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Experiences
from
STATE HEALTH SYSTEM
DEVELOPMENT PROJECT
WEST BENGAL
Selected indicators
0
500
1000
1500
2000
2500
3000
3500
No
of
inpatients
DH SD/SG RH
Average no. of admissions per
month per hospital
1997 2003
0
4000
8000
12000
16000
20000
No
of
patients
DH SD/SG RH
1997 2003
Average no. of outpatient attendance
per month per hospital
BED OCCUPANCY RATE
0
10
20
30
40
50
60
70
80
90
100
DH SD/SG RH
Percent 1997 2003
0
1
2
3
4
5
6
7
8
9
10
No.
served
per
bed
per
month
DH SD/SG RH
1997 2003
Bed Turn Over Rate
0
2
4
6
8
10
12
Percent
DH SD/SG
1997 2003
Percentage of major surgeries to
admission
Distribution of DHs by CUP sectors
0
10
20
30
40
50
60
70
80
90
100
110
120
0 10 20 30 40 50 60 70 80 90 100 110 120
BOR
BTR
1998
0
10
20
30
40
50
60
70
80
90
100
110
120
130
0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150
BOR
BTR
2003
Average monthly X-rays done, 1997-2003
 About one quarter of
project cost was
invested in
equipment
 The impact is quite
visible in terms of
increase in utilization
0
200
400
600
800
1000
1200
1400
DH SDH RH
1997
2003
Average monthly USGs done, 1997-2003
0
50
100
150
200
250
300
350
DH SDH
1997
2003
 Before project, some
of the diagonstic
services were almost
unavailable (e.g.,
USG) even at DH
level.
 After project, change
is dramatic.
Indicator Base line (1997) 2003 % change
Outpatients
D.H 2762640 3769525 36.45
S.D.H/S.G.H 5854536 8817853 50.62
R.H 6202620 9622930 55.14
Total 14819796 22210308 49.87
Inpatients
D.H 420840 584726 38.94
S.D.H/S.G.H 808128 999421 23.67
R.H 262140 424761 62.04
Total 1491108 2008908 34.73
Major Surgeries
D.H 32867 60047 82.70
S.D.H/S.G.H 54791 79798 45.64
Total 87658 139845 59.53
Deliveries
D.H 72384 112153 54.94
S.D.H/S.G.H 150958 191444 26.82
R.H 58431 87500 49.75
Total 281773 391097 38.80
IMPROVEMENT IN HOSPITAL UTILIZATION
Continued.
Indicator Base line (1997) 2003 % change
USG
D.H 1878 43009 2190.15
S.D.H/S.G.H 242 64366 26497.52
Total 2120 107375 4964.86
X-ray
D.H 134325 260136 93.66
S.D.H/S.G.H 229674 378213 64.67
R.H 39002 143549 268.06
Total 403001 781898 94.02
Laboratory tests
D.H 493150 940255 90.66
S.D.H/S.G.H 489756 1187223 142.41
R.H 246552 618447 150.84
Total 1229458 2745925 123.34
IMPROVEMENT IN HOSPITAL UTILIZATION
Access to the Poor
 Majority comes from the weaker section of the
community
31
18
15 15
21
32
20
14
12
22
Poorest 20% Next 20% Middle 20% Next 20% Richest 20%
IPD(%) OPD(%)
19
14
20
28
19
12
24
21
25
18
Poorest 20% Next 20% Middle 20% Next 20% Richest 20%
IPD(%) OPD(%)
Asset Index: Urban Patients
Asset Index: Rural Patients
Base 2003
DH 29256 34392 5136 1.22 41958
SDH/SGH 14220 14916 696 0.17 2536
RH 3444 4824 1380 0.58 2798
Total 46920 54132 7212 47292
Hospital
Gain in healthy man-days (per year per hospital)
New admissions per
year per hospital
Additional
admissions
per year per
hospital
Reduction
in ALOS
(number of
days)
Total
generated
healthy man-
days (per year
per hospital)
Gain in healthy man-days per year per
hospital
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
DH SDH/SGH RH
All patients
Poor patients
Poverty alleviation
0.2 million additional poor
patients served per year
0.9 million additional healthy
man-days created per year for
poor patients
17%
83%
Percentage of satisfied hospital
users
OPD
16%
84%
IPD
Satisfied
Satisfied
Factors determining patients’
satisfaction - Indoor
Doctors'
attention
26%
Overall
cleanliness
15%
Medical care in
time
13%
Nursing care
30%
Attitude of
others
15%
Availability of
diagnostic
1%
Source: Patient satisfaction survey, BMF
Factors determining patients’
satisfaction - Outdoor
Doctors'
attention
80%
Medical care in
time
6%
Nursing care
1%
Overall
cleanliness
3%
Availability of
diagnostic
10%
Source: Patient satisfaction survey, BMF
47 46
61
65
27 27
55
74
25
31
44
63
0
10
20
30
40
50
60
70
80
Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178)
District Sub-Division/State General Rural
Patient Satisfaction:
Cleanliness
Hospi
tal
Types
Target
DH 100
SD/S
GH
100
RH 100
% of Patients Highly Satisfied
68
75
60
80
70 71
60
84
59
67
56
60
0
10
20
30
40
50
60
70
80
90
Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178)
District Sub-Division/State General Rural
Patient Satisfaction: Adequate
Nursing Care
Hosp
ital
Types
Target
DH 100
SD/S
GH
100
RH 100
% of Patients Highly Satisfied
29
36
67
71
43
46
52
61
21
30
49
71
0
10
20
30
40
50
60
70
80
Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178)
District Sub-Division/State General Rural
Patient Satisfaction: Medical
Care in Appropriate Time
Hospi
tal
Types
Target
DH 100
SD/S
GH
100
RH 100
% of Patients Highly Satisfied
65 67
87
81
58
64
88
84
60 62
87
83
0
10
20
30
40
50
60
70
80
90
100
Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178)
District Sub-Division/State General Rural
Patient Satisfaction:
Doctors Attention Towards Patients’ Queries
Hospi
tal
Types
Target
DH 100
SD/S
GH
100
RH 100
% of Patients Highly Satisfied
A few examples
Equipment maintenance
Innovations
 AMC procedure
 Additional technical
staff on contract basis
Impact
 weakened the major
bottleneck in
maintenance
 eased the stress
especially at higher
levels.
Health management information system
Innovations
 Monthly report from all
hospitals on performance
indicators
 A quarterly report compiling
data from all hospitals on
performance and efficiency
indicators.
 Computerization at hospital
level
Impact
 A major breakthrough-shift
towards a objective, evidence-
based, professional approach
of data utilisation
 An immense scope for
planning, monitoring and
evaluation
 Computerization accelerated
the data management process
and ensured efficient, fast,
transparent hospital care for
the patients
 Initiating e- governance
Private Public Partnership
Innovations
 Collaborations with private
institutions like Asia Heart
Foundation to establish tele-
cardiology units.
 Scavenging, sanitary, security,
and diet services contracted
out
 Outsourced operations and
maintenance of generators,
laundry services, and staff car
etc
Impact
 Adds to quality of service and
patient satisfaction
Waste management
Innovations
 Substantial effort to introduce basic
tools and techniques for waste
management at all levels.
 Series of training to generate
positive perception and awareness
among hospital staff.
 Waste autoclave installed in Govt.
hospital utilised as CTF for private
units
Impact
 Almost all hospitals are using basic
tools (syringe and needle cutter,
dedicated trolley, burial pits, etc.).
 Independent studies show that the
concepts of and rationale behind
segregation, treatment, and disposal
are clear among key hospital staff.
 A good system for maintenance
with revenue generated, deserves
replication
.
Quality Assurance
Innovation
 Introducing
grading of hospitals
on the basis of
quality indicators.
 Incorporating
patient satisfaction
indicators.
Impact
Adds new dimension to
improvement of quality of
health care.
Increases quality
consciousness among
health care providers
Community participation
Innovation
Capacity building
of Panchayet Raj
Institution.
 Community
involvement through
Samities
Impact
Development of
ownership and
better monitoring
of public health
programme by the
community
Personnel management
Innovation
A transparent
transfer policy
with computerised
Personnel
Information
System introduced
Impact
Contributed to
motivation of
staff
User charges
Innovation
User charges
introduced in
lower tiers and
rationalised in all
tiers of hospitals
with exemption
for the poor
Impact
People’s
confidence in
Govt. health care
services
strengthened
Sunderbans component
Innovation
 Primary health care services are
targeted for intervention.
 A Government – NGO
partnership established to
provide mobile health care
services in remote and
inaccessible islands.
Impact
 The experiment with NGOs in
providing mobile services
generated huge benefits (next
slide).
 Strengthening primary health
centers has a positive effect on
the referral system.
.
Percentage distribution of patients in the
Sunderbans, by source of treatment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MHCS area Non-MHCS area
MHCS
Quack
Govt.
Others
Quack
Govt.
Others
Source: Hijli Inspiration report
Key challenges
 The progress in performance is directly linked not only to capital
investment, but also to increased recurrent inputs (maintenance
security, drugs, skilled manpower, etc.) implying that the flow of
key recurrent inputs should be assured in future.
 Initiatives for referral system should continue with renewed
emphasis on IEC
 Participation of medical providers (in sustaining the project)
based on complete ownership is a serious challenge.
 Monitoring of various norms and procedures at the hospital level
needs to be strengthened.
 There should be a mechanism to assess and monitor people’s
expectation. The District Health and FW Society has immense
potential in this direction.
Key challenges (continued)
 The non-salary recurrent expenditure is still lower than the
desired level.
 Primary sector needs to be pulled up to provide appropriate
support and to sustain the benefits of the project.
 The qualitative aspects of working force, especially motivation
and attitude, still remain an area of concern.
 Quality of private health care services needs to be streamlined
and monitored.
 People’s expectation is upwardly mobile.
Lessons learnt
Civil works
 Consultants with experience in hospital constructions should
be engaged for preparing plans, drawings and designs.
 Consultants should study in details the shortcomings of the
existing buildings, rearrangement of units required, drainage
system, water supply, power situation and total requirement,
drug storage facility, staff quarters, provisions in terms of
patients charter viz. public telephone booth, fair price shop,
canteen, pay & use toilet, bathroom. The providers are to
be consulted.
 The price variation clause in the tender for works with less
than 2 years completion time should be deleted in conformity
with PWD procedure . This may restrain the agency from
delaying construction works. Contd..2
Lessons learnt
Procurement
 Involvement of one Bio-Medical Engineer in
finalization of specification and inspection of equipment
is very important.
 Procurement of equipment should be staggered over
12/15 months phasing delivery to sites according to
completion of civil works.
contd…3
Lessons learnt
General
 A balanced mix of infrastructure development and system intervention
can produce substantial improvement in efficiency and effectiveness.
 Total improvement in referral mechanism requires parallel improvement
in the primary health care services. A weak primary sector is a barrier to
sustainability of improved secondary care.
 Since the public hospitals in West Bengal are used predominantly by
poorer section, most of the project benefits went to the poor. However, for
a full-proof safety net, free availability of all drugs must be ensured.
 Participation of private sector (for-profit and voluntary) is essential.
However, coordination and monitoring at the local level is extremely
important to make the partnership effective.
 More involvement of district health staff from the very beginning of a
project is necessary.
Thank
you

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Experiences from State Health System Development Project.ppt

  • 3. 0 500 1000 1500 2000 2500 3000 3500 No of inpatients DH SD/SG RH Average no. of admissions per month per hospital 1997 2003
  • 4. 0 4000 8000 12000 16000 20000 No of patients DH SD/SG RH 1997 2003 Average no. of outpatient attendance per month per hospital
  • 8. Distribution of DHs by CUP sectors 0 10 20 30 40 50 60 70 80 90 100 110 120 0 10 20 30 40 50 60 70 80 90 100 110 120 BOR BTR 1998 0 10 20 30 40 50 60 70 80 90 100 110 120 130 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 BOR BTR 2003
  • 9. Average monthly X-rays done, 1997-2003  About one quarter of project cost was invested in equipment  The impact is quite visible in terms of increase in utilization 0 200 400 600 800 1000 1200 1400 DH SDH RH 1997 2003
  • 10. Average monthly USGs done, 1997-2003 0 50 100 150 200 250 300 350 DH SDH 1997 2003  Before project, some of the diagonstic services were almost unavailable (e.g., USG) even at DH level.  After project, change is dramatic.
  • 11. Indicator Base line (1997) 2003 % change Outpatients D.H 2762640 3769525 36.45 S.D.H/S.G.H 5854536 8817853 50.62 R.H 6202620 9622930 55.14 Total 14819796 22210308 49.87 Inpatients D.H 420840 584726 38.94 S.D.H/S.G.H 808128 999421 23.67 R.H 262140 424761 62.04 Total 1491108 2008908 34.73 Major Surgeries D.H 32867 60047 82.70 S.D.H/S.G.H 54791 79798 45.64 Total 87658 139845 59.53 Deliveries D.H 72384 112153 54.94 S.D.H/S.G.H 150958 191444 26.82 R.H 58431 87500 49.75 Total 281773 391097 38.80 IMPROVEMENT IN HOSPITAL UTILIZATION Continued.
  • 12. Indicator Base line (1997) 2003 % change USG D.H 1878 43009 2190.15 S.D.H/S.G.H 242 64366 26497.52 Total 2120 107375 4964.86 X-ray D.H 134325 260136 93.66 S.D.H/S.G.H 229674 378213 64.67 R.H 39002 143549 268.06 Total 403001 781898 94.02 Laboratory tests D.H 493150 940255 90.66 S.D.H/S.G.H 489756 1187223 142.41 R.H 246552 618447 150.84 Total 1229458 2745925 123.34 IMPROVEMENT IN HOSPITAL UTILIZATION
  • 13. Access to the Poor  Majority comes from the weaker section of the community 31 18 15 15 21 32 20 14 12 22 Poorest 20% Next 20% Middle 20% Next 20% Richest 20% IPD(%) OPD(%) 19 14 20 28 19 12 24 21 25 18 Poorest 20% Next 20% Middle 20% Next 20% Richest 20% IPD(%) OPD(%) Asset Index: Urban Patients Asset Index: Rural Patients
  • 14. Base 2003 DH 29256 34392 5136 1.22 41958 SDH/SGH 14220 14916 696 0.17 2536 RH 3444 4824 1380 0.58 2798 Total 46920 54132 7212 47292 Hospital Gain in healthy man-days (per year per hospital) New admissions per year per hospital Additional admissions per year per hospital Reduction in ALOS (number of days) Total generated healthy man- days (per year per hospital)
  • 15. Gain in healthy man-days per year per hospital 0 5000 10000 15000 20000 25000 30000 35000 40000 45000 DH SDH/SGH RH All patients Poor patients
  • 16. Poverty alleviation 0.2 million additional poor patients served per year 0.9 million additional healthy man-days created per year for poor patients
  • 17. 17% 83% Percentage of satisfied hospital users OPD 16% 84% IPD Satisfied Satisfied
  • 18. Factors determining patients’ satisfaction - Indoor Doctors' attention 26% Overall cleanliness 15% Medical care in time 13% Nursing care 30% Attitude of others 15% Availability of diagnostic 1% Source: Patient satisfaction survey, BMF
  • 19. Factors determining patients’ satisfaction - Outdoor Doctors' attention 80% Medical care in time 6% Nursing care 1% Overall cleanliness 3% Availability of diagnostic 10% Source: Patient satisfaction survey, BMF
  • 20. 47 46 61 65 27 27 55 74 25 31 44 63 0 10 20 30 40 50 60 70 80 Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178) District Sub-Division/State General Rural Patient Satisfaction: Cleanliness Hospi tal Types Target DH 100 SD/S GH 100 RH 100 % of Patients Highly Satisfied
  • 21. 68 75 60 80 70 71 60 84 59 67 56 60 0 10 20 30 40 50 60 70 80 90 Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178) District Sub-Division/State General Rural Patient Satisfaction: Adequate Nursing Care Hosp ital Types Target DH 100 SD/S GH 100 RH 100 % of Patients Highly Satisfied
  • 22. 29 36 67 71 43 46 52 61 21 30 49 71 0 10 20 30 40 50 60 70 80 Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178) District Sub-Division/State General Rural Patient Satisfaction: Medical Care in Appropriate Time Hospi tal Types Target DH 100 SD/S GH 100 RH 100 % of Patients Highly Satisfied
  • 23. 65 67 87 81 58 64 88 84 60 62 87 83 0 10 20 30 40 50 60 70 80 90 100 Baseline (117) Cycle I (172) Cycle II (178) Cycle III (178) Cycle IV (178) District Sub-Division/State General Rural Patient Satisfaction: Doctors Attention Towards Patients’ Queries Hospi tal Types Target DH 100 SD/S GH 100 RH 100 % of Patients Highly Satisfied
  • 25. Equipment maintenance Innovations  AMC procedure  Additional technical staff on contract basis Impact  weakened the major bottleneck in maintenance  eased the stress especially at higher levels.
  • 26. Health management information system Innovations  Monthly report from all hospitals on performance indicators  A quarterly report compiling data from all hospitals on performance and efficiency indicators.  Computerization at hospital level Impact  A major breakthrough-shift towards a objective, evidence- based, professional approach of data utilisation  An immense scope for planning, monitoring and evaluation  Computerization accelerated the data management process and ensured efficient, fast, transparent hospital care for the patients  Initiating e- governance
  • 27. Private Public Partnership Innovations  Collaborations with private institutions like Asia Heart Foundation to establish tele- cardiology units.  Scavenging, sanitary, security, and diet services contracted out  Outsourced operations and maintenance of generators, laundry services, and staff car etc Impact  Adds to quality of service and patient satisfaction
  • 28. Waste management Innovations  Substantial effort to introduce basic tools and techniques for waste management at all levels.  Series of training to generate positive perception and awareness among hospital staff.  Waste autoclave installed in Govt. hospital utilised as CTF for private units Impact  Almost all hospitals are using basic tools (syringe and needle cutter, dedicated trolley, burial pits, etc.).  Independent studies show that the concepts of and rationale behind segregation, treatment, and disposal are clear among key hospital staff.  A good system for maintenance with revenue generated, deserves replication .
  • 29. Quality Assurance Innovation  Introducing grading of hospitals on the basis of quality indicators.  Incorporating patient satisfaction indicators. Impact Adds new dimension to improvement of quality of health care. Increases quality consciousness among health care providers
  • 30. Community participation Innovation Capacity building of Panchayet Raj Institution.  Community involvement through Samities Impact Development of ownership and better monitoring of public health programme by the community
  • 31. Personnel management Innovation A transparent transfer policy with computerised Personnel Information System introduced Impact Contributed to motivation of staff
  • 32. User charges Innovation User charges introduced in lower tiers and rationalised in all tiers of hospitals with exemption for the poor Impact People’s confidence in Govt. health care services strengthened
  • 33. Sunderbans component Innovation  Primary health care services are targeted for intervention.  A Government – NGO partnership established to provide mobile health care services in remote and inaccessible islands. Impact  The experiment with NGOs in providing mobile services generated huge benefits (next slide).  Strengthening primary health centers has a positive effect on the referral system. .
  • 34. Percentage distribution of patients in the Sunderbans, by source of treatment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MHCS area Non-MHCS area MHCS Quack Govt. Others Quack Govt. Others Source: Hijli Inspiration report
  • 35.
  • 36. Key challenges  The progress in performance is directly linked not only to capital investment, but also to increased recurrent inputs (maintenance security, drugs, skilled manpower, etc.) implying that the flow of key recurrent inputs should be assured in future.  Initiatives for referral system should continue with renewed emphasis on IEC  Participation of medical providers (in sustaining the project) based on complete ownership is a serious challenge.  Monitoring of various norms and procedures at the hospital level needs to be strengthened.  There should be a mechanism to assess and monitor people’s expectation. The District Health and FW Society has immense potential in this direction.
  • 37. Key challenges (continued)  The non-salary recurrent expenditure is still lower than the desired level.  Primary sector needs to be pulled up to provide appropriate support and to sustain the benefits of the project.  The qualitative aspects of working force, especially motivation and attitude, still remain an area of concern.  Quality of private health care services needs to be streamlined and monitored.  People’s expectation is upwardly mobile.
  • 38.
  • 39. Lessons learnt Civil works  Consultants with experience in hospital constructions should be engaged for preparing plans, drawings and designs.  Consultants should study in details the shortcomings of the existing buildings, rearrangement of units required, drainage system, water supply, power situation and total requirement, drug storage facility, staff quarters, provisions in terms of patients charter viz. public telephone booth, fair price shop, canteen, pay & use toilet, bathroom. The providers are to be consulted.  The price variation clause in the tender for works with less than 2 years completion time should be deleted in conformity with PWD procedure . This may restrain the agency from delaying construction works. Contd..2
  • 40. Lessons learnt Procurement  Involvement of one Bio-Medical Engineer in finalization of specification and inspection of equipment is very important.  Procurement of equipment should be staggered over 12/15 months phasing delivery to sites according to completion of civil works. contd…3
  • 41. Lessons learnt General  A balanced mix of infrastructure development and system intervention can produce substantial improvement in efficiency and effectiveness.  Total improvement in referral mechanism requires parallel improvement in the primary health care services. A weak primary sector is a barrier to sustainability of improved secondary care.  Since the public hospitals in West Bengal are used predominantly by poorer section, most of the project benefits went to the poor. However, for a full-proof safety net, free availability of all drugs must be ensured.  Participation of private sector (for-profit and voluntary) is essential. However, coordination and monitoring at the local level is extremely important to make the partnership effective.  More involvement of district health staff from the very beginning of a project is necessary.