S. and V. Tangcharoensathien. Thailand: Private Health Care Out of

Control, Ministry of Public Health, Bangkok, 1992

17. Munishi G.K., A. Yasbek and D. Lioneth,. Private Sector Delivery in Health Care in

Tanzania, Major Applied Research Paper No. 14, Health Financing and Sustainability

Project, 1995.

18. Duggal R. Where are we today, Unhealthy Trends-A Symposium on the State of Our

Public Health System, Seminar, 2000.

19. Homan R.K. and Thankappan K. R. An Examination of Public and Private Sector

I lealth Care Providers in Thiruvananthapuram District, Kerala, Centre for Development

Studies, Thiruvananthapuram, 1997.

20. Paula A. Tibandebage et.al. Private Sector Development: The Case of Private Health

Facilities, Economic and Social Research Foundation Discussion Paper No. 26, Dar Es

Salaam, Tanzania, 2001.

21. Sadanandan R. Government health Services in Kerala Who Benefits?, Economic and

Political Weekly, Aug11, 2001. 49

22. Berman P. Understanding the Supply Side: A Conceptual Framework for Describing and Analyzing the Provision of Health Care Services With an Application to Egypt,

International Health Systems Group, Harvard School of Public I lealth, July 1999.

23. Kavadi S.N. (ed). Health Resources, Investment and Expenditure- A Study ofllealth

Providers in a District in India, Foundation for research in community health Pune/

Mumbai, 1999.

24.Government of Kerala. Report on The Survey of Private Medical Institutions in

Kerala, 1995, Department of Economics and Statistics, Thiruvananthapuram, 1996.

25. WHO Evaluation of recent changes in the financing of health services. WHO,

Geneva, 1993.

26. Chawla M et.al. Paying the Physician: Review of Different Methods, Data for

Decision-Making Project, DP11-1, Harvard school of public health, Boston Massachusetts,

1997.

27. McPake and Ngalande Banda. Contracting Out of Health Services in Developing

Countries, Health Policy and Planning, 9 (1):25-30,1994

28. Bhatia M. A Study of Contracting Out of Dietary Services by Public Hospitals in

Bombay, Department of Health Services Studies, Tata Institute of Social Sciences,

Bombay, 1995.

29. Bennet S, Mc Pake B, Mills A (ed). Private Health Providers in Developing Countries

London, Zed Books, 1997. 50

Annexures

1. Details from Stays 2 of the study

Facilities available

Table 1: Facilities available in allopathic institutions

Facilities Number of institutions (n=14) Diagnostic services Laboratory 13 Foetal monitor / foetoscope 9 CT scan 2 MRI scan Treadmill 2 Angiogram 1 Blood bank 2 Uteroscopy 1 Echocardiography 3 EEG 3 Gastroscopy 1 Radio diagnosis 3 Endoscopy 1 Ultrasound scan 8 X-ray 9 ECG 12 Cardiac monitor 7 Special services Operation theatre 12 ICU / CCU 7 Labour room 9 Incubator 24-hour casualty 9 Physiotherapy unit 8 Immunization 11 Baby friendly 3 Post operative ward 8 Photo therapy 2 Ventilator 4 Clinical psychology unit Mobile unit 1 New born resuscitator Key hole surgery 1 Autoclave sterilization 13 Other services Generator 11 Elevator Canteen 51

Telephone / telephone booth 14 Hostel / quarters 10 Laundry 7 Ambulance / vehicle 9 Medical store Waiting shed 1 Night shelter 1 Paramedical institute i 3 Medical records 4 Mobile / mortuary Library Incinerator Pharmacy 13 Kitchen

The availability of continuous power supply is very important for running a hospital. 11

of the 14 (79%) hospitals reported that they have a generator. Communication and

transport is a prerequisite for the functioning of a hospital. All the hospitals have

telephone facility and 9 hospitals have either an ambulance or a vehicle available.

All the nine hospitals that have an O&G specialty have a labor room and foetal monitor or

foetoscope.

3 hospitals in the sample are declared as baby-friendly. Baby friendly hospital initiative is

a WHO / UNICEF sponsored global programme launched in 1992 for promoting,

protecting and supporting exclusive breast-feeding. The programme is hospital based and

aims at training of health personnel for properly motivating and correctly initiating

mothers into breast-feeding. Kerala is the first State in India to get the 'baby-friendly

State' status--which means that more than 80 per cent of the maternity hospitals here

'protect, promote and support breastfeeding', discourage use of baby foods and support a

breast milk-friendly atmosphere. Kerala is said to be the only State in the world to go

baby-friendly. In Kerala, UNICEF sponsored the programme from 1993. It can be said as

a method to assess the quality of care. 52

Nursing and other paramedical courses are conducted by many of the non-government institutions. So the non-government institutions are not only engaged in curative but also academic activities.

Pharmacy and lab exists in almost all the institutions. Immunisation is conducted in 8 of the non-government facilities. Post partum sterilization is done in 7 of the institutions.

Some of the Christian institutions do not do PPS as it is against their preaching. A family planning unit works in a non-government institution under the grant-in-aid programme of the government. 53

Table 2: Facilities available in ayurveda and other systems of medicine

Facilities Number of institution (n=7) Diagnostic services Lab 4 X-ray 2 ECG Special facilities Panchakarma theatre Physiotherapy unit 2 Psychology unit Autoclave sterilization Theatre Examination rooms 3 Casualty / 24 hour service Modern dental unit Other services Pharmacy Canteen 6 Botanical garden 4 Medicine Manufacturing unit Medical shop_ Generator 2 Hostel / quarters 3 Paramedical course 2 Laundry 5 Telephone Ambulance Elevator Provision store / cooperative society Kitchen

Telephone facility is available in all the institutions. Botanical garden and medicine

manufacturing unit is available in 57.1 % Of the institutions. This exists because different

physicians use different kinds of medicines to cure their patients. Canteen or kitchen is

available since patients are supposed to be in a specific diet during their treatment period.

The presence of facilities like lab, X-ray and ECG shows that the other systems of

medicine have also started using modern diagnostic facilities. 54

2. Checklists and Interview Schedules

2.a. Telephonic Survey —Check List

1. Name:

Address: Tel:

2. Taluk: 3. Location a. Corporation b. Panchayat (Name) 4. System of Medicine

a. Allopathic b. Ayurvedic c. Homeopathic d. Sidha e. Unani f. Others (specify)

5. Does your hospital have IP?

a. Yes b. Bed Strength c. No

6. Ownership:

a. Government: Central State Local body

b. Non-Government

Sole Proprietorship Partnership Private limited company Public limited company Trust Cooperative Society Charitable Society Others (please specify)

7. Ownership of premises:

a. Own premise b. Rented/leased c. License d. Mortgage e. Others (please specify)

8. Year of establishment: 9. Registered: a. Yes b. No 10. If yes, with whom? 11. Specialties and facilities available 12. No. of hospitals within 1-5 km radius:

a. Within 1 km b. Within 5 km

Remarks 55

2.b In-Patient Facility Check List

1. Name of the hospital:

2. Address:

Telephone No:

3. Located in

a) Panchayat Area b) Corporation Area

4. Year of Establishment

5. Total land area of the hospital:

6. Total building space (in sq. ft.):

7. Ownership of premises

a) Owned b) Rent/Lease c) License d) Mortgage

e) Others (Please specify)

8. Registration Status

a) Registered b) Unregistered

9. Registering body

a) Corporation b) Panchayat c) Any other body (please specify)

10. System of Medicine

a) Allopathic b) Ayurvedic c) Homeopathic d) Sidha e) Unani

0 Others (Please Specify)

11. Ownership:

a) Government

i. Centre ii State iii Local body iv Others (Please Specify) 56

b) Non-government

ii. Sole Proprietorship

iii. Partnership

iv. Private Limited Company

v. Public Limited Company

vi. Trust vii. Charitable a. society h. trust

viii. Others (Please specify)

12. Departments, doctors (regular & visiting), OP, lP Doctors' Strength S No Department / Yes-1 OP-1 Specialty No-2 IP-2 IP+OP-3 Regular Visiting 1. General Medicine 2. General Surgery 3. Obstetrics & Gynecology 4. Pediatrics 5. Anesthesia 6. Dermatology 7. Psychiatry 8. ENT 9. Orthopedics 10. Ophthalmology II. Physiotherapy 12. Cardiology 13. Neurology 14. Nephrology 15. Plastic surgery 16. Cancer 17. Oncology 18. Cardio Thoracic Surgery 19. Vascular surgery 20. Neuro Surgery 21. Urology 22. Endocrinology 23. Gastroenterology: Medical Surgical 24. Burns 57

25. Cosmetic Surgery 26. Rehabilitation 27. Dental: General Special 28. Pathology 29. Hematology 30. Rhumatology 31. Microbiology 32. Radiology 33. Traumatology 34. Tuberculosis and Chest Disease 35. Family Welfare 36. Neonatology 37. Others (Specify) 38. Geriatrics 39. Emergency services 40. Diabetology 41. RMO 42. Junior doctors 43. Total 13. Names, qualification, specialization, hours/day worked and days/week worked by

doctors and the physician payment mechanism (Monthly salary —1, Fee for service

- 2, Profit sharing - 3, Per day charges - 4, Others (please specify) — 8)

Permanent doctors

SL Name of the Qualification Specialisation Hours/day Days/week Payment No doctor mechanism

Visiting doctors

ISL Name Qualificatio Specialisation 1P ( 1 ), OP Hours/ Days/ Payment NO n (2), Both day week mechanism (3)

14. Total Bed strength:

15. Hospital admissions during 2002 (Jan-Dec):

16. Accident cases:

17. Medico-legal cases: 58

18. Surgeries performed:

a) Minor

b) Major

19. Total inpatient load during 2002 (Jan-Dec):

20. Average length of stay of patients (In days as informed)

a) Surgical Patients

b) Medical

c) Obstetric

d) Gynaecology

e) Paediatric

0 Others

21. Average bed occupancy rate (%)

22. Number of discharges yesterday:

23. Availability of Facilities

SI No Facilities No. of units Year of Establishment 1. Pharmacy 2. Laboratory 3. Operation Theatre 4. Intensive Care Unit ICCU Surgical ICU Cardio Thoracic ICU Burns Pediatric ICU 5. Labour Room 6. Foetal Monitor 7. New born resuscitator 8. Incubator 9. X Ray 10. Ultrasound Scan 11. CT Scanner 12. MRI Scanner 13. ECG 14. EEG 59

15. Treadmill Analysis 16. Echo Cardiography 17. Gastroscopy 18. Endoscopy 19. Ventilator 20. Angiogram 21. Cardiac Monitor 22. Post Operative Ward 23. Emergency Department Casualty (24Hrs) 24. Clinical Psychology Unit 25. Physiotherapy Unit 26. Dialysis 27. Radio Diagnosis 28. Immunization 29. Autoclave (sterilization) 30. Generator 31. Elevator 32. Canteen 33. Laundry 34. Ambulance 35. Hostel/quarters 36. Telephone booth 37. Paramedical institute 38. Blood Bank 39. Mortuary (mobile) 40. Others (please specify)

24. Does your hospital have a published fixed fee schedule for Yes/No Publicized Yes/No :_. No Categories 1. Room and board charges 2. Laboratory Procedures 3. Consultations 4. Any package deal/health scheme vis-a-vis institutions 5. Package deal/scheme for other patients/clients

25. Who are involved in billing/charging of patients?

a) Hospital manager

b) Other hospital staff (nurses, clerk, etc.)

c) Doctors

d) Others (Please Specify) 26. What role does each play?

27. Other hospital staff than doctors Number S NO Designation

28. Is there any contracting, hiring in, or renting out of the hospital and hospitality

services? If yes, please specify.

Remarks 61

2.b.1 Specialty and Facility List of Ayurveda Health Care Institutions

Departments, Doctors (regular and visiting). OP, IP

SL NO Department/ Specialty Yes-1 OP-1 Doctors Strength No-2 IP-2 Regular Visiting IP+OP-3 1. Kaya Chikilsa (G. Medicine) 2. Salya Chikilsa (Surgery) 3. Salakyam Chikilsa (-Eye) 4. Udvangam (ENT) 5. Dravyagunavijhanan (Pharmacology) Non Clinical 6. BhaishajyakalpanalRasashast hra Pharmacy (NC) 7. Prasoothithanthram (Gynecology, Maternity) 8. Basic Principles (NC) 9. Swasthavridham (SPM) Yoga, Naturopathy 10. Kaumaravhruthyam 11. Agathathanthram (Toxicology) 12. Panchakarmam 13. Manasikarogachikilsa 14. Nidhanam (Pathology) 15. Kriyashareerain (Phisiology NC) 16. Rachanasharecram (Construction) 17. Jhara (Geriatrics) 18. Vrushyam (Aphrodisaic) 19. RMO 20. Junior doctors Total

*1 62 availability of Facilities

L NO Facilities No. of Units Year of Establishment I) X Ray 2) Laboratory 3) Physiotherapy Unit 4) Music Therapy Unit 5) Labour room 6) Examination rooms 7) Other rooms 8) Theatres 9) Panchakarma Theatre 10) Pharmacy I I) Botanical Garden 12) Observation room 13) New born resuscitator 14) Casualty 15) Clinical Psychology Unit 16) Ambulance 17) Autoclave (sterilization 18) Generator 19) Elevator 20) Canteen 21) Laundry 22) Hostel/quarters 23) Paramedical Institute 24) Telephone Booth 25) Others (please specify) 62

;vailability of Facilities

, L NO Facilities No. of Units Year of Establishment 1) X Ray 2) Laboratory 3) Physiotherapy Unit 4) Music Therapy Unit 5) Labour room 6) Examination rooms 7) Other rooms 8) Theatres 9) Panchakarma Theatre 10) Pharmacy I I) Botanical Garden 12) Observation room 13) New born resuscitator 14) Casualty 15) Clinical Psychology Unit 16) Ambulance 17) Autoclave (sterilization 18) Generator 19) Elevator 20) Canteen 21) Laundry 22) Hostel/quarters 23) Paramedical Institute 24) Telephone Booth 25) Others (please specify) 63

2.c. In-Patient Exit Survey

1. Name of the hospital: Date: 2, Name of the patient: 3. Sex: 4. Age: 5. Education (years of schooling): 6. Occupation: 7. Approx family income per month: 8. How far is your house from this hospital? 9. Transport used to reach the hospital: 10. Illness for which treatment is sought: 11. Reasons for choosing this hospital a) Free/cheap care b) Good care c) No other hospital in this area d) Hospital existing but too expensive e) Hospital existing but not good t) The type of service sought is available only here g) Came because the doctor I looked for is employed here h) Others (please specify) 2. Who referred you to this hospital a. Came on my own b. Relative suggested this hospital c. Referred by a private practitioner d. Referred by a government doctor e. Others (specify) I iow many days have you stayed? Who fixed the duration of your stay? a. Doctor b. Other staff c. My choice d. Relative e. Others (specify) 64

15. Materials/services received from the hospital a. Drugs b. Injections c. Supplies d. X ray e. Scans f. Others (specify) 16. Materials/services sought from outside a. Drugs b. Injections c. Supplies d. X ray e. Scans 17. Were you able to pay for all the materials/services? a. Yes b. No 18. If yes, how much did you spend on them? 19. What is the source of payment for the treatment/purchase of materials/service? a. Past Savings b. Relatives/Friends (no interest) c. Loan/Borrowing (with interest) d. Selling of assets e. Insurance f. Office reimbursement g. Others (Specify) 20. Where do you go for health care normally?

Illness Institution Public or private Common Emergency Antenatal care Delivery Preventive care (vaccination)

Others

21. Have you ever come here before for treatment a. Yes b.no 22. If yes, how many times and for what ailments? 23. How frequently did the doctor visit you a) Very often b) Only when needed c) not at all 24. How much time did the doctor spend with you each time a) less than 5 minutes b) upto 15 minutes c) more than 15 minutes 25. Doctors behaviour towards you a. Always good b. Somewhat good c. Not-so-good d. Bad 26. Behaviour of other staff a. Always good b. Somewhat good c. Not-so-good d. Bad 27. Would you refer someone else to this hospital? MARKS 66

2.d. Staff Interview

1. Name of the hospital: Date: 2. Name of the Staff: 3. Position 4. Qualification 5. Years of service in this hospital: 6. Employment Status a. Permanent b. Visiting c. Contract d. Casual e. Others (Specify) 7. Nature of Work

Activity Time allotted (Hrs/week) Patients seen/day Inpatient care Outpatient care Supervision Office work Others

8. Do you think your present job suits your qualification?

a. Yes b. No

9. If no, what kind of responsibility will suit you the most?

10. Reason for choosing to work in this hospital?

11. flow are you paid? a. Monthly Salary b. Fee-for-service c. Profit sharing d. Per day charges e. Others (Please Specify) Remarks