Technical due diligence District : Kalahandi ()

1 DISCLAIMER

1. The purpose of this document is to provide interested persons with information that may be useful to them in the preparation and submission of their bids for the projects. The document includes statements which reflect various assumptions and assessments arrived at by the Government of and IFC for the projects. Such assumptions, assessments and statements do not purport to contain all the information that such persons may require. The information contained in the document may not be appropriate for all persons and it is not possible for the Government of Odisha and IFC, its employees, its consultants or advisors to consider the investment objectives, financial situation and particular needs of each party who reads the document. The assumptions, assessments, statements and information contained in the document may not be complete, accurate, adequate or correct. Each person should, therefore, conduct its own investigations and analysis and should check the accuracy, adequacy, correctness, reliability and completeness of the assumptions, assessments, statements and information contained in the document and obtain independent advice from appropriate sources. The Government of Odisha and IFC accept no responsibility for the accuracy or otherwise for any interpretation expressed in the document.

2. The Government of Odisha and IFC, its consultants, employees and advisors make no representation or warranty and will have no liability to any person under any law, statute, rules or regulations or tort, or otherwise for any loss, damage, cost or expense which may arise from or be incurred or suffered on account of anything contained in the document or otherwise, including the accuracy, adequacy, correctness, completeness or reliability of the document and any assessment, assumption, statement or information contained in the document or deemed to form part of the document or arising from it in any way.

3. The Government of Odisha and IFC, its consultants, employees and advisors also accept no liability of any nature, whether resulting from negligence or otherwise, howsoever caused arising from reliance of any person upon the content of this document.

4. The Government of Odisha and/or IFC may, in its absolute discretion, update, amend or supplement the information, assessment or assumptions contained in this document.

5. The issue of this document does not imply that the Government of Odisha is bound to award the projects to any bidder.

2 SUMMARY

• The district of Kalahandi has 65 government health care facilities and 12 private hospitals with a bed strength of 744 beds only. • Among the other public health facilities CHC’s share the highest percentage of OP consultations (61%), whereas DHH share the highest IP admissions (56%). • DHH has a startling occupancy rate of 328 as per the HMIS data provided by the facility. The BOR of DHH is calculated against the sanctioned beds only, whereas during onsite assessment , around 40- 50 floor beds were noticed at the facility especially in Medicine ward. • OP to IP conversion has been higher than industry standards at DHH (51%). • Considering data for FY 2015-16, surgeries performed at the district are majorly minor surgeries(89%).Private hospitals account for only 9% of the total surgeries conducted in the district. • For FY 2015-16 data indicate over utilization of OT at DHH with more than 18 surgeries per OT per day. The OT register data revealed these were mostly minor surgeries. • For FY 2015-16 , the share of C-sections in the district was 11%. 67% of these C-sections were carried out at DHH. ▪ For FY2015-16, overall lab tests accounts for majority (95%) of total diagnostics at the studied facilities, whereas X-ray and USG constitute of only 2% and 1% of the diagnostics. ▪ It can be inferred that at secondary care level only 21% of the existing demand is being met for OPD and 31% for IPD. ▪ Considering the WHO norm of 3.5 beds per 1000 population, the district has a shortfall of 5292beds (i.e. a gap of 88% beds).

3 SUMMARY

▪ Considering the WHO norm of 1 doctor per 1000 population, the district has a shortfall of 1599 doctors. ▪ Considering the WHO norm of 2 nurses per 1000 population, the district has a shortfall of 3411 nurses. ▪ For gaps under service facilities, when compared with IPHS for district hospitals, major gaps are in the areas of Diagnostics and Specialty OPDs. ▪ The general population survey response indicate people visit healthcare facility,everytime someone is sick in the family,73% of the respondents opined that they prefer private healthcare facility. ▪ While reputation of the doctor and proximity of the facility were the main reason for choosing private health care facility. Large infrastructure and service availibility all under one roof were the main reason for choosing government healthcare facility. ▪ Of the total inpatient survey respondents at DHH , 56% had to purchase medicines from external pharmacy. ▪ While Majority of the respondents depend on savings for their healthcare spending only 18% of the patients surveyed had health insurance as a primary source of health related costs. ▪ All the surveyed physicians indicated that patients from the district travel to other districts / cities for availing tertiary level healthcare, of which majority ailments pertain to cardiology and urology followed by oncology.

4 SECTION 1: PROJECT SNAPSHOT

5 PROJECT BACKGROUND

▪ As a part of a broader health sector enhancement program, the Government of Odisha (GoO), wants to strengthen and enlarge the private health sector facilities and promote the participation of quality private health providers across all the 30 districts in the state to enhance the health infrastructure in the state by structuring and implementing the rollout of low cost hospitals across the state in a PPP model which will offer decent quality care at affordable prices.

▪ The project will look at the entire state as a whole and based on detailed financial, fiscal, logistics and operational due diligence a network will be developed with recommendations on the number, size, type and locations of the hospitals.

6 SECTION 2: METHODOLOGY FOR TECHNICAL AND MARKET DUE DILIGENCE

7 TECHNICAL DUE DILIGENCE

Demand & Supply Assessment Paying Capacity Assessment

• Assessment of district level demand for health services, • Assessment of patient profile – APL through primary research such as surveys, interviews of & BPL patient/ doctor and review of available clinical data at • Prevailing market rates, CGHS and hospitals and MIS data from NHM various industry empanelled rates • No. of patients referred outside •Assessment of existing clinical services, infrastructure Odisha for secondary and high and resources secondary care • Additional sources such as Centre & • Capacity Utilisation Assessment of existing capacity State’s healthcare support schemes including OPD and IPD Numbers, bed occupancy, average – RSBY, BKKY, ESIS etc length of stay, OT utilisation, major and minor surgeries and other clinical procedures

Assessment of Gap in Health Facilities with respect to existing and future demand

8 METHODOLOGY

•Secondary data survey: based on information available over public domain •Primary data survey: Onsite healthcare facility assessment, data collection from government offices, interviews with hospital administrators, clinicians and Step 1 general population

•Preliminary assessment to cover the functional feasibility of developing a Step 2 hospital along with the mapping of road and rail connectivity.

•Correlation of primary and secondary data that is already collected from districts and state •Data analysis the overall state and each of the 30 districts. Step 3 •Presentation on the findings of the market assessment to Government of Odisha.

9 SECTION 3: DISTRICT PROFILE

10 DEMOGRAPHIC PROFILE

Particulars Odisha Kalahandi

Total Population 4,19,74,218 1,576,869

Urban 16.6% population 7.74% Decadal population 14.05% 18.07% growth rate Mean household 4.35 size 3.93

BPL households* 44,08,070 163,695

BPL Population* 1,91,75,105 643,302

BPL % 46% 41%

• Kalahandi is the 27th district in terms of size and 12th in terms of population. • Kalahandi is the 12th urbanized district in state having only 12.34 percent of its Bhawanipatna (Kalahandi population living in urban areas. District HQ Town) • Kalahandi has 15th rank in terms of sex ratio in the state.

Source : 11 Census of India – 2011, Odisha * RSBY status 2015-16, Odisha HEALTH INDICATORS

Key Health Indicators District Odisha India

297

230

178

75 79 56 59 55 39 44 30 31 20.219.822.2 6.7 8.2 7.1

Maternal Mortality Neonatal Morality Infant Mortality Under 5 Mortality Crude Birth Rate Crude Death Rate Ratio* Rate Rate Rate

Source : Annual Health Survey Report 2011-12

12 Causes of deaths (Infants & Child)

Kalahandi - Causes of Infant & Child Deaths - Odisha - kalahandi - Causes of Infant & Child Deaths against Total Reported Infant & Child Deaths-Apr'15 to Mar'16 Apr'15 to Mar'16

Measles 0 Sepsis Asphyxia 4.1% 10.3% Diarrhoea 2 LBW Others 18.3% Sepsis 44 52.8%

Fever 63

Pneumonia Pneumonia 90 8.4%

Asphyxia 110 Diarrhoea Low Birth Weight (LBW) 196 0.2% Others (for age upto 4 weeks of Fever related 243 5.9% birth) Others (for 1 month to 5 years) 322

Total 1070 Source : HMIS Data Analysis 2015-16, Kalahandi

13 Causes of deaths (above 6 years of age)

Causes of deaths (above 6 yrs of age) Apr'2015-March'16 Odisha - kalahandi - Cause of deaths 6 yrs & above against 15-55 Above total reported deaths 6 yrs & above - Apr'15 to Mar'16 Causes 6-14 yrs yrs. 55yrs Total HIV/AIDS - 3 1 4 Respiratory Other fever Malaria 9 7 3 19 Diseases (Other Related Animal Bites & Stings 6 24 10 40 than TB) 6.9% 1.5% Diarrhoeal Diseases 1 13 64 78 Heart Disease/ Tuberculosis Malaria Hypertension HIV/AIDS Tuberculosis 1 55 34 90 1.2% 0.2% related 0.1% Respiratory Diarrhoeal 8.1% Diseases(other than TB) 4 39 71 114 Diseases Neurological Disease Trauma/Accidents/ Burn 1.0% including Cases 7 99 32 138 strokes Suicide 1 68 75 144 2.3% Neurological Disease Trauma/Acciden ts/ Burn Cases including strokes 3 48 123 174 1.8% Known Acute Disease 5 104 192 301 Other fever Related 41 263 218 522 Suicide 1.9% Heart Disease/ Hypertension related 9 251 353 613 Animal Bites & Known Chronic Disease 23 320 1,069 1,412 Stings Causes not 0.5% Causes not known 107 946 2,900 3,953 known Known Chronic Known Acute Total Deaths 217 2240 5145 7602 52.0% Disease Disease 18.6% 4.0%

Source : HMIS Data Analysis 2015-16,Kalahandi

14 SECTION 4: SUPPLY ASSESSMENT

15 BEDS AVAILABILITY

Number of Facility type Number of beds facilities District Headquarters Hospital 1 165 Sub-divisional hospitals 1 55 Govt. & Private beds availability in Community Health Centers 16 242 district Primary Health Centers & IDH 45 0 Other hospitals / Area 2 12 Hospital Private Hospitals 12 232 Private Beds Total 77 706 33%

Bed category at DHH Sanctioned beds Functional beds Private beds 0 10 Public General ward beds 165 165 Beds 67% Day care beds 0 0 Emergency beds 0 0 ICU/MICU/SICU 0 6 NRC 0 10 SNCU 0 12 Floor beds 0 0 Total 165 203

Source: Primary data from DHH & Pvt. hospital & Secondary data from ▪ None of the PHCs have any functional beds NHM and DHS Odisha

16 ABOUT DISTRICT HEADQUARTERS HOSPITAL,KALAHANDI

Total number of Sanctioned 165 beds Functional 203 Service specialties Internal medicine, General surgery, Gynecology and obstetrics, Neonatology, Pediatrics, Orthopedics, Ophthalmology, ENT Dentistry, TB & Chest, Emergency Diagnostic X-ray, USG,CT-Scan, ECG, facilities TMT, Holter monitor, Endoscopy, A-scan, Audiometry,Laboratory Operating rooms 2 major OT, 4 labour tables and Labour Established in the year 1910, DHH Kalahandi is the most tables renowned and preferred healthcare facility of the district. Unlike other district hospitals it provides all the major Other clinical Blood bank, Pharmacy, clinical services and diagnostic facilities. facilities Physiotherapy, Speech therapy In adherence to Kayakalapa Guideline, To promote cleanliness, hygiene and Infection Control Practices in public Outsourced Laundry, Dietary, Biomedical healthcare facilities, DHH Kalahandi was runners up securing Support facilities waste management, nd 2 highest mark in the external asessment Security, Housekeeping

17 Major Private Healthcare Facilities

Private Facilities Beds Sardar Rajas Medical College & Hospital, Jering Bahawanipatna (Closed down, permission not granted by MCI) 350

Modern Medical Nursing Home,Dharamagarh 15

Maa Health Home, Palace Garden, Kalahandi 12

Balaji Nursing Home, Bhanjapatna,Kalahandi 24

Shree Jagannath Netralaya, Bhawanipatna,kalahandi 12

18 OPD Consultation & IPD Admission

OPD Consultation IPD Admission 350,000 100,000 300,000 80,000 250,000 200,000 60,000 150,000 40,000 100,000 20,000 50,000 0 0 Pvt. Pvt. Pvt.Life Pvt. Life DHH SDH CHC Balaji DHH SDH CHC Balaji Hosp.1worth Hosp.2 Hosp.1worth Hosp.2 2013-14 75,041 8,727 40448 419 822 2013-14 149,337 36,841 286506 11,234 5,219 2014-15 84,929 11,416 41,902 467 924 2014-15 175,004 39,737 315,109 14,553 5,893 2015-16 68,089 9,185 43,167 588 1,014 2015-16 134,213 54,983 326,905 13,261 6,197 ▪ OPD consultations have consistently increased over the years at SDH and CHC. Facility wise share of OPDs during Facility Wise Share of IPD during ▪ During FY 2015-16, per day OP FY 2014-15 FY 2015-26 consultations at DHH was 447 and 183 at Pvt.Hosp. Pvt.Hosp. SDH, whereas on an average per day Pvt.Hosp. 2 2 1 OPD per CHC was 68. Pvt.Hosp. 1% 1% 1 0% ▪ OP consultations at Pvt.Hosp.1 and 3% DHH CHC Pvt.Hosp.2 for FY 2015-16 was 44 and 25% 35% 20 respectively. ▪ IP admissions have consistently increased SDH DHH over the years at the CHC’s, with on an 56% CHC 10% average 8 IP admisiions per day per CHC 61% SDH in the FY 2015-16. IP admissions per day 8% at DHH was 187 and at SDH was 25. ▪ CHC’s in the district share the highest percentage of OP consultations (61%) whereas DHH share the highest percentage IP admissions (56%) among the studied facilities in the district. Source: Primary data from DHH & Pvt hospital & Secondary data from NHM and 19 DHS Odisha BED UTILIZATION

OPD to IPD Conversion ▪ OP to IP conversion has been higher than industry standards at all the public health facilities, however at 2013-14 2014-15 2015-16 DHH it has been significantly higher compared to other public health facilities. 50%49%51% ▪ It is to be noted that although OP consultations at 29% 24% Pvt.Hosp.2 hospital has been low in comparison to the 17% 16% public health facilities, it still has a higher OP to IP 14%13%13% 16%16% conversion. As opined by hospital manager of 4% 4% 3% Pvt.Hosp.2, patient flow to Pvt.Hosp.2 are majorly Pvt. Pvt. surgical interventions. . DHH SDH CHC LifeHosp.1 worth Hosp.2Balaji ▪ OP to IP conversion and BOR of Pvt.Hosp.1 is less in comparison to the other studied facilities, since the Bed Occupancy Rate (BOR) hospital IP services were temporarily shut down by 327.9% SPCB authority due to pending BMW clearances.

▪ DHH has a startling occupancy rate of 328 as per the HMIS data provided by the facility. The BOR of DHH is calculated against the sanctioned beds only, whereas during onsite assessment , around 40- 50 floor beds were noticed at the facility especially in Medicine ward. 40.5% 21.5% ▪ As opined by ADMO (Med.), DHH is the first Pvt. Pvt. preference of patients due to availability of secondary care services. DHH LifeHosp.1 worth Hosp.2Balaji Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM and DHS Odisha

20 GENERAL SURGERIES

Categorization of General Surgeries Facility Name Major Minor TOTAL during FY 2015-16 Major 11% DHH 1,987 12,127 14,114

SDH 95 1,769 1,864 Minor CHC 188 8,280 8,468 89%

Pvt.Hosp.1 346 579 925

Pvt.Hosp.2 137 186 323 ▪ Considering data for FY 2015-16 Surgeries performed at the district are majorly minor Facility wise Major & Minor Surgeries during surgeries. FY 2015-16 Major Minor ▪ For the FY 2015-16, of all the surgeries performed at DHH, only 14% comprise of major 12,127 surgeries.

8,280 ▪ Of the total surgeries for FY 2015-16 , 55% of the surgeries was conducted at DHH, however 86% of these surgeries were minor surgeries. 1,987 1,769 95 188 346 579 137 186 ▪ Private hospitals together accounts for only 5% of Pvt. Pvt. the total surgeries in the FY 2015-16 Hosp.1 Hosp.2 DHH SDH CHC Life worth Balaji Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM and DHS Odisha

21 OT UTILIZATION

Procedure per Name of Number of Total number Procedures per Number of OT Surgeries per surgeon per Facility surgeon of procedures day in the facility OT per day day DHH 12 16,709 55.7 4.6 3 18.6 SDH 2 1,957 6.5 3.3 2 3.3 CHC 17 8,607 28.7 1.7 17 1.7 Pvt.Hosp.1 2 1,218 4.1 2.0 2 2.0 Pvt.Hosp.2 2 364 1.2 0.6 2 0.6

▪ Data indicate over utilization of OT at DHH with 18.6 IPD to Surgery Conversion during FY 2015-16 surgeries per OT per day. However these are mostly minor surgeries. 207% ▪ The IP to surgery conversion at Pvt.Hosp.1 is highest. Overload of surgical cases at DHH, explains the patient preference for surgery and referrals from DHH t o Pvt.Hosp.1.

36% . 25% 21% 20%

Pvt. Pvt. DHH SDH CHC LifeHosp.1 worth Hosp.2Balaji Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM and DHS Odisha

22 INSTITUTIONAL DELIVERIES

2013-14 2014-15 2015-16 Trend of Institutional Deliveries Name of Facility Normal C - Normal C - Normal C - Delivery Section Delivery Section Delivery Section 19,525 18,865 DHH 6,527 1,274 7,319 1,454 5,496 1,189 16,562 SDH 1,469 316 900 76 913 93 CHC 9,662 194 8,633 54 8,177 139 Pvt.Hosp.1 0 0 141 205 186 293 Pvt.Hosp.2 52 31 46 37 35 41 2013-14 2014-15 20152014-15-16 Sub Total 17,710 1,815 17,039 1,826 14,807 1,755

▪ Institutional deliveries in the district show a slight Category of Institutional deliveries decreasing trend (3%) over the years at the studied during FY 2015-16 facilities , as opined by the hospital manager the increase of institutional deliveries at PHC’s is one reason for the same. C - Section 11% ▪ In 2015–16, DHH performed 18 deliveries per day (@10normal and 3 C-section). Normal Delivery ▪ 67 % of the total C-sections during FY 2015-16 has been 89% carried out at DHH .

Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM and DHS Odisha

23 DIAGNOSTICS PROCEDURES

Diagnostic Facility Wise SHare of diagnostic tests X Ray USG ECG CT Scan Lab Tests Test during FY 2015-16 Balaji Pvt.Hosp.1 1% DHH 5,382 3,219 5,546 678 286,245 5%

SDH NA NA NA 0 12,494 CHC 30% CHC NA NA NA 0 146,781 DHH Pvt.Hosp.1 2,358 3,218 438 0 16,237 61% Pvt.Hosp.2 1,418 0 495 0 4,985 SDH 3% Total 9,158 6,437 6,479 678 466,742 ▪ Overall Lab tests accounts for majority (95%) of total diagnostics. Facility Wise Diagnostic Tests during FY 2015-16 ▪ X-ray and USG constitute of only 2% and 1% of the total 103,780 diagnostic procedures conducted at the district which is far below industry standards.

▪ Data indicate majority of the diagnostic procedures are conducted at DHH (61%).

14,339 14,517 5,490 ▪ CT Scan facility in the district is available only at DHH and account for 1% of the total diagnostic procedure. Pvt. Pvt. DHH CHC ShubhamHosp.1 Hosp.2Padhi

Source: Primary data from DHH & Pvt. hospital & Secondary data from NHM and DHS Odisha 24 ECONOMIC SEGMENT & MODE OF PAYMENT

Economic Segment of Patients

DHH Pvt.Hosp.1 Pvt.Hosp.2

BPL (Below BPL (Below BPL (Below poverty line) poverty line) poverty line) 10% APL - Low APL - Low 10% APL - Low 40% 15% 20% 15% 25% Income Income Income APL - Middle APL - Middle 25% APL - Middle 40% 25% 25% income income 50% income APL - High APL - High APL - High income income income

Mode of Payment by Patients to the Hospital

DHH Pvt.Hosp.1 Pvt.Hosp.2 OSTF BKKY 4% RSBY 6% Free 10% 15%

Cash Cash Cash 100% 65% 100%

Note: estimations given above are based on discussion with ADMO Medical and Hospital Manager

25 SECTION 5: CATCHMENT AREA & REFERRALS

26 CATCHMENT OF DHH

Distanc Catchment Name of the Population e from Type block HQT Primary Bhawanipatna 192,115 - Junagarah 195,248 27 Golamunda 129,499 30 Narala 120,992 33 Keshinga 137,416 35 Dharamgarah 139,359 47 Secondary Madanpurram 102,112 57 pur Lanjigarh 114,767 60 Kalampur 60,075 60 Kokasara 119,304 62 Karlamunda 57,418 70 Thuamul 77,840 75 rampur Jayapatna 130,724 79 TOTAL 1,576,869

27 SOURCE OF PATIENT INFLOW

Source of Patient Inflow

DHH Pvt.Hosp.1

From within the 5% From within the district town district town 10% 40% 35% From the district From the district 60% 50% other than the other than the district town district town Other districts Other districts

Pvt.Hosp.2

0% From within the district town 40% From the district 60% other than the district town Other districts

Source: estimations given above are based on discussion with ADMO Medical and Hospital Manager

28 POINTS OF REFERRAL

29 Top specialties of referral from DHH to other district

Specialty Kalahandi Top 5 specialities for which patients are referred (Monthly) Cardiology 40 18%

Orthopedics 25 11% 11% 9% 9% 8% 9% Top 5 Neurology 25 7% 7% 5% 5% specialities Gynaecology and 20 obstetrics

General Surgery 20 Cancer

Urology/Nephrology 18 Others*

Neurology y

Cardiology

Paediatrics

Orthopedics

Gastro medicine

Gastro enterology/surgery 15 obstetrics

General Surgery General

General/Internal

Gynaecology and Gynaecology Urology/Nephrolog Other Paediatrics 15 enterology/surgery specialities Top 5 specialities General/Internal medicine 10

Cancer 10 ▪ Top 5 specialties of referrals accounts close to 60% of total referrals.

Others 20 ▪ * Others include: Cardiac surgery, Radiation oncology, Medical Oncology, Total (per month) 218 Surgical Oncology

Source: Interviews from ADMO (Med.), Specialist Physicians and General Physicians.

30 CONNECTIVITY & TRANSPORT

▪ Nearest railway station : Kesinga is the gateway of Kalahandi for rail connectivity. It is directly linked with most of the major cities in India, such as , Delhi, Chennai, Kolkata, Bangalore, Hyderabad, Ranchi, Vishakhapatnam, Raipur, Nagpur ,Ahmadabad.

▪ Road ways: National Highway 201 and 217 pass through Kalahandi. Regular buses are available to Bhubaneswar,,Raipur,Visakhapatnam, and from Kalahandi.

▪ Airport : The nearest airport is in Raipur (200–250 km).

▪ Nearest government referral centre: VSS Medical College Burla (229 km).

Bhawanipatna( HQ Town)

31 SECTION 6: DEMAND-SUPPLY-GAP ASSESSMENT

32 DEMAND - OPD and IPD

▪ Out Patients: As per NSSO 60th round data, the estimates of spells of ailment in Odisha population and percentage of the spells of aliment seeking non-institutional treatment i.e., ambulatory care, applied to the catchment population gives estimates of OP demand in the population. The PAP (proportion of ailing person) per 1000 population in 15 days is 77 for Odisha and spells of ailments treated during 15 days is 76%.

▪ Percentage of specialty mix for OPD is derived from morbidity rate of NSSO data 2004-05, 60th Round, increased by a factor of 1.5 to develop a conservative estimate of patient need.

▪ Further the OP estimates has been extrapolated to include the load of estimated pregnant women in a population, to cover ANC visits as OPD in health facilities.

▪ In patient: For the FY 2015-16, OP to IP conversion rate for 30 DHHs in Odisha has been 15%. Hence for the calculation purpose OP to IP conversion rate is taken on an average to be at 15%.

▪ Diagnostics: Diagnostics demand is extrapolated as per industry standards.

▪ Population: Projected population for 2016 has been considered for estimation of OPD and IPD demand

▪ * Other specialties include: Skin & VD, Psychiatry and Dental

33 Demand – Supply – Gap of OPD consultations

Department/ Estimated % Estimated Actual Estimated Gap assessment of OPD specialty mix Specialties of OPD demand Supply Gap Estimated Demand Actual Suppy Gen Med 22 571,768 121,542 450,226

OBG 14 363,852 73,054 290,798 Gen Med

Pediatrics 12 311,873 63,893 247,980 OBG

Gen. Surgery 11 285,884 60,253 225,631 Paediatrics

Orthopedic 9 233,905 49,549 184,356 Gen. Surgery

ENT 7 181,926 36,427 145,499 Orthopaedic

Ophthalmology 7 181,926 36,427 145,499 ENT Others 18 467,810 94,413 373,397 Opthalmology specialties Others specialties TOTAL 100% 2,598,946 535,559 2,063,387

Total OPD Gap 79%

Source : -NSSO 60th Round data 34 -Journal: the cost of universal healthcare in India – A model based estimate, 2012 Demand – Supply – Gap of IPD admissions

Estimated IPD Gap assessment of IPD specialty mix Department/ demand (@ Actual Estimated Specialties 15% OP-IP Supply Gap Estimated Demand Actual Supply conversion) Gen Med 85,765 26,947 58,818 Gen Med

OBG 54,578 16,902 37,676 OBG

Pediatrics 46,781 14,553 32,228 Paediatrics Gen. Surgery 42,883 13,449 29,434 Gen. Surgery Orthopedic 35,086 11,518 23,568 Orthopaedic ENT 27,289 8,431 18,858 ENT Ophthalmology 27,289 8,431 18,858 Others Opthalmology 70,172 21,813 48,358 specialties Others specialties TOTAL 389,842 122,043 267,799

Total IPD Gap 69%

Source : -NSSO 60th Round data 35 -Journal: the cost of universal healthcare in India – A model based estimate, 2012 Demand – Supply – Gap of Diagnostics (OPD+IPD)

Key Demand OPD Demand IPD Total Total Actual diagnostics Estimated Estimated Total % of Estimated Total % of Estimated Supply services Demand Gap OPD Demand IPD Demand

X Ray 15% 389,842 50% 194,921 584,763 9,158 575,605

USG 20% 519,789 35% 136,445 656,234 6,437 649,797

ECG 10% 259,895 60% 233,905 493,800 6,479 487,321

CT Scan 2% 51,979 5% 19,492 71,471 678 70,793

Lab Tests (number of 60% 1,559,367* 100% 389,842** 1,949,209 466,742 1,482,467 patients)

* Considering industry standards 60% of OPD patients undergo at least 2 tests per patient. Hence, demand number of OPD lab tests would be 3,118,734 tests.

** Considering industry standards 100% of IPD patients undergo at least 5 lab tests per patient. Hence, demand number of IPD lab test would be 1,949,210

36 GAP - HOSPITAL BEDS

Hospital beds available in the district

Primary Community Sub district District Other Private Total Bed health health centers Hospital hospital Hospital Hospital strength centers & IDH 53 7 0 01 3 21 0 beds 242 beds 55 beds 165 beds 12 beds 232 beds 744

Gap in bed availibility The district of Kalahandi has 65 public 12 private health care facilities with a 5272 bed strength of beds only.. 6000 Considering the WHO norm of 3.5 beds 5000 per 1000 population, the district with a 4000 population of 17,24,582 falls short of 3000 706 beds 5292 (i.e. a gap of 88% beds). 2000 1000 0 Beds available Beds required as per WHO norm * Source : Bed Strength, DHS Odisha and Clinical Establishment, DMET Odisha

37 GAP – DOCTORS AND NURSES

Gap in doctors availibility Gap in nurses availibility 3449 1725

1800 3500 1600 3000 1400 1200 2500 1000 2000 800 126 600 1500 400 1000 38 200 500 0 Doctors available Doctors required as 0 per WHO norm Nurses available Nurses required

▪ There are 193 sanctioned positions for doctors, of ▪ As per primary and secondary data collected There are which 67 positions are vacant. only 38 nurses posted in the district. (4 nursing sister and 32 staff nurse, 2 Asst Matron). ▪ Considering the WHO norm of 1 doctor per 1000 population, the district has a shortfall of 1599 doctors ▪ Considering the WHO norm of 2 nurses per 1000 population, the district has a shortfall of 3411nurses.

* Source : Staff position list received from DHH and nursing staff * Source : District wise Incumbency list , DHS Odisha list from directorate of nursing, Odisha.

38 SERVICE AVAILIBILITY AND GAPS

Clinical Facility Diagnostic Facility Name of facility IPHS Requirement Available Name of facility IPHS Available Requirement 500 M.A X-ray machine 1 0 General OPD 1 1 300 M.A. X-ray machine 1 1 Speciality OPD 8-10 8 100 M.A. X-ray machine 1 0 60 M.A. X-ray machine (Mobile) 1 1 Major OT 2 1 Dental X-ray machine 1 1 Emergency OT 1 0 USG with colour doppler 3 1 Ophthalmology/ ENT OT 1 0 ECG computerized 1 1 Minor OT 1 0 ECG ordinary 2 1 (non- Gyneaecology OT 1 1 functional) Labour Table 11 4 TMT 1 0 Pharmacy 1 1 A Scan 1 0 Blood Bank 1 1 B Scan 1 0 Ambulance (BLS) 1 2 Audiometry 1 0 PFT 1 0 Bronchoscope 1 0 When compared with IPHS for district Haematology lab 1 1 hospitals, major gaps are in the areas of Biochemistry lab 1 1 Diagnostics and Specialty OPDs Microbiology lab 1 0 Histopathology lab 1 0 Immunology and Serology lab 1 0 Source : IPHS for District Hospital, Equipment norms 101 – 200 bedded

39 SECTION 7: FINDINGS OF GENERAL POPULATION SURVEY

40 INCOME AND OCCUPATION

Occupation of the respondents Source of health related costs 25% 83% 20% 18% 15% 13%

5% 3% 3%

18%

0% 0%

From savings Loan from Sold assets Health insurance family/friends

Annual family income of the respondents 73% ▪ Majority of the respondents were Housewife followed by people in service with an annual income not more than 2,00,000. 20% 8% 0% 0% 0% ▪ Only 18% of the patients surveyed had health insurance as a primary source of health related costs, which indicates lack of awareness in insurance coverage.

41 HEALTH SEEKING BEHAVIOUR

Do you visit a doctor / health facility whenever Why, Not always? someone is sick in your family? 67% 70%

30% 25%

8%

The doctor/hospital is Visiting a The clinical condition Yes always Not always far from my residence doctor/hospital is is always not that expensive serious

Have you consulted /visited any other doctor What is the type of healthcare facility that you /hospital before coming to this hospital,in this had visited before coming to this hospital? instance and for this ailment

83% Yes 24%

17% No 0% 0% 76% A private A private A local govt. District practitioner hospital hospital hospital

The survey response indicates that most of the people visit health care facility every time when someone is sick & first they consult with the doctors of local Govt Hospital

42 HEALTH SEEKING BEHAVIOUR

Reason for choosing a hospital Govt. hospital Pvt. Physician clinic Pvt. Hospital

100% 100%

50%

33%

17%

0% 0% 0% 0% 0% 0% 0%

My Preferred doctor I have been visiting the The facility is large and most The facility is proximate to practices there facility for a long time services offered under one my residence roof

▪ Preference for doctors are the main reason for choosing private practitioners & private healthcare facility. Large infrastructure & service availability are the main reason for choosing Govt hospital.

43 VISITING EXTERNAL FACILITIES

Did you have to visit any other hospital/diagnostic center Did you have to buy any medicine from an external for any diagnostic test? pharmacy?

81% 56%

44%

19% 19%

Yes No I was not prescribed Yes No

Tests that has been performed from other hospital/diagnostic centres

40% ▪ Only 19% of the respondents at DHH, had visited external diagnostic centre for blood test ,& CT Scan

20% 20% 20% ▪ 56% of respondents had to purchase medicines from external pharmacy due to unavailability of the required medications.

CT Scan Dengue Malaria Blood Sugar

44 REGULAR MEDICATION BEHAVIOUR

Does any member of your family take Common specialities of consultation regular medications? 33% 67%

16% 11% 9% 7% 7% 4% 4% 33% 2% 2% 2% 2%

Yes No

▪ The findings indicate a high prevalence of chronic Conditions for which patients take regular medications diseases requiring continued treatment, with gastric problem, diabetes, orthopedic, hypertensions being the 45% total condition for which people take regular 36% medications.

9% 9% ▪ Majority of the respondents replied they have consulted health care facilities majorly for general medicine ailments.

45 IP ADMISSIONS There was atleast one hospital admission in Specialty of admission at hospital the family in the last one year 50% 60%

17% 17% 17%

40%

obstetrics

neonataology Paediatricsand

Yes No General Surgery

Gynaecology and General Medicine

Place of admission Frequency of hospital visit before this admission 100% 64%

32%

4% 0% 0%

Government hospital Private hospital This is the first 2-6 visits 7-12 visits >12 visits

The survey response indicates that there has been atleast of the 47% of respondents who got admitted atleast once in last one year & chose a government hospital majorly for general medicine ailment. 96 % of population visit hospital at least once in two months.

46 SECTION 8: FINDINGS OF OUTPATIENT AND INPATIENT SURVEY

47 Specialty of the ailment of admission Amount spent on visit to the hospital

30% 30% 139

20% 20%

33 32

2 0 0

Registration Consultation Diagnostic Medicines Any minor Travel to tests porcedure health facility General Medicine General Surgery Orthopedics/joint Gynaecology and replacement obstetrics Average (Rs)

Specialty of consultation Amount spent during admission 33% 100%

20% 13% 7% 7% 7% 7% 7% 0% 0% 0% 0% 0%

▪ Majority of inpatient respondents at DHH were admitted for general medicine followed by general surgery. Majority of OP respondents had consulted for general medicine.

▪ Patients tend to spend mostly on medicine & diagnostic tests,. This indicates that people are aware & ready to purchase healthcare if services are available. ▪ Mostly the amount spent The amount spent during this admission is l The average amount spent during an inpatient admission was found Rs 5713 /-(In this amount informal charges are included among which there are two high informal charge payments of Rs 12000 and Rs 15000 (as per the inpatient survey)).

48 SECTION 9: FINDINGS OF PHYSICIAN SURVEY

49 COMMON SPECIALITIES OF CONSULTATION BY GENERAL PHYSICIAN

COMMON SPECIALITIES OF CONSULTATION BY GENERAL PHYSICIAN

20% 20%

16%

8% 8% 8%

4% 4% 4% 4% 4%

0%

50 ECONOMIC AND GEOGRAPHIC STRATIFICATION OF PATIENTS

GENERAL PHYSICIAN RESPONSE SPECILAIST PHYSICIAN RESPONSE

Economic class of patients Economic class of patients 66% 44% 44%

31%

12%

3%

Upper economic class Middle economic class Low economic class Upper economic class Middle economic class Low economic class

Geographic classification of patients Geographic classification of patients 57% 40% 34%

26% 27%

16%

From within the town/city From the district other From adjacent districts From within the From the district other From adjacent districts than the town/city town/city than the town/city

51 REASON FOR REFERRAL

Reasons to refer a patient to a particular hospital

General Physician Specialist physician

33%

27% 27% 27% 27%

13% 13% 13% 13%

7%

0% 0%

Your professional Low pricing of Availability of Availability of Good infrastructure Good clinical serice affiliation with the services/price known/reputed comprehensive and high end facilities quality hospital/referral fee discounts to your physicians in the treatment facilities from the hospital patients hospital and capability to handle complications

52 SPECIALITIES OF CARE FOR WHICH PATEINT TRAVEL TO OTHER CITIES SPECIALITIES OF CARE FOR WHICH PATEINT TRAVEL TO OTHER CITIES

19%

15% 13% 12% 12%

8% 6% 6% 6% 4%

The above are averages of the responses from both general and specialist physicians. All the surveyed physicians indicated that patients from the district go to other districts / cities for availing tertiary level healthcare, of which majority ailments pertain to cardiology and nephrology followed by cancer & Orthopedic.

53 SPECIALTIES THAT A NEW HOSPITAL SHOULD FOCUS

SPECIALTIES THAT A NEW HOSPITAL SHOULD FOCUS

General Physician Specialist Physician

25%

21% 21%

19% 19% 19%

14% 14% 13%

7% 7% 7% 7% 6%

0% 0%

Cardiology / Neurology / Gastro Cancer Urology Nephrology Orthopaedics Gynaecology & cardiac surgery Neuro Surgery enterology / Obstetrics surgery

A mix of higher secondary and tertiary care facilities is what doctors voted for an upcoming hospital to focus on.

54 FACILITIES RECOMMENDED BY THE PHYSICIANS

Specialities General Physician Specialist Physician Cardiology / cardiac CCU, Cath Lab, ECHO, Holter surgery CCU, Cath Lab, Holter Monitor Monitor

Neurology / Neuro Surgery EEG EMG EEG,Emg,Specialised OT Gastro enterology / surgery Endoscopy,Colonoscopy,USG Radiation Oncology, Cancer Chemotherapy Radiation Oncology

Urology Lithotripsy,TURP Lithotripsy,TURP

Nephrology Dialysis Dialysis

Orthopaedics BMD,C-arm,OT BMD, Specialized OT

Gynaecology & Obstetrics More OT & doctors

ENT Audiometry Bera

Pediatrics and neonatalogy Specialists, PICU SNCU, PICU

55 THANK YOU

56