Health care terrain of a district nashik 2011

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This is my study of the health care sector of a district in Maharashtra-(Nashik) in 2011. How do we go from here to Universal Health care? I invite comments

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Health care terrain of a district nashik 2011

  1. 1. Dr Shyam AshtekarMD (Preventive & Social Medicine) Nashik 422013 1st April 2011 11/21/2012 1
  2. 2.  Nashik is said to be part of the ‘golden triangle’ of Pune-Mumbai-Nashik Has all ingredients –a booming city, rural, tribal, draught prone. The prestigious Maharashtra University of Health Sciences is in this city. This district has all types of medical colleges: Modern medicine, Ayurveda, Homeopathy, Unani, Dental, Pha rmacy, Nursing etc. 11/21/2012 2
  3. 3.  We started with NMC registry data for clinics and hospitals (2009-10), However we had to revise the data after checking other relevant sources. We obtained figures from various medical associations/members for each category of doctors. Rates of some typical medical services have been obtained through telephonic enquiries from some hospitals/close sources. Estimates of pharmacy sales are based on distributors’ average monthly proceeds from reliable sources, and in case of Malegaon from octroi-tax information. 11/21/2012 3
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  6. 6. Super specialty 25 25 ENT sp 26 50 Anesthetists 65 65 gen Physician 75 80 Radiologists 83 85 Orthopedic sp 87 100 Child sp 140 200 C) Specialists 1106 B) Dentists 350 7degree not Avialble 91 121 Homeopaths# 153 1250A) Gen Practitoners 1622 0 200 400 600 800 1000 1200 1400 1600 1800 11/21/2012 6
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  8. 8. Hospital beds by location 15 Rural blocks 4162 32% Nasik city,Ozar, Nasik city,Ozar, Devli Devlali Malegaon city 7815, 61% 15 Rural blocksMalegaon city 891 7% 11/21/2012 8
  9. 9. Govt; 2828; 22% Mun/ cant ; 716; 6%Pvt; 7859; 61% Trusts; 1468; 11% 11/21/2012 9
  10. 10. 200018001600 Nashik city: Pvt & Trust Hospitals by bed capacity14001200 N(units) beds1000 800 600 400 200 0 71+ 81+ 91+ 0-4 11--20 5--10 21-30 31-40 41-50 51-60 61-70 101+ 11/21/2012 10
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  13. 13.  Dysfunctional SS Shalimar hospital Overcrowded district Hospital, Public hospitals are last option for poor families Specialist scarcity in public hospitals Only 4 anesthetists in 26 Rural Hospitals! Scant C-section services in RH (state data < 10 per yr per RH) 11/21/2012 13
  14. 14.  For all the state Govt facilities-the district has only 96 specialists for over 1600 beds spread in 24RH, 5SDH, 1DH, 1 Super specialty H, and an ESIS hospital. In contrast, NMC has 67 specialists for 600 beds in the 5 hospitals. The State Govt needs to look at this generic problem. 11/21/2012 14
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  16. 16. Public sector 174 14% Pharma Public sector 536 42% Pvt Trust Hosp Pvt Pharma 527Trust Hosp 42% 27 2% 11/21/2012 16
  17. 17. Table3: Fees and rates of various sector in Nasik Private sector charges RSBY offers MVP hospital Item (without medicine) Cover up toGP fees (usually includes an -injection) 30-50 NonePG-Consulting-specialist 200 NoneSuper specialist consulting fees 500-1000 NoneNormal delivery $ 10000-30000 2500 1500LSCS (Caesarian section)$ 25000-50000 4500 1500MTP (medical abortion) 2000-4000 500Appendix surgery 15000-40000 8000 1000Hernia 10000-25000 8000 1500Hip fracture: surgery with 1000-1500prosthesis 25000-70000 10000Cataract (Indian lens) 5000-12000 5000 500Angiography 6000-10000 10000 ?Heart -Bypass surgery (CABG) 150000-200000 NAICU daily charge 2000-5000 300 200Ventilator 750Bed charges 500 150SONOGRPHY# 600 100-250X-ray chest adult size 250-500 110Hysterectomy vaginal 25000-50000 10000 2000Medicine costs As per details 15000 ?$ in MVP hospital 1&2nd delivery and LSCS are free & there is no separate charge for LSCSHernia in pediatric age group is free*MTP with TL is free in MVP, # obstetric sonography in MVP hospital costs Rs 100 11/21/2012 17
  18. 18.  Rates of private medical services are going up due to many factors-investment in building and technology, increasing competition for patient volume, changing nature of medical practice (more investigations, defensive medicine) and better income of some clients. Trust hospitals represent a scenario of rates with ‘no capital investment’, which is a potent formula for affordable care for future. PPPs can help. The equally big public hospital sector can work as a good parallel care-provider, and needs to be looked as such. Can we make it a vibrant system? 11/21/2012 18
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  20. 20.  Do all or most people in need get care : Equity Can all people-the last man –get care: Access Can all people afford it: The price factor Are the services good: Outcomes Is it efficient: Is it worth the rupees spent by clients Does it improve health situation: Decrease in mortality and morbidity 11/21/2012 20
  21. 21. Context public: pvt Number dichotom s y Public healthclients’ perspective Distribut angle ion efficienc Quality y of care 11/21/2012 21
  22. 22.  If we want to ensure HEALTH CARE FOR ALL/ UNIVERSAL HEALTH CARE- is our hospital sector rightly poised? Is there a correct mix of pre-hospital and post-hospital care with the hospital sector, Are there synergies? 11/21/2012 22
  23. 23.  Nearly 1 bed for 470 people, satisfies UHC recommendation of 2 beds for 1000 pop. We do not know about occupancy/utilization rates Is it an oversupply, will it escalate costs? 11/21/2012 23
  24. 24. This is about various aspects of care given: Appropriate interventions for client needs Result oriented Timely Rational & Scientific Humane Ethical Accountable (procedure audits?) 11/21/2012 24
  25. 25.  The BNHRA is an underdeveloped/ rudimentary act. Rules & byelaws are awaited. But many nursing homes may not conform to it, esp the small ones. Infrastructure, HR and transparency are issues in some cases. Many units may not qualify for medical insurance (<20 beds) Hospital accreditation system is still not very popular. 11/21/2012 25
  26. 26.  Rural sector, with 60% population has 32% beds, but this is OK since hospital system is always clustered in urban areas. Pvt sector is naturally clustered in better off areas Public sector has to compensate or reach out. 11/21/2012 26
  27. 27.  Efficiency is productive utilization of beds We dont know about bed-occupancy We dont know about outcomes We dont know about costs and earnings of various units- Since most Exp is from private sources, the efficiency factor is largely invisible, It will be visible and operative only when third party payment or UHC will come into force. 11/21/2012 27
  28. 28.  What does it cost to clients..the price tables is suggestive Pvt Insurance is still not very large enough, may cover only 20% clients is the Pvt sector affordable to most clients? There are no local studies But national studies suggest hardships..one cause of client dissatisfaction 11/21/2012 28
  29. 29.  10% doctors are in public sector, 90% in pvt and trust sector 61% Hospitals beds are in Pvt sector 70% specialist positions are vacant in rural hospitals Super-specialty hospital is still largely defunct Govt is instead pushing schemes like Jeevandai, which buys pvt care for poor clients We need to count Trust Hospitals in a semi-public sector 11/21/2012 29
  30. 30.  The Govt floated the scheme, of providing cover to all ‘procedures’. Cover upto 2 lakh annual. operated thru Star Health established network of corporate hospitals, 50+ bedded private hospitals, government medical colleges, district hospitals and area hospitals Public-private partnership Focus on Tertiary Care 11/21/2012 30
  31. 31.  Many hospitals in smaller towns in the state were performing unnecessary hysterectomies to benefit from the scheme. Normally the insurance company maximizes its profits by closely monitoring the hospital’s practice and claims to limit payouts. In Arogyashri, the insurance company benefits every time bills are paid since they take 20% of the amount paid out. 11/21/2012 31
  32. 32.  The Aarogyasri scheme has been revolutionary in placing health on the political map in the state. It is a major landmark in India’s administrative approach to health and has emerged as a popular scheme among the masses. It has given hope to multitudes where none existed. However in its current form, the programme is a means to fund corporate hospital profit and distorts the pattern of healthcare in the state. A re-examination of the Aarogyasri programme is urgently necessary, especially in the context of its emergence as a possible model for universal healthcare. 11/21/2012 32
  33. 33.  The NHS British Model (Beveridge)-The sarkari model (so is Canada, Cuba) American Model- Private Insurance, Private providers, Health Management Organizations ( insurance and provision by same company) Bismarck Model: Social Health Insurance wherein social contribution/Cess flows into sickness fund, also fund from Govt. The fund is managed by providers’ collective, everyone gets care Chinese model: Public health system pyramid, paid post 1979 by users, now converting into social health insurance model, Govt bears small part Our Desi model: Mixed Health system 11/21/2012 33
  34. 34.  Has a good Primary sector (gatekeeper) Institutiinal secondary-tertiary health care Universal access-all people get care All conditions are covered Most/All providers participate Payment not at point of service. Both client and provider are not worrying about payment. Some arrangement of pre or post payment, either through tax or social insurance 11/21/2012 34
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  36. 36.  12th FY plan wants to increase allocation to health sector from 1.2% to 2.5% of GDP The states may not be able to improve their allocation UHC by HLEG intends to improve (a)public hospitals (b) offer cashless care to all clients thru free health cards (c) declare a national health package. 11/21/2012 36
  37. 37.  An opportunity, influential doctors can lobby for taking N as a pilot district. With known limitations, UHC is still a potent tool for offering free health care to all How it translates in a district is something to see—the HOW’s are very important. It wants to steer clear of Pvt health insurance, close user fees in public hospitals, PPPs with large hospitals on exclusive terms, contracts with primary care providers, invest in health promotion etc. 11/21/2012 37
  38. 38.  Small units may start closing down due to problems of technology & capital, HR and issues regarding scale of operations. However Gynec, Pediatric units may hold ground no matter how small they are. Costs and prices of medical care will rise. All super-specialty work may cluster in few units. PPPs may happen under UHC, Jeevandai is an insidious start. 11/21/2012 38
  39. 39.  Maharashtra may expand its Jeevandai yojna, with more families under cover, listing more conditions, higher compensation packages. Health Cess may come! GOI was considering a National Health package, cashless cover (BPL and APL), Free drugs for all, even for private care seekers ( cover for generics and EDL) New RSBY may appear. 11/21/2012 39
  40. 40.  Broadly Nashik district spends about 1263 crores—or 2000 Rs per capita on health care thru public, private sources Theoretically, the district can develop social health insurance model for all including BPL, including public hospitals. The NMC and ZP and local bodies can experiment in some wards/blocks. 11/21/2012 40
  41. 41. •GP will nearly consist of AYUSH doctors, while PG mostly from MM- how do we cope with this legally and academically?The GP-PG •If GP sector declines what happens to economics of health care? issue Where is the family doctor? •Do more patients now go directly to PG-consultants rather than GPs? • Increasing specialization and deconstruction of medical A diagnosis and treatment is unfavorable to holistic health.deconstruct How do we correct this? of medical • What is the legal responsibility of a specialist to problems approach. of other organs? • Surely some can afford the current costs of care, but definitely not all can pay the rising bills, esp lifeRising Cost threatening/terminal chronic illnesses. of care • Are Medicines costlier than doctors? Can doctors remedy this problem? 11/21/2012 41
  42. 42. Insurance • How can medical insurance help families to contain costs? & RSBY • How can RSBY be available and actually help families? Public • Only select Govt and Municipal hospitals are fully utilized Health • How do we put other facilities to use?facilities. • How to fully activate the Shalimar Super Specialty hospital? • Are all charitable hospitals fully functional, and fully utilized?Charitable • Are all charitable hospitals offering services at affordable andhospitals charitable prices? 11/21/2012 42
  43. 43. 6. Review prescription practices for rational therapeutics 5. Efficient utilization of pubic & Trust facilities4. Promote public hospitals & affordable charitable hospitals 3. Expansion of RSBY and Group insurance2. Programs by NMC/Govt for preventing Diabetes, High BP, IHD, Develop Open information sources/campaigns 1. Improve pre & post hospital care, esp home care and GP sector, AYUSH, 11/21/2012 43
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  45. 45.  Wherein capital costs are borne by other sources Transparent and dedicated management Provides both secondary and tertiary care Owns or links with primary care network 11/21/2012 45
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