FOR R 31; •:13E STUOIEI Sree Clitr I , • Z. Nor Taedica I S.' 7 Nt': THIAIJVAIIANT0APUBOA
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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.