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

1. Dr Shyam Ashtekar
MD (Preventive & Social Medicine)
Nashik 422013
1st April 2011
11/21/2012 1

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.  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

4. 11/21/2012 4

5. 11/21/2012 5

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
7
degree not Avialble 91
121
Homeopaths# 153
1250
A) Gen Practitoners 1622
0 200 400 600 800 1000 1200 1400 1600 1800
11/21/2012 6

7. 11/21/2012 7

8. Hospital beds by location
15 Rural blocks
4162
32%
Nasik city,Ozar,
Nasik city,Ozar, Devli
Devlali
Malegaon city
7815, 61%
15 Rural blocks
Malegaon city
891
7%
11/21/2012 8

9. Govt; 2828;
22%
Mun/ cant ;
716; 6%
Pvt; 7859;
61%
Trusts; 1468;
11%
11/21/2012 9

10. 2000
1800
1600
Nashik city: Pvt & Trust Hospitals by bed capacity
1400
1200 N(units) beds
1000
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+
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11. 11/21/2012 11

12. 11/21/2012 12

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.  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

15. 11/21/2012 15

16. Public sector
174
14%
Pharma
Public sector
536
42% Pvt
Trust Hosp
Pvt Pharma
527
Trust Hosp 42%
27
2%
11/21/2012 16

17. Table3: Fees and rates of various sector in Nasik
Private sector charges RSBY offers MVP hospital
Item (without medicine) Cover up to
GP fees (usually includes an -
injection) 30-50 None
PG-Consulting-specialist 200 None
Super specialist consulting fees 500-1000 None
Normal delivery $ 10000-30000 2500 1500
LSCS (Caesarian section)$ 25000-50000 4500 1500
MTP (medical abortion) 2000-4000 500
Appendix surgery 15000-40000 8000 1000
Hernia 10000-25000 8000 1500
Hip fracture: surgery with 1000-1500
prosthesis 25000-70000 10000
Cataract (Indian lens) 5000-12000 5000 500
Angiography 6000-10000 10000 ?
Heart -Bypass surgery (CABG) 150000-200000 NA
ICU daily charge 2000-5000 300 200
Ventilator 750
Bed charges 500 150
SONOGRPHY# 600 100-250
X-ray chest adult size 250-500 110
Hysterectomy vaginal 25000-50000 10000 2000
Medicine costs As per details 15000 ?
$ in MVP hospital 1&2nd delivery and LSCS are free & there is no separate charge for LSCS
Hernia 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.  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

19. 11/21/2012 19

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. Context
public:
pvt Number
dichotom s
y
Public
health
clients’ perspective Distribut
angle ion
efficienc Quality
y of care
11/21/2012 21

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.  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. 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.  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.  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.  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.  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.  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.  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.  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.  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.  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.  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

35. 11/21/2012 35

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.  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.  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.  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.  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. •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 life
Rising Cost
threatening/terminal chronic illnesses.
of care
• Are Medicines costlier than doctors? Can doctors remedy
this problem?
11/21/2012 41

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 and
hospitals charitable prices?
11/21/2012 42

43. 6. Review prescription practices for rational therapeutics
5. Efficient utilization of pubic & Trust facilities
4. Promote public hospitals & affordable charitable hospitals
3. Expansion of RSBY and Group insurance
2. 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

44. 11/21/2012 44

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

46. 11/21/2012 46