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. 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
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
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
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
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
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