Study of District Hospital Raisen and Sehore – an Analysis of out of Pocket Expenses

Project Report

Study of district hospital Raisen and Sehore – An analysis of out of pocket expenses

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis

Project Report

Study of district hospital Raisen and Sehore –

An analysis of out of pocket expenses

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis

Project Team

Under the Guidance of

Shri Madan Mohan Upadhyay, Principal Advisor, Centre for Social Sector Development, AIGGPA

Project Coordinator

Ms Richa Sharma, Deputy Advisor, State Health Resource Centre (SHRC), Centre for Social Sector Development, AIGGPA

Research Associate

Mr Vipul Shrivasatava

Index S.No Particulars Page No Executive Summary 1 Introduction 1 1.1 Introduction to Government supported urban 1 health care infrastructure in India 1.1.1 Primary health care services 1 1.1.2 Secondary health care services 2 1.1.3 Tertiary health care services 3 1.2 Introduction to Out of Pocket Expenditure 4 1.3 Health System Financing 5 1.4 Catastrophic Health Expenditure 6 1.5 Out of pocket expenses on health in India as per 7 National Health Accounts 2 Objectives and methodology 12 2.1 State wise variation of out-of-pocket expenses on 13 health in India 2.2 Objectives of the study 13 2.3 Sampling 14 2.4 Methodology 14 2.5 Limitations of the study 15 3 Findings and analysis of data 16 3.1 District Hospital Raisen 16 3.1.1 Socio economic status of the patients availing 16 treatment at District hospital Raisen 3.1.2 Out of pocket expenses and experiences during 20 treatment at District hospital Raisen 3.2 District Hospital Sehore 27 3.2.1 Socio economic status of the patients availing 27 treatment at District hospital Sehore 3.2.2 Out of pocket expenses and experiences during 31 treatment at District hospital Sehore 4 Recommendations 41 References 44 Annexures

Abbreviations and Acronyms

AIGGPA Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis ANM Auxiliary Nurse Midwife CHE Current Health Expenditures DES Department of Economics and Statistics EMAS Emergency Medical Ambulance Service GDP Gross Domestic Product GHE Government Health Expenditure IPD Indoor patients/ admitted patients JSY Janani Suraksha Yojana JSSK Janani Shishu Suraksha Karyakram NFHS National Family Health Survey NHA National Health Accounts NHM National Health Mission NRHM National Rural Health Mission NUHM National Urban Health Mission OOPE Out of Pocket Expenses OPD Out-door patients PPP Public Private Partnership RCH Reproductive and Child Health TB Tuberculosis THE Total Health Expenditure WHO World Health Organization

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Executive Summary

Public health facilities are expected to offer health care services free of cost or at minimal cost. However, at times people incur a significant expenditure while trying to avail services from the government healthcare institutions also, which is a cause of concern. When the poor move out of the domain of availing the benefits of public health they face a lot of hardship due to ignorance and end up paying a very heavy price in the private health set up which at times forces them to enter a trap of a high interest loan which affects their life.

Health care out-of-pocket payments may result in a number of households facing catastrophic payments. Such high expenditure can mean that people have to cut down on necessities such as food and clothing, or are unable to pay for their children's education. To address the issue of out-of-pocket expenses several schemes have been followed by the Government for the benefit of the poor and to minimize the health related expenditure and suffering to the poor.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 1

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Data is available under NFHS 4 only for average state wise out of pocket expenditure per delivery in public health facility and not the full range of services provided in the public health facilities. In light of these circumstances the Department of Health and Family Welfare , Govt of MP requested Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis (AIGGPA) to take up a detailed study regarding out-of-pocket expenses at District hospital Sehore and Raisen covering both indoor and outdoor patients and covering range of services provided by the hospital. Since both the said district hospitals cater to the health needs of significant portion of rural population the same were studied to get an understanding of their needs.

Overall both the said District hospitals worked reasonably well on account of fulfilling the mandate of the National Health Policy of providing health care while trying to minimise the cost or financial hardship to the patients. It was found that the facility of the hospital is mostly used by the people from the low socio-economic background. It was also found that in some cases the patients had to get the investigation done from outside on account of delay in the investigation at the hospital and so end up paying money for the same. In rare cases medicine was purchased from outside especially in case of admitted patients. Such cases should be minimised. It was found that if the patients end up in the private health facility then the cost of treatment both direct cost and indirect cost increases exponentially. The staff of the Government health facility should be sensitive towards the importance of the service provided by them is on the life of the patients. The Government of Madhya Pradesh has provided the facility of free transport for patients under 108 ambulances and for pregnant women and infants under Janani Express. Majority of the pregnant women who came to the hospital for delivery were able to get the benefit of Janani Express or 108 ambulances to reach the hospital. Certain instances were found when the patients paid money even when they availed the facility of government supported transport the Janani Express and the 108 ambulance even when the facility should be available free of cost to the patients. Such instances cause dissatisfaction among the patients and efforts must be done to minimise such instances. There is high importance of each level of functionary in a government hospital including doctors, nurses, pharmacists, technicians, cleaner, driver etc needs to be taken into consideration. Each of the service providers has an important role to play in the smooth running of the mechanism. Also since the facility of hospital has to function 24 by 7

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 2

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses throughout the year it is important to have a contingency plan for dealing with staff related issues in case of an emergency. Deficiency of health personnel is not limited to doctors alone. In the case of district hospital Raisen almost 50 % of the posts lie vacant. Similarly lack of staff was found at district hospital Sehore also. In light of these circumstances the patients and services of the hospital suffer. There is shortfall in various categories of paramedical personnel which is a cause of concern. Thus there is an urgent need to address the staff related issues.

The referral system is very important for the smooth functioning of the system. It is essential to strengthen the institutions of PHC and CHC to be able to rationalise the flow of patients, it was found that majority of the patients came to the district hospitals. This scenario leads to over load at the district hospital .It is essential that training calendar be developed and the staff of PHC / CHC visit the district hospital and take training of dealing with basic health issues. The general population availing the facility of the district hospital must also be counselled and encouraged to visit the neighbouring health facilities.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 3

How important is the access to medical facility for a common man

Dashrath Manjhi famously known as the Mountain Man who single-handedly carved a path through a mountain. He gave 22 years of his life to his village and made a difference in the lives of the people of a small village, in Bihar.

Using only a hammer and chisel, Dashrath Manjhi, a landless farmer, carved a path through a mountain in the Gehlour Hills, Bihar so that his village could have easier access to medical facilities. It shortened the distance from 71 Km to 1 Km to the nearest town for getting medical attention. Dashrath Manjhi's wife Falguni Devi died from lack of medical care. In the memory of his wife; he carved the path in the Gehlour hills so that his village could have easier access to medical attention.

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Chapter 1 Introduction

Importance of district hospital in India: Every district is expected to have a district hospital. In the present 3-Tier structured level of care being provided by public health facilities, the District Hospital (DH) serves at the secondary referral level. The objective of a district hospital is to provide comprehensive secondary health care services to the people in the district at an acceptable level of quality and being responsive and sensitive to the needs of people and referring centres. As the population of a district is variable, the bed strength also varies depending on the size, terrain and population of the district. There is one district hospital available in the head quarter of each of the 51 districts of Madhya Pradesh.

1.1 Introduction to Government supported health care infrastructure in India The Government supported health care system in India consists of primary, secondary and tertiary care institutions, manned by medical and paramedical personnel and other staff at various levels. The district hospital is strategically positioned at the secondary level. Thus it is essential to have a fair understanding of the various health care facilities at primary, secondary and tertiary level .The various health care facilities provided by the Government at various levels is as under: 1.1.1 Primary health care services

The primary health care infrastructure provides the first level of contact between the population and health care providers. It consists of Sub-health centre and Primary Health Centre.

Sub-health centre: A Sub-health centre (Sub-centre) is the most peripheral and first point of contact between the primary health care system and the community. In the field of rural health, effort is to provide one sub-centre for a population 5000 people in the plains and for 3000 in tribal and hilly areas. However, as the population density in the country is not uniform, it shall also depend upon the case load of the facility and distance of the village/habitations which comprise the Sub-centre. A Sub-centre provides interface with the

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 1

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses community at the grass-root level, providing primary health care services. A sub- centre is generally staffed with a multipurpose worker male and multipurpose worker female.

Primary Health Centre: Primary Health Centre (PHC) serves as a first port of call to a qualified doctor in the public health sector in rural areas providing a range of curative, promotive and preventive health care. Primary Health Centre is the cornerstone of rural health services- a first port of call to a qualified doctor of the public sector in rural areas for the sick and those who directly report or referred from Sub-Centres for curative, preventive and promotive health care. A typical Primary Health Centre covers a population of 20,000 in hilly, tribal or difficult areas and 30,000 population in plain areas with 4-6 indoor/observation beds. It acts as a referral unit for 6 Sub-centres and refer out cases to CHC (30 bedded hospital) and higher order public hospitals located at sub-district and district level.

1.1.2 Secondary health care services

Community Health Centre: The secondary level of health care essentially includes Community Health Centres (CHC), constituting the First Referral Units (FRUs) and the Sub- district/Sub-divisional Hospital and District Hospitals. The Community Health Centres are designed to provide referral as well as specialist health care to the rural population. The CHC were designed to provide referral health care for cases from the Primary Health Centres level and for cases in need of specialist care approaching the centre directly. 4 PHCs are included under each CHC thus catering to approximately 80,000 populations in tribal/hilly/desert areas and approximately 1, 20,000 populations for plain areas. CHC is generally is a 30-bedded hospital providing specialist care in Medicine, Obstetrics and Gynaecology, Surgery, Paediatrics, Dental and AYUSH.

Sub-district / Sub-divisional hospital: Sub-district (Sub-divisional) hospitals are below the district and above the block level (CHC) hospitals and act as First Referral Units for the Tehsil/Taluk/block population in which they are geographically located. Specialist services are provided through these Sub district hospitals and they receive referred cases from neighbouring CHCs, PHCs and SCs. They form an important link between sub-centre, PHC and CHC on one end and District Hospitals on other end. It also saves the travel time for the cases needing emergency care and reduces the workload of the district hospital. In some of

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 2

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses the states, each district is subdivided in to two or three sub divisions. A subdivision hospital caters to about 5-6 lakh persons. In bigger districts the Sub-district hospitals fills the gap between the block level hospitals and the district hospitals. A sub-district hospital usually has about 31 to 100 beds.

District Hospital: District Hospital is a hospital at the secondary referral level responsible for a district. Its objective is to provide comprehensive secondary health care services to the people in the district at an acceptable level of quality and being responsive and sensitive to the needs of people and referring centres. Every district is expected to have a district hospital. District Hospital should be in a position to provide all basic specialty services. District Hospital also needs to be ready for epidemic and disaster management all the times.

1.1.3 Tertiary health care services

The Government also provides certain tertiary care institutions which provide super-specialty services for the patients. All hospitals - even those providing secondary or tertiary care also provide primary health care services to rural and urban population. The urban health facilities especially the tertiary care institutions cater to both the urban and rural population.

Thus there are several tier of Government facility available for the patients and effort is done to provide maximum coverage of the facility and provide health care facility at a nearest location .This is done to ensure that health care facility is available at a reasonable distance and good functioning of the referral system will help in ensuring that only cases which need the services of the district hospital actually reach there , otherwise this may result in flooding of the district hospitals.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 3

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Overall coverage of health care facility below the district hospital is as under: Community Health Centre (CHC)

(Average radial distance covered: 1433 Km)

Population served: 1,20,000 (80, 000 in tribal/hilly areas) Primary Health Centre (PHC) A 30 bedded Hospital/(Average Referral radial distance Unit for c 4overed: PHCs with 6.42 Specialized Km) services Population Served: 30,000 (20,000 in tribal/hilly areas) A Referral Unit for 6 Sub Centers 4-6 bedded manned with A Medical Officer In charge and 14 subordinate paramedical staff

Sub centre (Average radial distance Covered: 2.59 Km) Population Served: 5,000 (3,000 in tribal/ hilly areas) Most Peripheral Contact Point between Primary Health Care System & Community Manned With One HW (F) ANM& One HW (M) and 3-5 ASHA Workers

Abbreviations HW (F) =Health Worker (Female). ANM= Nurse Midwifery; HW (M) = Health Worker (Male), ASHA= Accredited Social Health Activists Source; Adapted From Rural Health Statistics in India (2012) Statistics Division Ministry Of Health and Family Welfare, Government of India.

The government health facilities aim to provide health facility at minimum cost to the poor. Poor health is a common consequence of poverty and vice versa. Poor health leads to poverty through the inability to work and generate income. For people with low income this is one of the devastating consequences of falling ill. Sometimes people do not seek treatment until the disease has affected their daily activities, this could be due to financial reasons or unavailability of healthcare services. Thus for the poor the nature and the quantum of health care depends on the cost involved and the source from which the expenditure is financed.

1.2 Introduction to Out of Pocket Expenditure

Households, in general, avail healthcare services from public as well as private health care facilities, depending on their accessibility, affordability to these facilities and multiple other factors. In public health institutions, Government incurs expenditure for providing healthcare infrastructure as well as payment of salaries for medical staff, while in private sector hospitals, the service providers charge directly from households for their services. Although the services provided by public health institutions particularly sub centres , primary health centres, community health centres , sub-district hospitals, district hospitals and other government hospitals are accessible to the public, mostly free of cost, in practice, there are various instances, where households have to pay ‘out of pocket expenditure’. These expenses could be medical as well as non-medical expenditure. Out of Pocket Medical expenditure

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 4

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses could be payments towards doctor’s fees, medicine, diagnostics, operations, charges for blood, ambulance services etc, while non-medical expenditure include money spent towards travelling expenses, lodging charges of escort, attendant charges, etc. Out-of-pocket expenditure (OOPE) on healthcare forms a major barrier to health seeking behaviour. The poor sections do not have any form of financial protection and are forced to make OOPE when they fall sick. At times, these households have to resort to borrowings or sell assets to meet this expenditure.

1.3 Health System Financing

Health System consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities [1] .The ultimate goals of a health system are improving health status, health equity and to make the most efficient use of the available resources. There are also intermediate goals which to achieve more coverage and better access to health services without having to compromise on quality and safety. Universal health coverage means that everyone in the population has access to preventive, curative and rehabilitative health care at the time they need it and at a cost they can afford [2]

There are four main types of financing for healthcare: Government funded (through taxes), social insurance (through payroll, taxes or direct contributions) private insurance and Out-Of-Pocket (OOP). The first three types are pre-paid financing mechanisms and have some form of risk pooling. There is variation across countries in determining their health financing mechanism, but it mainly depends on the country’s economic status. The poorer the country, the more is the dependence on out of pocket payment. The mechanism of fund flow under health system in India has a complex set of interlink ages mentioned in Annexure –I.

Out-of-Pocket Payment is the most important means of healthcare financing in most developing countries. It can be divided into direct or indirect costs. Direct costs include doctor’s consultation fees, medications, tests, procedures, hospital bills etc. Indirect costs include transport charges to treatment site, daily living cost for accompanying household members and loss of income due to illness[3].

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 5

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Often the OOP expenditure poses a colossal burden on poor households. The costs are frequently high enough and households are unable to recuperate them from existing resources, and, hence, ultimately slip deeper into poverty. As a result, protecting households from health expenditure continues to remain as a challenge, particularly for countries with high levels of poverty. Out-of-Pocket healthcare expenditure remains one of the most typical means of financing health expenditure around the world and more specifically in developing countries where access to financial protection provided by health insurance is minimal due to low income levels by citizens. This situation is made worse by the fact that in some countries, the burden of out of-pocket spending creates barriers to health care access and use.

1.4 Catastrophic Health Expenditure

Catastrophic health expenditure is not always synonymous with high health-care costs [4].A large bill for surgery, for example, might not be catastrophic if a household does not bear the full cost because the service is provided free or at a subsidised price, or is covered by third- party insurance. On the other hand, even small costs for common illnesses can be financially disastrous for poor households with no insurance cover. World Health Organization has used the following definition of Catastrophic Expenditure .An expenditure is considered as being catastrophic if a household’s financial contributions to the health system exceed 40% of income remaining after subsistence needs have been met[5]. The impact of health care financing systems on the welfare of households, particularly poor households is mainly regarded as an important issue encountered by policy makers when developing healthcare systems and insurance mechanisms.

Several studies of Indian villages to determine why households descent into poverty find that in a majority of cases of decline into poverty, three principal factors are at work: health expenses, high-interest private debt, and social and customary expenses[6].Healthcare access in India is affected with 70:70 paradox; 70 per cent of healthcare expenses are incurred by people from their pockets, of which 70 per cent is spent on medicines alone, leading to impoverishment and indebtedness [7].

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 6

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

1.5 Out of pocket expenses on health in India as per National Health Accounts Table 1: As per National Health Accounts (NHA) Estimates for India 2014-15

Particulars Amount Remarks Total Health Expenditure Rs. 4,83,259 crores (3.89% Total Health Expenditure (THE) for India for the of GDP and Rs. 3,826 per constitutes current and year 2014-15 capita) capital expenditures incurred by Government and Private Sources including External/Donor funds

Government Health Rs. 1,39,949 crores (29 % This amounts to about Expenditure (GHE) of Total Health 3.94% of General including capital Expenditure (1.13% GDP Government Expenditure expenditure for the year and Rs. 1,108 per capita) in 2014-15 2014-15 Out of Pocket Expenditure Rs. 3,02,425 crores (62.6% (OOPE) on health by of Total Health households Expenditure, 2.4% of GDP, for the year 2014-15 Rs. 2,394 per capita) Private Health insurance Rs. 17,755 crores (3.7% of expenditure Total Health Expenditure)

Table 2 : Key Health Financing Indicators for India across National Health Accounts Rounds S.No Indicator NHA NHA NHA 2014-15 2013-14 2004-05

1 Total Health Expenditure (THE) as per cent 3.9 4 4.2

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 7

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

of GDP

Total Health Expenditure (THE) per capita 2 (Rs.) 3826 3638 1201 Current Health Expenditures (CHE) as % of 3 Total Health Expenditure 93.4 93 98.9 Government Health Expenditure (GHE) % of 4 Total Health Expenditure 29 28.6 22.5 Out of pocket Expenditures (OOPE) as % of 5 Total Health Expenditure 62.6 64.2 69.4 Private Health Insurance Expenditures as % 7 of of Total Health Expenditure 3.7 3.4 1.6 External/Donor Funding for health as % of 8 Total Health Expenditure 0.7 0.3 2.3

Source: National Health Accounts (NHA) Estimates for India 2014-15 Though there has been a reducing trend of Out of Pocket Expenditure (OOPE) as percentage of Total Health Expenditure over a period of time, yet OOPE of 62.6 % is still an area of serious concern. Private Hospital Vs Government Hospital As per National Statistical Survey 71st round covering key indicators of social consumption in India health held during Jan 2014 to June 2014 it was seen that private doctors were the most important single source of treatment in both the sectors. They accounted for around 50% of the treatments in rural as well as urban areas. In fact, more than 70% (72 per cent in the rural areas and 79 per cent in the urban areas) spells of ailment were treated in the private sector (consisting of private doctors, nursing homes, private hospitals, charitable institutions, etc) [8].

To address the issue of Out-of-Pocket Expenses several schemes have been followed by the Government for the benefit of the poor:

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 8

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Free Medicines: The Sardar Vallabh Bhai Free Medicine Distribution Scheme has been implemented since October 2012 in all 1595 health institutions in the state. About 3 lakh patients are availing its benefit daily. Most required generic medicines are provided 24 x 7 hours to OPD as well as indoor patients in hospitals. Free Pathology Tests: This measure has been initiated by State Government towards ensuring better health to people. Objective of the scheme is to provide free pathological test facility to people in government hospitals. The facility is available right from district hospitals to sub-health centres. Several categories of pathological tests are provided based on the level of facilities at the respective health care facility.

Madhya Pradesh Rajya Beemari Sahayta Nidhi: Under the scheme, financial assistance of Rs. 25,000 up to Rs. 2 lakh is provided to a member of BPL family suffering from identified and deadly diseases. Under it, financial assistance of Rs. 25,000 up to Rs. 1 lakh is sanctioned at district level and Rs. 1 lakh to Rs. 2 lakh at division level.

The scheme is targeted for all the BPL families who cannot bear the expenses for serious diseases that are specified in the scheme. Under the scheme, the beneficiary has to be a resident of Madhya Pradesh. The eligible people for the scheme get financial aid for the treatment. The range of the financial aid depends upon the criticality of the disease. However, there are certain conditions also mentioned in the scheme. The health benefits can also be availed of from accredited health organizations. The payment in such cases is made through cheque to the health organizations where the patient is undergoing treatment.

Mukhyamantri Bal Hriday Upchar Yojana: Under the scheme, financial assistance up to maximum Rs. 1, 00,000 is provided to concerning government and recognized private hospitals for heart surgery of BPL children from 0 to 15 years of age, who suffer from heart disease.

Health services being strengthened in rural areas: Village Health Centres have been set up. Village health register is maintained at these health centres where necessary medical equipments and medicines are available.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 9

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Janani Suraksha Yojana: Janani Suraksha Yojana (JSY) is a safe motherhood intervention. The scheme focuses on the poor pregnant woman with special dispensation for states having low institutional delivery rates. All pregnant women delivering in Government health centres like Sub-centre, PHC/CHC/FRU/general wards of District and state Hospitals or accredited private institutions are eligible. Table 3: Incentives under Janani Suraksha Yojana Incentive to be provided to Incentive to be provided to ASHA in Category mother in Rupees Rupees (per delivery)

Rural area 1400 600

Urban 1000 200 Area

Janani Express: The Janani Express Yojana aims at providing benefit of transportation to all of the expectant mothers for their institutional deliveries. It benefits them also in emergency circumstances during pre and post-delivery periods. Besides this, eligible beneficiaries of Deendayal Antodaya Upchar Yojana and sick infants can also avail the services of Janani Express for their casual medical treatment under the scheme.

Mamta, Astha and Kayakalp Abhiyans: Mamta, Astha and Kayakalp Abhiyans are being implemented to effectively monitor all schemes and services of Health Department. Maternal and child health, vaccination and family welfare programme have been included in mamta abhiyaan, TB, leprosy, blindness, malaria, dengue, chikanguiniya and swine flu and seasonal diseases in astha abhiyaan and works of entire infrastructure and development of health institutions is being done under kayakalp abhiyaan. These include construction of new buildings, up gradation of old buildings, cleaning, safety, free medicines and pathology tests, food, transport etc for patients.

Source: http://www.mpinfo.org/MPinfoStatic/english/articles/2013/100813Lekh22.asp, Department of Public affairs, govt of MP accessed on 10th May 2018

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 10

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

About 108 ambulance facility: The Government of M.P. is running an ambulance service project. It is an emergency medical ambulance service (EMAS) which is running across the state of M.P. and is also popularly known as "108 Ambulance Service". The ambulances are deployed strategically across MP supported with a fully functional centralized call centre which receives more than 25,000 calls per day and handling approximately 2500 emergencies on daily basis. GPS with biometric system has been installed in these ambulances. The project is being managed under public private partnership (PPP) mode and financials are on reimbursement basis. The project aims to provide round the clock pre-hospital emergency transportation care (ambulance) services across the state. It aims to improve the access to medical & health care, police and fire service, particularly attending emergency situations relating to pregnant women, neonates, parents of neonates, infant and children in situations of serious ill health and all other emergencies in the general population. It covers emergency cases including pregnancy cases, accidental, unconscious, paralysis, fever, heart attack. Any person in need of emergency help can dial a toll free number 108 from any landline or mobile set. The ambulance reaches the site and rushes the victim to the nearest hospital during the transit; pre-hospital care is to be provided to the patient. Source: http;//www.nhmmp.gov.in/hc-sanjeevanilexp-background.aspx accessed on 10th May 2018

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 11

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Chapter 2 Objectives and Methodology

One of the goals of the recent National Health Policy 2017 is "the attainment of the highest possible level of health and well-being for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence. This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery". Public health facilities are expected to offer health care services free of cost or at minimal cost. However, at times people incur a significant expenditure while trying to avail services from the government healthcare institutions also, which is a cause of concern. When the poor move out of the domain of availing the benefits of public health they face a lot of hardship due to ignorance and end up paying a very heavy price in the private health set up which at times forces them to enter a trap of a high interest loan which affects their life. Though numerous schemes are announced by the health department and made available for the poor, access to them is at times difficult. Proper dissemination of information about the schemes also remains a challenge. While government has launched several schemes aimed at mitigating the financial burden on the persons visiting hospitals, poor have to spend money from their own resources in meeting various other types of associated expenses. The financial burden of out-of-pocket payments at the time of health care utilization can lead individuals to spend high amounts compared to their available incomes, thereby reducing spending on other basic items. Increasing the availability and use of health services is critical with a view to improving health systems. However, if health systems financing basically relies on out-of- pocket payments and financial risk protection measures are missing, unwanted effects may be observed. Health care out-of-pocket payments may result in a number of households facing catastrophic payments. Catastrophic payments occur when households need to spend an important fraction of their net income on health care, some of them being pushed into poverty and others giving up the care needed. Therefore, it is a major challenge for health

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 12

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses systems to protect households from the risk of impoverishment resulting from health expenditure, and to ensure that the population receives the needed health services.

2.1 State wise variation of out-of-pocket expenses on health in India

As per the Healthy States ,Progressive India report on the ranks of States and Union Territories the National Family Health Survey (NFHS)-4 data on average out-of-pocket (OOP) expenditure per delivery in public health facility was considered as a proxy indicator for overall OOP expenditure. This data is available only for 2015-16 and hence the indicator is reported only for the reference year. There is significant variation in the average OOP expenditure per delivery in public health facilities across the States. The expenditures range from as low as Rs 471 in Dadra & Nagar Haveli to as high as Rs 10,076 in Manipur. The top five States and UTs with average expenditure above Rs 6,000 per delivery in a public facility are Manipur Rs 10,076, Delhi Rs 8,719 West Bengal Rs 7,782 Kerala Rs 6,901 and Arunachal Pradesh Rs 6,474. The average OOP expenditure per delivery in public health facility for Madhya Pradesh was found to the lowest among states at Rs 1,387 as per NFHS 4 data [9]. Given the number of NHM interventions targeting pregnant women, such as Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), and referral transport to ensure free delivery at public health facilities, the states should aim to reduce such OOP expenditure.

Data is available under NFHS 4 only for average state wise out of pocket expenditure per delivery in public health facility and not the full range of services provided in the public health facilities. In light of these circumstances the Health department, Govt of Madhya Pradesh requested Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis (AIGGPA), Bhopal to take up a detailed study of district hospital Raisen and Sehore with an analysis of out of pocket expenses including covering both indoor and outdoor patients covering the range of services provided by the hospital.

2.2 Objectives of the study

1. To identify the nature and the amount spent by the family as out of pocket expenses in order to avail treatment at District Hospital Raisen and Sehore.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 13

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

2. To identify the bottlenecks in availing facility of the Government Schemes for IPD and OPD patients. 3. To identify socio-cultural health practices prevalent in the area that influences the access and utilization of various health schemes. 4. To map the pattern of patients visiting respective district hospital and to identify the services this could have been availed at the neighbouring PHC/CHC.

2.3 Sampling

Information was taken from the hospital regarding the number of patients who have availed the services of District Hospital Raisen and Sehore as out-door patients (OPD) and those who have been admitted in the hospital for treatment as indoor patients (IPD). For the purpose of the study it is essential to determine an optimal number of patients to be included in the sample. The sample size was determined using Slovin’s formula for sampling at 92% confidence level for outdoor patients and at 90% confidence level for indoor patients. The sample comprised of 200 outdoor patients and 100 admitted patients covering all the departments in district hospital Raisen and Sehore respectively.

Table 4: Total number of patients included in the study Name of the Hospital Particulars Number of Patients surveyed District Hospital , OPD patients surveyed 200 Raisen Admitted patients surveyed 100 District Hospital , OPD patients surveyed 200 Sehore Admitted patients surveyed 100 Total number of patients surveyed 600

2.4 Methodology Both primary and secondary data was used for the purpose of the study. Secondary data was collected by means of various websites and brochures of various government schemes and series of interactions with the staff at respective district hospital. Primary data was collected by means of a detailed questionnaire which was developed based on a series of interactions

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 14

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses with various officers and staff working in the Raisen and Sehore District Hospitals and concerned officers in the Department of Health and Family Welfare, Govt of MP. Department of Economics and Statistics, Govt of Madhya Pradesh supported in development a mobile application for the same. For the purpose of collecting data from the patients in the form of questionnaire, two field investigators were identified. Since the data was required to be collected from male as well as female patients; it was essential to hire the services of a male and a female field investigator for each of the District Hospital. The eligibility criterion applied was that the field investigators were graduates and competent of interacting with the patients and entering the data in the mobile application. Interaction with the patient was done at the time when the patient was returning home after obtaining treatment in case of OPD patients or after discharge from the hospital in the case of indoor patients.

The questionnaires were pre-tested by means of a pilot test before conducting the study. Efforts were made to include patients from all the functional departments in the hospital for the purpose of the study.

2.5 Limitations of the study

The study is mainly based on primary data. There is a risk that because of the presence or influence of the interviewer in a face-to-face interaction, the interviewer might unknowingly bring out an untrue response to sensitive questions, e.g. the respondent may craft an answer to please the interviewer instead of answering truthfully or the interviewer might record a verbal response incorrectly because the statement is not interpreted correctly. Nevertheless, efforts were made to minimize the possibility of error since the field investigators, who were selected for the purpose of the study, were local from the respective district only.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 15

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Chapter 3 Findings 3.1 District Hospital Raisen: The observations of the study are based on the responses received from the respondents comprising of patients. Almost all patients availing the service of district hospital Raisen were from Raisen district itself. Against 200 beds sanctioned for the hospital, there are 283 beds available in the hospital. Details of section wise beds is given in Annexure -II

The status of staff position of the district hospital is available in Annexure –III . Almost 50 % of the posts lie vacant.The hospital is facing shoratge of not just doctors but also for staff nurse, ward boy , pharmasist etc.

Rural /Urban mix of patients: Majority of the inflow of patients were from the rural area (63 %) while only approximately 37 % of the patients who availed the services of the Raisen district hospital were from urban area.

District Hospital Raisen -Pateints from Rural Area or Urban Area

Urban Area 37%

Rural Area 63%

3.1.1 Socio economic status of the patients availing treatment at District Hospital Raisen B.P.L card holders: The Government hospital in a great boon to the patients facing financial hardship. Majority approximately 60 % of the families surveyed which availed the facility of Raisen District hospital were B.P.L card holders.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 16

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Age group of the patient: The district hospital covers an entire basket of services dealing with patients of almost all age groups including infants, children, adults and the aged. Efforts were made to include patients of all age groups for the purpose of the study. Out of the patients surveyed, about 15% were less than 10 years of age, 7% were in the age group 10 to 18 years, 70% were more than 18 years of age but less than 60 while approximately 8 % patients were more than 60 years of age.

District Hospital Raisen Number of respondent patients falling in different age groups

80 70% 70

20 15% 8 % 10 7%

0 0-10 years >10 years upto >18 years upto > 60 years 18 years 60 years

Category of patients: About 32% of the respondent patients who availed the services of Raisen District Hospital were from general category, approximately 17% were from scheduled caste, and 9% were from scheduled tribe while 42% were from other backward classes.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 17

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Category of respondent patients who availed treatment at District Hospital Raisen

General Other 32% Backward classes 42%

Scheduled Scheduled Tribe Caste 9% 17% Level of education of the head of the household:

Education level of the head of household of the patients surveyed in District Hospital Raisen Post Graduate Graduate Upto 12th 2% Standard 2% 4% Upto 10th Illiterate Standard 28% 12%

Upto 8th Upto 5th Standard Standard 31% 21%

Occupation: An effort was done to identify the main source of income of the family of the patients availing the treatment facilities at the hospital were as under: Majority of the patient’s family worked as labourers with almost 55 % of the surveyed families working as labourer. Almost 27% derived their major source of income from

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 18

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses agriculture, 14% of patients surveyed were self employed / had business, almost 3% were in Government job while 1 % did other work.

Main source of income for the family of the patients - District Hospital Raisen Others 1% Self employed / Business 14%

Agriculture Govt. Service 27% 3%

Labourer 55%

Monthly income of the household from all sources: An effort was also done to classify the families of the patients on the basis of the monthly income of the families. Huge majority (72%) of the families covered in the survey earned less than Rs 10,000 per month, approximately 18 % of the families earning income in the range more than Rs 10,000 but less than Rs 15,000. Only 10 % of the respondents mentioned that their monthly income from all sources was more than Rs 15,000. Monthly income from all sources of family of patients availing facility of District Hospital Raisen (value in %)

37 40 35 30 18 20 7 10 1 0 2 0

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 19

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

It is a usual perception that Government hospitals are flooded with people and number of persons accompanying the patient to the hospital is very high. An effort was done to know how many persons accompanied the patient to the hospital. In 20% of the cases two persons or more persons were accompanying the patient.

Number of persons accompanying the patient to District Hospital Raisen (value in %) 70 60 57 50 40 30 23 19 20 10 1 0 No Patient +1 Patient +2 Patient + 3 accompanying person

3.1.2 Out of pocket expenses and experiences during treatment at District hospital Raisen Mode of transport: Among the admitted patients, about 22 % used the Government supported transport facility like 108 or Janani express. The government supported facility was used in cases pertaining to delivery of the baby, accident etc. Majority of the patients mentioned that they got the government supported facility free of cost; however, in few cases they mentioned that they had to pay some money for the service. 60 % of the admitted patients used public transport like bus, tempo etc. 18 % of the patients made their own arrangement.

Amongst the outdoor patients, 67 % used public transport like bus, tempo etc. 23 % of the outdoor patients came cycle or by foot. 33 % of the respondents made their own arrangement for travel to the hospital including two-wheeler or by foot and in rare cases some of the patients came to the hospital by car.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 20

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Cost of travel incurred by the patients: The average cost borne on account of travel by the indoor patients amounted to Rs 164. Certain instances were found when the patients paid money even when they availed the facility of government supported transport the Janani Express and the 108 ambulance even when the facility should be available free of cost to the patients. Such instances cause dissatisfaction among the patients and efforts must be done to minimise such instances. The average cost of travel for the outdoor patients was Rs 124. Note: The information was gathered by means of a questionnaire at the time of discharge from the hospital .Thus the travel cost as informed by the patient was multiplied by 2 to be able to get the approximate travel cost involved.

In spite of the fact that some of the admitted patients used the government facility of 108 ambulances or Janani express, the average cost of travel is more in case of admitted patients than the cost of travel borne by the outdoor patients. This is because the family bears travel cost on account of visit of attendants of the patient to the hospital in the case of admitted patients.

Cost of stay in case of admitted pateints : Information was gathered from the admitted pateints for cost incurred during stay in the hospital for treament.Majority of the attendants of the patients shared the bed with the patient or slept on the floor.

Amount spent on food during treatment at the hospital: There is a facility of free food for the admitted patients in the hospital. In spite of the fact that food is provided free of cost the admitted patients, some expenses are incurred on food for attendants. Also, some amount is spent on food by outdoor patients and their attendants. An average sum of Rs 228 was spent for food related expenses in case of admitted patients. The duration of stay of the patients in case of admitted patients was in the range 1 day to 35 days depending on the nature of the disease. The average duration of day of the admitted patients in the hospital was 5 days. The average amount spent on food was Rs 60 per day in case of admitted patients while in case of outdoor patients they spent an average amount of Rs 7 on food.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 21

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Expenses for medicines and investigation: Medicines: Medicines were provided free of cost in case of majority of the patients. Investigations: The facility of free investigation was provided to majority of the patients. Pathological investigation and X-ray etc was done free of cost for the patients .However, one patient mentioned that he had to get MRI done from outside.

Health care seeking behaviour: The patients were also asked about the treatment taken, if any course of action taken by them in the past for treatment of the same disease in the past. About 77 % of the patients either treated the patient at home or did not take any action for treatment prior to bringing the patient to the district hospital. Approximately 15 % of the respondents had visited same or other government health facility in the past for treatment of the same disease. Only 8 % of the patients used the facility of private hospital/ clinic in the past for the treatment of same disease. The usage of facility of CHC/ PHC was also found to be very low likewise the usage of jadi-booti or traditional medicine was also found to be low among the respondents.

The patients who used the private hospital / facility before availing the Govt facility had a total out of pocket expenditure of Rs 1217.

The respondents were asked about the nearest government health facility for them. Majority 85 % of the respondents mentioned District hospital Sehore to be the nearest Government

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 22

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses supported health facility. 15 % of the respondents mentioned that other health facility was available close to their residence at average distance of about 10 km, yet they preferred to come to District hospital for treatment. This shows lack of awareness about the facilities available at the PHC/CHCs and the need to strengthen the same. Referral mechanism: Ideally the patient should visit the neighbouring Sub – centre or PHCs and in case of problem referred to CHC of sub-district hospital. However, it was found only 6% of the patients surveyed were referred to the hospital.

Travel time to reach the hospital: Information was gathered from the respondents regarding the travel time required to reach the hospital. Almost 83 % of the patients reached the hospital within one hour, 13 % of the respondents reached took more than one hour but less than 2 hours to reach the hospital while 4 % of the respondents travelled for more than 2 hours to reach the hospital .Almost all of the indoor patients who used the Govt supported transport facility like the Janani Express or 108 ambulance were also able to get the vehicle in 1 hour’s time.

Waiting time to show the patient to the doctors: Once the patient reaches the hospital he /she are required to get the token and then stand in a queue waiting to be seen by the doctor. About 63% of the respondents mentioned that they waited for almost half an hour to meet the doctor. About 28% of the patients waited more than 30 minutes but within 1 hour. 4% of the patients had to wait for more than one hour but less than 2 hours. 4 % of the patients had to wait more than two hours to show the patient to the doctor. It is a major complaint by the patients that they were not seen by the doctors in Government hospital do no not see the patient or listen to their complaint for sufficient duration of time. The summary of the responses is as under:

Time taken by doctors to see the outdoor patients (responses value in %) 0-5 minutes 68 5-10 minutes 28 10-30 minutes 1 > 30 minutes 1

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 23

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

The patients who were seen by the doctor for more than 10 minutes mainly comprised of fracture, accident, cataract procedure etc.

Opinion of patients regarding behaviour or the doctors: Opinion was taken from the patients regarding on the behaviour of the doctors during the course of the treatment approximately 20 % of the outdoor patients and indoor patients found the behaviour of the doctor to be good or very good, while almost 80 % of the patients were of the view that the behaviour of doctors was average.

Opinion of patients regarding behaviour of the staff: 15 % of the indoor patients were of the view that the behaviour of staff was good while 10 % of the outdoor patients found the behaviour of the staff to be good or very good. 85 % of the indoor patients and 90 % of the outdoor patients were of the view that the behaviour of staff was average.

Facility of drinking water in the hospital: The admitted patients and the outdoor patients were asked to give their opinion in the facility of drinking water in the hospital. Almost 21 % of the patients were of the view that the facility of drinking water was good, almost 63 % found the same to be average .Approximately 16 % of the patients felt that the facility of drinking water in the hospital was bad or very bad.

Opinion of patients about facilty of drinking water at Raisen District Hospital (value in percent)

67 70 58 60

30 23 20 16 20 10 10 3 3 0 0 0 Very good Good Average Bad Very Bad

Admitted Patients Outdoor Patients

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 24

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Facility of toilets in the hospital: Almost 48 % of the admitted patients were of the view that the facility of toilets in the hospital was bad or very bad while 53 % of outdoor patients who mentioned that the facility of toilets was bad or very bad.

Response of admitted patient for certain facilities availed by them exclusively: The admitted patients were asked about the quality of food, the response of the patients on the same is as under. 21 % of the admitted patients found the food served to them as good, 79 % felt that the food was average.

The admitted patients were asked to rate the stay facility for the attendants at the hospital. 74 % of the patients said that the facility for stay for the attendants in the hospital was either bad or very bad. 24 % of the indoor patients found the stay facility to be average, only 2 % of the respondents found the stay arrangement to be good.

The patients were asked if they would like to come back to the hospital if they faced any medical problem. This is an indicator of overall satisfaction from the services of the hospital. Almost all the patients mentioned that they would like to come back to the hospital in case of health related problems .However it must be kept in mind that majority of the patients who availed the facility of the district hospital Raisen were found to be from the relatively poor community also the education level of the families of the patient was also found to be not very high. Considering the cost of treatment to be much higher in the private institutions which has also been validated by the means of the study, it seems that the patients did not have many other options.

Private Hospital Vs Government Hospital

The respondents were asked if they availed the facility of treatment in private hospital / clinic during the last one year, 40 % of the respondents mentioned that they availed the facility of private hospital / clinic during the last one year.

The respondents were asked about the average monthly expenses on medicines for common problems like cough, cold, fever etc which they at time purchase directly from the chemist at

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 25

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses times based on the prescription given by the doctor much earlier or based on advice from the chemist, friends, relatives etc. On an average the patients spent Rs 728 per annum on purchase of medicines from common household health related problems. This is another aspect of out-of –pocket expenses on health which generally gets ignored.

The patients were asked about any other specific complains that they had or any suggestion they had to make improvement in the facility at the hospital. The major complaints and suggestions were:

Shortage of beds in the hospital Need for better arrangement for the attendants

The overall out of pocket expenses for patients who availed the facility of District hospital Raisen was found to be very low as compared with the out-of-pocket expenses incurred by the patient in the private facility. Particulars Amount spent by patients availing facility of district hospital Raisen ( amount in rupees) Indoor patients Outdoor patients Transport 164 124 Food related 228 7 expenses Stay facility 0 0 Pathological 0 0 investigation Investigation X- 0 6 ray, scan , other investigation Medicines 0 0 Total 392 137

The average cost of treatment in private hospital for the same disease among the patients of Raisen district was found to be Rs 1217.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 26

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

3.2 Findings of District Hospital Sehore:

District Hospital Sehore pattern of patients: The observation of the study is based on the responses received from the respondents comprising of patients. Almost 97 % of patients surveyed were from Sehore district itself. However, some patients from neighbouring districts like Raisen, Ujjain, Shajapur, Dewas etc also availed the facility of treatment at District Hospital Sehore. Against 200 beds sanctioned for the hospital, there are 260 beds available in the hospital. The detail of staff posted in the hospital is available in Annexure – IV. 3.2.1 Socio economic status of the patients availing treatment at District hospital Sehore Rural /Urban mix of patients: Majority of the inflow of patients were from the rural area (69 %) while only approximately 31 % of the patients who availed the services of the Sehore district hospital were from urban area.

B.P.L card holders: Approximately 53% of the families surveyed which availed the facility of Sehore District Hospital were B.P.L card holders.

Age group of the patient: The hospital provides a range of facilities for patients of all age groups. About 18% of the patients covered under the study were less than 10 years of age, 8 % were more than ten years but less than 18 years of age, and about 65% were in the age group 18-60 years while approximately 9% patients were more than 60 years of age. The range of facilities available in the hospital includes delivery, paediatrics, nutrition rehabilitation centre, surgery, ophthalmology, medicine, ENT, gynaecology, urology, dental etc. There is facility of OPD for outdoor patients and for admission of the patients. The average duration of stay in case of admitted patients was 5 days with a minimum duration of stay at the hospital for 1 day while the maximum duration of stay for the admitted patients covered under the survey was 14 days.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 27

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

District Hospital Sehore -number of respondent patients falling in different age groups

70 65% 60 50 40 30 18% 20 9 % 10 8% 0 0-10 years >10 years upto >18 years upto > 60 years 18 years 60 years

Category of patients: Almost 12% of the respondent patients who availed the services of Sehore District Hospital were from general category, approximately 9% were from scheduled caste, and 15% were from scheduled tribe while 64% were from other backward classes.

Category of respondent patients who availed treatment at District Hospital Sehore General 12% Scheduled Caste 9%

Scheduled Other Tribe Backward 15% classes 64%

Level of education of the head of the household: In 39 % of the cases the head of the household was either illiterate or had completed primary education. In 15 % of the cases the head of household was educated up to middle school. 25 % and 11% had completed high

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 28

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses school and higher secondary school respectively. Only in 10 % of the cases the head of the house hold were either graduate or post–graduate.

Education level of the head of household of the patients surveyed in District Hospital Sehore Graduate Post Graduate 9% 1% Illiterate Upto 12th 22% Standard 11%

Upto 10th Standard 25%

Upto 5th Standard 17%

Upto 8th Standard 15%

Occupation: Information was gathered on the main source of income of the family of the patient availing the treatment facilities at district hospital Sehore. Majority of the patient’s family worked as labourers with almost 51% of the surveyed families working as labourer. Almost 24% derived their major source of income from agriculture, 16% of patients surveyed were self employed / had business, almost 4% were in government job while 5 % did other work like plumber, tailor, driver etc.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 29

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Main source of income for the family of the patients who availed treatment at District Hospital Sehore Others Self employed / 5% Business Agriculture 16% 24%

Govt. Service 4%

Labourer 51%

Monthly income of the household from all sources: Information was also gathered and classification was done on the basis of the monthly income of the families. Majority (56%) of the families earned less than Rs 5,000 per month while 27% of the families had monthly income in the range Rs 5,000 to Rs 10,000 approximately 6% of the families earning income in the range Rs 10,000 to Rs 15,000. Only 11% of the families covered under survey earned more than Rs 15,000 per month.

Monthly income from all sources of family of pateints visiting District Hospital Sehore(value in %)

60 56

40 27 30

20 6 10 5 2 3 1 0

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 30

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

It is a usual perception that Government hospitals are flooded with people and a numbers of persons accompanying the patient to the hospital are very high. The respondents were asked about the number of persons accompanying the patient to the hospital .In 17% of the cases there more than two persons were accompanying the patient.

Number of persons accompanying the patient to District Hospital Sehore (value in percentage)

80 64 60

40 19 20 12 4 1 0

3.2.2 Out of pocket expenses and experiences during treatment at District hospital Sehore Mode of transport: Among the admitted patients, about 25% used the Government supported transport facility like 108 or Janani express. The government supported facility was used in the cases pertaining to delivery of the baby, accident etc. Majority of the patients mentioned that they got the government supported facility free of cost; however, in few cases they mentioned that they had to pay some money for the service. Almost all the patients who availed the service of Janani Express / 108 ambulances received the same within 1 hour of calling the ambulance. 23% of the admitted patients used public transport like bus, tempo etc. 48% of the patients made their own arrangement including two -wheeler or car. 4 % of the patients came on foot.

Amongst the outdoor patients, 24% used public transport like bus, tempo etc. 23% of the outdoor patients came cycle or by foot. 53% of the respondents made their own arrangement

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 31

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses for travel to the hospital including two-wheeler and in rare cases some of the patients came to the hospital by car.

Cost of travel incurred by the patients: The average cost borne on account of travel by the indoor patients amounted to Rs 356, it was observed that few of the patients came from neighbouring district Shajapur and had to incur a cost of Rs 3,000 on account of travel to the hospital. Certain instances were found when the patients paid money even when they availed the facility of government supported transport the Janani Express and the 108 ambulance even when the facility should be available free of cost to the patients. Such instances cause dissatisfaction among the patients and efforts must be done to minimise such instances. The average cost of travel for the outdoor patients was Rs 78. Note: The information was gathered by means of a questionnaire at the time of discharge from the hospital .Thus the travel cost as informed by the patient was multiplied by 2 to be able to get the approximate travel cost involved.

In spite of the fact that some of the admitted patients used the government facility of 108 ambulances or Janani express, the average cost of travel is more in case of admitted patients than the cost of travel borne by the outdoor patients on account of certain cases were the patient had to spent higher amount as travel cost in case of emergency. The family also bears travel cost on account of visit of attendants of the patient to the hospital in the case of admitted patients.

Cost of travel in rupees -for pateints who availed the facility of treatment at District Hospital Sehore

356 400 300 200 78 100 0 Admitted patients Outdoor patients

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 32

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Cost of stay in case of admitted pateints : Inforamtion was gathered from the admitted pateints for cost incurred during stay in the hospital for treament.Majority of the attendants of the patients shared the bed with the patient or slept on the floor.Few respondents mentioned paying amount in the range Rs 50 to Rs 200 on account of stay.

Amounts spent on food during treatment at the hospital: There is a facility of free food for the admitted patients in the hospital. The food being served to the patients was also observed. In spite of the fact that food is provided free of cost the admitted patients, some expenses are incurred on food for attendants. Also, some amount is spent on food by outdoor patients and their attendants. An average sum of Rs 313 was spent for food related expenses in case of admitted patients. The average duration of stay in case of admitted patients was 5 days with a minimum duration of stay at the hospital for 1 day while the maximum duration of stay for the admitted patients covered under the survey was 14 days. The admitted patients spent Rs 56 per day on an average on account of food during stay at the hospital .While in case of outdoor patients they spent an average amount of Rs 9 on food.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 33

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Average cost of food in rupees availing treatment at District Hopsital Sehore

313

300 250 200 150 9 100 50 0 Admitted Patients Outdoor Patients

Expenses for medicines and investigation: Medicines: Medicines were provided free of cost in case of majority of the patients, however, purchase of medicine was reported in few cases since the medicine was not available in the hospital.

Investigations: The facility of free investigation was provided to majority of the patients. Some patients reported that paid money for pathological investigations and x-ray .The reason reported for the same were: delay in investigation or it was informed by the doctor that the investigation needs to be done form outside the district hospital. Efforts must be done to minimise such cost to the extent possible.

CT scan machine is available in the district hospital Sehore on a PPP mode. The BPL patients are not charged any amount for the scan facility. There is a rate list applicable for the scan facility of the APL patients. It was observed that CT scan was being done free of cost for the BPL patients.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 34

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Health care seeking behaviour: The patients were also asked about the treatment taken, if any course of action taken by them in the past for treatment of the same disease in the past. About 50 % of the patients either treated the patient at home or did not take any action for treatment prior to bringing the patient to the district hospital. The patients availing the facility of district hospital Sehore showed higher faith in the Govt supported facility as approximately 40 % of the respondents had visited same or other government hospital in the past for treatment of the same disease. Only 7 % of the patients used the facility of private hospital/ clinic in the past for the treatment of same disease. The usage of facility of CHC/ PHC was also found to be very low likewise the usage of jadi-booti or traditional medicine was also found to be low among the respondents.

The respondents were asked about the nearest government health facility for them. Majority 86 % of the respondents mentioned District hospital Sehore to be the nearest Government supported health facility. 14 % of the respondents mentioned that other health facility was available close to their residence at average distance of about 9 km, yet they preferred to come to District hospital for treatment. This shows lack of awareness about the facilities available at the PHC/CHCs and the need to strengthen the same.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 35

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Action taken for treatment of same disease prior to bringing the pateint to district hospital PHC / CHC Treatment at 2% home only 12%

Same/other Government hospital 40%

No action taken prior to this 38%

Private clinic/hospita l Used Jadi- 7% booti 1%

Note: The patients who used the private hospital / facility before availing the Govt facility had a total out of pocket expenditure of Rs 2566.

Referral mechanism: Ideally the patient should visit the neighbouring Sub – centre or PHCs and in case of problem referred to CHC of sub-district hospital. However, it was found only 2% of the patients surveyed were referred to the hospital.

Travel time to reach the hospital: Information was gathered from the respondents regarding the travel time required to reach the hospital. Almost 94 % of the patients reached the hospital within one hour, 6 % of the respondents reached took more than one hour to reach the hospital while in case of 1 % of the respondents it took them more that 2 hours to reach the hospital .Almost all of the indoor patients who used the Govt supported transport facility like the Janani Express or 108 ambulance were also able to get the vehicle in 1 hour’s time.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 36

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Travel time to reach Distrct Hospital- Sehore

1 hour to 2 more than 2 hours hours 6% 1%

upto 1 hour 94%

Waiting time to show the patient to the doctors: Once the patient reaches the hospital he /she have do the registration and then stand in a queue waiting to be seen by the doctor. About 73% of the respondents mentioned that they waited for almost half an hour to meet the doctor. About 25% of the patients waited more than 30 minutes but within 1 hour. 2% of the patients had to wait for more than one hour but less than 2 hours.

It is a major complaint by the patients that they were not seen by the doctors in Government hospital do no not see the patient or listen to their complaint for sufficient duration of time. The summary of the responses is as under:

Time taken by doctors to see the outdoor patients (responses value in %) 0-5 minutes 62 5-10 minutes 26 10-30 minutes 9 > 30 minutes 3

Opinion of patients regarding behaviour or the doctors: Opinion was taken from the patients regarding on the behaviour of the doctors during the course of the treatment approximately 70 % of the outdoor patients and indoor patients found the behaviour of the doctor to be good or very good, while almost 30 % of the patients were of the view that the behaviour of doctors was average.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 37

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Opinion of patients regarding behaviour of the staff: 72 % of the indoor patients were of the view that the behaviour of staff was good or very good approximately while 68 % of the outdoor patients found the behaviour of the staff to be good or very good. Almost 30 % of the patients were of the view that the behaviour of staff was average.

Major portion of the Sehore district hospital was renovated in the recent past. Some construction work was still going on at the time of data collection.

Facility of drinking water in the hospital: The admitted patients and the outdoor patients were asked to give their opinion in the facility of drinking water in the hospital. 66 % of the indoor patients and 63 % of the outdoor patients were of the view that the facility of drinking water was very good or good in the hospital .Approximately 35 % of the patients felt that the facility of drinking water in the hospital was average or bad.

Facility of toilets in the hospital: The admitted patients stay and use the facility of toilets in the hospital for a longer duration of time. 67 % of the admitted patients were of the view that the facility of toilets in the hospital was good or very good while 62 % of outdoor patients who mentioned that the facility of toilets was good or very good.

Response of admitted patient for certain facilities availed by them exclusively: The admitted patients were asked about the quality of food, the response of the patients on the same is as under. 15 % of the admitted patients found the food served to them as very good, 61 % felt that the food was good while 24 % of the admitted patients found the quality of food to be average.

The admitted patients were also asked to give their opinion on the facility of stay for the attendants, 66 % of the responded found the facility to be good, 32 % found it to be average while 2 % of the respondents mentioned that the facility of stay was bad.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 38

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

The patients were asked if they would like to come back to the hospital if they faced any medical problem. This is an indicator of overall satisfaction from the services of the hospital. Almost all the patients mentioned that they would like to come back to the hospital in case of health related problems .However it must be kept in mind that majority of the patients who availed the facility of the District hospital Sehore were found to be from the relatively poor community also the education level of the families of the patient was also found to be not very high. Considering the cost of treatment to be much higher in the private institutions which has also been validated by the means of the study, it seems that the patients did not have many other options.

The respondents were asked if they availed the facility of treatment in private hospital / clinic during the last one year, 53 % of the respondents mentioned that they availed the facility of private hospital / clinic during the last one year.

The respondents were asked about the average monthly expenses on medicines for common problems like cough, cold, fever etc which they at time purchase directly from the chemist at times based on the prescription given by the doctor much earlier or based on advice from the chemist, friends, relatives etc. On an average the patients spent Rs 745 per annum on purchase of medicines from common household health related problems. This is another aspect of out-of –pocket expenses on health which generally gets ignored.

The patients were asked about any other specific complaints that they had or any suggestion they had to make improvement in the facility at the hospital. The major complaints and suggestions were: ‘ilaj time se kiya jaye’ which is an indicator of the time spent by the patients and their attendants during the course of the treatment. Patients also complained about the excess time taken for the investigations, lack of cleanliness in the toilets and scarcity of staff in the hospital.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 39

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

The overall out of pocket expenses for patients who availed the facility of district hospital Sehore was found to be low as compared with the out-of-pocket expenses incurred by the patients in the private facility.

Particulars Amount spent by patients availing facility of district hospital Sehore ( amount in rupees) Indoor patients Outdoor patients Transport 356 78 Food related 313 9 expenses Stay facility 5 0 Pathological 66 2 investigation Investigation X- 80 20 ray, scan , other investigation Medicines 87 0 Total 907 106

The average cost of treatment in private hospital by patients of Sehore district for the same disease was found to be Rs 2566.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 40

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

Chapter 4 Recommendations

Overall the district hospitals seems to have worked reasonably well on account of fulfilling the mandate of the National Health Policy of providing health care while trying to minimise the cost or financial hardship to the patients. The following recommendations are made based on the feedback received from the patients and the findings of the study:

1. Minimise cost of treatment to the patient: Health problem in the family coupled with expenditure on account of treatment is a great cause for concern especially to the poor. It was found that the facility of the hospital is mostly used by the people from the low socio- economic background. It was found that in some cases the patients had to get the investigation done from outside on account of delay in the investigation at the hospital and so end up paying money for the same. In rase cases medicine was purchased from outside especially in case of admitted patients. Such cases should be minimised. It was found that if the patients end up in the private health facility then the cost of treatment both direct cost and indirect cost increases exponentially. The staff of the Government health facility should be sensitive towards the importance of the service provided by them is on the life of the patients. 2. Improved awareness and availability of transport for the patients to the hospital: The Government of Madhya Pradesh has provided the facility of free transport for patients under 108 ambulances and for pregnant women and infants under Janani Express. Majority of the pregnant women who came to the hospital for delivery were able to get the benefit of Janani Express or 108 ambulances to reach the hospital. Certain instances were found when the patients paid money even when they availed the facility of government supported transport the Janani Express and the 108 ambulance even when the facility should be available free of cost to the patients. Such instances cause dissatisfaction among the patients and efforts must be done to minimise such instances. 3. Staffing in the hospitals: There is high importance of each level of functionary in a government hospital including doctors, nurses, pharmacists, technicians, cleaner, driver etc needs to be taken into consideration. Each of the service providers has an important role to play in the smooth running of the mechanism. Also since the facility of hospital has to function 24 by 7 throughout the year it is important to have a contingency plan for dealing with staff related issues in case of an emergency. Deficiency of health personnel is not Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 41

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses limited to doctors alone. In the case of district hospital Raisen almost 50 % of the posts lie vacant. Similarly lack of staff was found at district hospital Sehore also. In light of these circumstances the patients and services of the hospital suffer. There is shortfall in various categories of paramedical personnel which is a cause of concern. Thus there is an urgent need to address the staff related issues.

4. Attitude of the doctor and staff towards the patients: Opinion was taken from the patients regarding on the behaviour of the doctors and staff during the course of the treatment , in almost while 30 % of the patients who availed the facility of district hospital Sehore felt that the attitude of the doctors and the staff members towards the patients was average or bad .It is proposed that a short training on soft skills and sensitivity to the needs of the patient be organised for staff in the hospital.

5. Cleanliness and facility of toilets: There is a high risk of spread of infection if the hospital premises are not kept clean. Maintenance of the hygiene and cleanliness of health facilities and the toilets helps in reducing the risk of Hospital Acquired Infections (HAI). Maintaining cleanliness in a health care facility differs from the conventional cleaning. The admitted patients stay and use the facility of toilets in the hospital for a longer duration of time. 33 % of the admitted patients for District hospital Sehore were of the view that the facility of toilets in the hospital was bad or very bad as compared to 30 % of outdoor patients for District hospital Sehore who mentioned that the facility of toilets was bad or very bad .Thus, there is a the need to ensure that the toilets are functional and cleaned regularly in a phased manner round the clock in the hospital.

Based on the responses from the patients it is known that the condition of toilets in District Hospital Raisen was even worse with 48 % of the admitted patients and 53 % of the outdoor patients stating that the facility of toilets in the hospital was bad or very bad . This issue needs to be addressed immediately.

6. Facility of drinking water: The facility for drinking water is a very important for the smooth functioning of the hospital. Approximately 35 % of the patients who availed the facility of district hospital Sehore said that the facility of drinking water was either average or bad. There is a need to ensure regular supply of clean drinking water in the hospital.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 42

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

The facility of drinking water was not very good at District Hospital Raisen was not very good with almost 63 % of the respondents stating that the facility of drinking water was average and 16 % of the patients felt that the facility of drinking water in the hospital was bad or very bad. This is an area of concern and it is proposed that immediate action be taken to improve the facility of drinking water in the hospital.

7. Increased use of information technologies: One of the common problems reported by the patients was delay in investigations. A number of modern technologies have become available over the years to improve the functioning of public hospitals. The guiding principle for their use should be that these technologies should be used to maximize the patient welfare, rather than for curtailing patient services. Diagnostic equipment, like auto analyzers that are now available, have replaced the manual diagnostic processes and can be deployed to do laboratory investigations round the clock without necessarily having to deploy larger manpower as was necessary with manual processes. 8. Strengthening the referral mechanism: The referral system is very important for the smooth functioning of the system. It is essential to strengthen the institutions of PHC and CHC to be able to rationalise the flow of patients, it was found that majority of the patients came to the district hospitals. This scenario leads to over load at the district hospital .It is essential that training calendar be developed and the staff of PHC / CHC visit the district hospital and take training of dealing with basic health issues. The general population availing the facility of the district hospital must also be counselled and encouraged to visit the neighbouring health facilities.

The task of making the primary and secondary level health institutions functional ought to be the utmost priority, such that people can access effective healthcare for common and easily treatable conditions nearest to their homes. Urgent steps need be taken to provide working and living conditions in the peripheral areas that will encourage doctors and other health personnel to be willing for rural service. Family hostels should be built in the nearby urban centres to house the families of doctors and other medical personnel, while they are posted in remote areas. It may be noted that such steps are taken in the case of defence personnel , if comparable status is given to health care professionals if will go a long way in improving the health scenario.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 43

Study of district hospital Raisen and Sehore – An analysis of out of 2018 pocket expenses

References: http://www.mpinfo.org/MPinfoStatic/english/articles/2013/100813Lekh22.asp, Department of Public affairs, govt of MP accessed on 10th May 2018 and brochures on the government schemes National Health Accounts Estimates of India 2014-15 - https://mohfw.gov.in/sites/default/files/National%20Health%20Accounts%20Estimates%20Report%2 02014-15.pdf Vikas Bajpai, the Challenges Confronting Public Hospitals in India, Their Origins, and Possible Solutions, Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India, Advances in Public Health Volume 2014 (2014), Article ID 898502 Nicholas Otieno Okello and Dr. Agnes Njeru- Factors Affecting Out-Of-Pocket Medical Expenditure Among Out Patients in Hospitals in Nairobi County- International Journal of Scientific and Research Publications, Volume 5, Issue 6, June 2015

Footnotes:

1. Xu K (2004) Distribution of health payments and catastrophic expenditures. World Health Organization. 2. Carrin G, James C, Evans D (2005) Achieving universal health coverage: Developing the health financing system. World Health Organization, Geneva. 3. Puteh SEW, Almualm Y. Catastrophic Health Expenditure among Developing Countries. Health Syst Policy Res. 2017, 4:1. doi:10.21767/2254-9137.100069. 4. Wyszewianski L. Financially catastrophic and high-cost cases:definitions, distinctions, and their implication for policy formulation.Inquiry1986; 23:382–94 5. http://www.who.int/health_financing/documents/lancet-catastrophic_expenditure.pdf accessed on 21/08/2018. 6. Krishna, Anirudh, M Kapila, M. Porwal and V. Singh. Why Growth is not enough: Household Poverty Dynamics in Northeast Gujarat, India. Journal of Development Studies, Vol. 41, No. 7. October 2005 7. Golechha M (2015) Healthcare agenda for the Indian government. Indian J Med Res 141:151-153. 8. Key indicators of Social Consumption in India Health, Ministry of Statistics and Programme Implementation, National Sample Survey Office, NSS round 71. 9. Healthy States, Progressive India report on the ranks of States and Union Territories, Ministry of Health and Family Welfare, Govt of India, Niti Aayog and the World Bank.

Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 44

Financial flow of funds in health system Annexure I

- State Enterprises- NPISH External Union Governments ULBs/RLBs Households nt

Government Public & Private (NGOS) Donors ssssolds

care Financing Financing care (FS) Schemes Revenues of Health of Revenues Private Health OOPE State Other State/District Trusts for Schemes OCMS MoHFW State DoHFW ESIC Depts. Societies on social Insurance MMS hawk protection/NPISH

HF)

(

–

Government

Financing Financing Schemes Healthcare Healthcare health insurance

Government Health facilities (Center of Excellence, Medical College Private Health Facilities (HP) Hospitals, all public health facilities including Hospitals/ Dispensaries of - ULB, Defense, ESI, ECHS, Railways, CGHS) (Private Hospitals/ clinics, Enterprises Hospitals/ Clinics, NPISH Hospitals/Clinics)

Providers ( Households (as a source of finance and consumer of healthcare services and goods)

Find flow Fund flow to Government Taxes Payments OOPE NHM fund Premiums Fund Flow to NPISH Health Facilities flow to Private Facilities

ULB- Urban Local Bodies; RLB- Rural Bodies ESIC- Employees State Insurance corporation NPISH- Non- Profit Institutions Serving Households (NGOs) ECHS- Ex- Servicemen Contributory Health Scheme OCMs- Other Central Ministries);DH – District Hospital;SDH – Sub District Hospital CGHS- Central Government employee Health Scheme CHC- Community Health centre; PHC- Primary Health Centre; SC- Sub-centre OOPE- Out of pocket Expenditure; DoHFM- Department of Health and Family Welfare NHM- National Health Mission

Source : National Health Accounts Guidelines for India 2016 , National Health Accounts Technical Secretariat , National Health System Resouce Centre , Ministry of Health and Family Welfare , Govt of India

Annexure – II Strength of ward wise beds in Raisen District Hospital ftyk fpfdRlky; jk;lsu es orZeku esa iyaxks dh la[;k

1 esy okMZ 85 2 Qhesy okMZ 58 3 cPpk okMZ 17 4 ,u +vkj +lh +okMZ 10 5 ,l +,u +lh +;w +okMZ 22 6 vkbZ +lh +;w +okMZ 4 7 izk;osV okMZ 4 8 ih +ih +okMZ 55 9 eerk okMZ 10 Lokbu ¶yw 4 esu vksVh ,y +Vh +Vh + 4 10 vkbZ okMZ 10 ;ksx 283

Annexure-III jk;lsu ftyk vLirky& laoxZ ds Lohd`r dk;Zjr ,oa fjDr inksa dh tkudkjh

Ø + in dk uke Lohd`r in dk;Zjr in fjDr in 1 mi izca/kd 1 0 1 2 esMhdy fo'ks"kK 5 1 4 3 us= jksx fo'ks"kK 2 1 1 4 'kY; fØ;k fo'ks"kK 2 1 1 5 L=h jksx fo'ks"kK 4 2 2 6 f'k'kq jksx fo'ks"kK 7 2 5 7 fu'psruk fo'ks"kK 4 1 3 8 jsfM;ksykftLV 2 1 1 9 vfLFk jksx 3 1 2 10 iSFkkykftLV 2 2 0 11 ukd dku xyk fo'ks"kK 2 0 2 12 nar jksx fo'ks"kK 1 0 1 13 {k; jksx fo'ks"kK 1 0 1 14 esMhdy vkWQhlj 28 8 20 15 nar 'kY; fpfdRld 2 2 0 16 vk;q"k fpfdRld 1 0 1 17 izk'kkldh; vf/kdjh 1 0 1 18 , +,l +vks + 1 0 1 19 eq[; fyfid 1 1 0 20 ys[kkiky 3 2 1 21 dsf'k;j 1 0 1 22 lgk;d xzsM&2 2 1 1 23 lgk;d xzsM&3 3 4 -1 24 LvhoMZ 1 0 1 25 ck;ksdsfeLV 1 1 0

26 ySc VsDuhf'k;u 15 8 7 27 jsfM;ksxzkQj 5 3 2 28 us= lgk;d 3 2 1 29 QkekZflLV xzsM 2 8 1 7 30 Msªlj 8 8 0 31 ySc lgk;d 1 1 0 32 MkdZ#e lgk;d 3 2 1 33 osDlhusVj 1 0 1 34 bysDVªhf'k;u 1 0 1 35 okgu pkyd 2 1 1 36 esVªu 7 0 5 37 uflZx flLVj 4 0 2 38 LVkQ ulZ 115 69 46 39 , +,u +,e 3 2 1 40 nkbZ 4 4 0 41 Hk`R; 12 10 2 42 pkSdhnkj 1 1 0 43 Dqd 1 0 1 44 Dyhuj 2 0 2 45 MkdZ#e vVsaMsV 3 1 2 46 vks +Vh +vVsaMsaV 10 0 10 47 vk;k 2 2 0 48 ysc vVsMsaV 6 2 4 49 okMZ ok; 25 7 18

50 Lohij 7 9 -2 51 okMZ ck; lafonk 20 0 20 52 dEI;wVj vkWijsVj lafonk 4 0 4 okgu pkyd lafonk ij 53 4 0 4

Total 358 164 194

Annexure –IV Status of staff at district hospital Sehore