Health Resources, Investment and Expenditure A Study of Health Providers in a District in India
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- Title
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Health Resources, Investment
and Expenditure
A Study of Health Providers in a District in India
- extracted text
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Health Resources, Investment
and Expenditure
A Study of Health Providers in a District in India
Edited by
Shirish N. Kavadi
rc
Fi oundation
---- ^5 3 39
for [Research in [§ ommunity E ealth
w
Health Resources, Investment
and Expenditure
A Study of Health Providers in a District in India
Edited by
Shirish N. Kavadi
Foundation for Research in Community Health
Pune / Mumbai
3 9^
First published in 1999 by
The Foundation for Research in Community Health
84 - A, R. G. Thandani Marg
Worli Sea Face
Mumbai 400 018
3 & 4 Trimiti B Apts.,
85, Anand Park,
Aundh,
Pune 411 007
© FRCH, 1999
he.- i oo
05607
Of
Graphics, Typesetting and Layout :
J.
Rajesh Ingle at the FRCH Computer Unit, Pui
Printed at :
Shailesh Printers,
Pune - 411 030
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J;A HG AtO^-r
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Summary
Health Resources, Investment and Expenditure
A Study of Health Providers in an Indian District
Available information on health expenditure in
India is inadequate and unreliable, making sound health
policy formulation and planning difficult. Expenditure
incurred and investment made by health providers for
the running of a health service is an important
component of health expenditure. The present study
seeks to enrich the information base on health
expenditure, especially of the non-govemment or private
sector with the focus on a district in India. The study
was undertaken largely as an exploratory exercise in
understanding and critically analysing the investment
and expenditure patterns in health care delivery.
The study was carried out in the district of
Ahmednagar in the state of Maharashtra. The district
was selected on the basis of the CMIE indices for levels
of socio- economic development for the year 1980.
1. Objectives of the Study
The study had two objectives : (1) To conduct
a comprehensive survey of the nature and volume of
health resources available and accessible to the
population of a district.
(2) To analyse the nature and pattern of health
investment and expenditure incurred by health
providers.
2.1
The First Phase : Mapping Health Resources
Information on health resources in the district
was compiled by scrutiny of official sources such as
registers of Medical Councils, the Civil Surgeon’s
Office, the District Health Office, Panchayat Samiti
Offices (taluka level), town municipalities. Food and
Drug Administration. Private sources- such as
associations of doctors such as the Indian Medical
Association, National Integrated Medicine Association,
Medical Sales representatives and their association and
medical stores also provided the necessary information.
1
The accuracy and reliability of the collected data
was verified in two ways : A sub-sample survey was
planned in villages randomly selected. Also through
Questionnaire schedules prepared for community
members. Medical Officers and paramedics in
government establishments and for private practitioners,
the authenticity of the information gathered was
ascertained.
A postal survey was also carried out through
a questionnaire mailed to all the listed health providers.
In the questionnaire in addition to information regarding
the practice and delivery of health care in their area,
the respondents were also asked to identify other
practitioners in their locality.
2.2
Findings
The final list identified 3059 doctors (qualified
and unqualified) located in urban and rural areas,
representing all systems of medicine. Though doctors
from both the public and private sector were included,
nearly 92 per cent were from the latter sector. Overall
the health institutions numbered 860 which included
around 274 hospitals - with bed strength ranging from
3 to 200 beds, while 565 medical stores were found
to be functioning in the district.
The report looks into questions of availability
of and accessibility to these health providers and the
nature of the services provided. The analysis highlights
the volume, distribution over sector (public and private),
geographical location and services available with the
health providers for both individual practitioners and
medical establishments. The geographical distribution
of medical practitioners, and hospitals in particular,
only confirmed the generally known bias in favour of
urban and developed areas. The report also presents
a profile of the practitioners, qualifications, system of
medicine and practice.
Allopathic doctors were outnumbered by nonallopathic. health providers, both qualified and non
qualified. Those practicing Indian (Ayurvedic and
Unani) systems of healing constituted 41.7% of the
total, while homeopaths made up 16% RMPs were 3.5%
and non-qualified quacks and folk healers formed 0.2%
of the names collected and dentists accounted for 1.5%,
for the entire district. The low proportion of non
qualified and Registered Medical Practitioners’ (RMP)
was due to the tact that they were not likely to appear
I
J
Sample Selection and Techniques
in published lists.
3.2
The geographical distribution pattern for
doctors reflected the same urban bias so evident in all
developing countries. The overall distribution of doctors
appeared even, with 51% doctors based in urban areas
and the remaining 49% spread out to the rural areas.
But the unequal distribution of doctors between the
urban and rural was noticeable in the proportion of
doctors to population. The doctors to population ratio
in urban areas worked out to 3 per 1000 against the
ratio of 0.5 doctors per 1000 population in the rural
areas. The propensity of modem medical practitioners
to be based in urban areas was determined by the
availability of ‘market’. This‘market’ is created by the
level of economic development. Thus the five
economically developed talukas of Nagar, Kopargaon,
Sangamner, Rahuri and Shrirampur, had a concentration
of doctors accounting for 71% of the total. This unequal
distribution was further highlighted in the proportion
of doctors to population, wherein the five above
mentioned talukas had a ratio of 1.26 doctors per
thousand population. As against this the remaining 8
economically backward talukas had a proportion of 0.56
doctors per thousand population.
For the second phase of the study on expenditure
and investment 137 units from 6 talukas were randomly
selected mainly from respondents to the mailed
questionnaires. It was decided to have 80 per cent of
the sample from the respondents to the mailed
questionnaire and 20 per cent from the non-respondents.
Hospitals (Nursing and Maternity Homes, TB and
leprosy hospitals included) were distributed on a pattern
similar to that of doctors. The five developed talukas
accounted for 80% of the total hospitals, and urban
centres 77% of the total.
3.1
The Second Phase : Investment and
Expenditure Study
For the second phase of the study a second set
of mailed questionnaires to doctors and health
establishments was prepared. The questionnaire
addressed such issues as fees from patients and
expenditure incurred on maintaining their
establishment. This questionnaire was only sent to the
respondents of the first round of the postal survey, the
response rate was around 20 per cent All this information
was then entered into the computer.
Another techniques used to gather information
on medical practice was the holding of 3 workshops
for a few selected practitioners from among the
respondents to the mail survey. The focus of the
workshop was on the setting up of medical practice
- the economics of setting up practice, problems and
constraints encountered in setting up and continuing
practice etc.
The six talukas were randomly selected, however,
keeping in mind the regional differentials in socio
economic development. Thus, from the developed
talukas Nagar and Kopargaon were selected, while
Akole, Pathardi, Shrigonda and Shevgaon fell in the
underdeveloped category. Almost all of the various
categories of selected health providers were located in
these talukas, distributed between the rural and urban
areas. Nagar and Kopargaon towns were in the
underdeveloped talukas of Pathardi and Shrigonda.
Thus, there was equal urban representation between
the developed and underdeveloped talukas.
The study covered various categories of health
providers some of which were not located in the selected
talukas. These categories had to be identified and
selected from other talukas. Thus, besides units in
the above mentioned six talukas, units in Sangamner
and Shrirampur talukas were also studied. These covered
private practitioners representing all systems of
medicine (qualified and unqualified), general
practitioners and specialists, and public and private
health facilities with varying bed strength, located in
the urban and rural areas of these talukas. Health
personnel categories were based on qualification, system
of medicine, specialization and geographical location
- both regional and urban/rural.
Health establishments were selected from the
three subsectors, public, private and NGO, also by social
geography, bed size and type of services offered. The
questionnaire focussed on historical information about
practice or facility, information on investment and
finance, experience related to raising finance, revenue
and current health care provision and expenditure
profile.
3.3
Findings
It is apparent from the present study that the
private health sector in Ahmednagar district began
expanding during the 1980s. This trend conformed to
the national trend. During this period there was an
increase in the number of private medical colleges in
1
f
the State contributing to an increase in the number of
doctors passing out. The non-availability of sufficient
public sector jobs and the reluctance of doctors to serve
in rural public health services contributed to the further
growth of the private sector. Government policies were
no less important factors in encouraging the private
sector. Besides supporting the establishment of private
medical colleges, the government created opportunities
for doctors to avail of loans for setting up medical
practice. For example, the Maharashtra State Finance
Corporation and Nationalised banks extended loans to
doctors to set up dispensaries and nursing homes. This
availability of capital gave a boost to the private sector.
The study shows investment was made mainly
for the creation of infrastructure. Money was spent on
buildings, furniture and medical equipment. This
suggests expansion in specialised medical care and
emphasis on technology based medical care.
*
S'
The public sector barely expanded during this
period. Very little investment appears to have gone into
creating new public health facilities. Most of the units
covered by this study came up more than a decade
ago. Very rarely did additional investment go into
expanding their services, despite the burden of providing
medical care on the public health services, a fact that
is well known. This suggests both the non-availability
of funds in the public sector and also the low priority
the government attached to health services.
The study showed that the burden of
expenditure incurred by health providers was on
recurring heads of expenditure. Thus, the salaries, drugs
and maintenance of equipment consumed the bulk of
the funds spent by health providers in delivering health
care.
□□
Contents
Summary Report
>1 HJ0
Acknowledgments
ovil*
iv
Research Team
iv
Foreword
V
List of Tables
List of Graphs
vii
Map of Ahmednagar District
Chapter 1
viii
Introduction
1
- Shirish N. Kavadi
Chapter 2
Mapping Health Resources
6
- Shirish N Kavadi and Manjiri Sule
Chapter 3
Health Manpower in the District
11
- Manjiri Sule
*
Chapter 4
Health Institutions in the District
23
- Sunil Nandraj and Shirish N. Kavadi
Chapter 5
Individual Practitioners : Investment and
Expenditure
32
- Manjiri Sule and Shirish N. Kavadi
Chapter 6
Health Institutions : Investment and Expenditure
40
- Shirish N. Kavadi
Chapter 7
Conclusion
58
- Shirish N Kavadi
Appendix A
*
District Profile
63
- Manjiri Sule and Maya Nirmala
Appendices B - K
References
Study Questionnaires
66
92
Acknowledgements
Our most sincere thanks to :
The Ford Foundation for financial support;
In Ahmednagar, Pune and Mumbai
Shri P. P. Mahana, former Health Secretary, Government of Maharashtra; District Collector, Chief Executive
Officer (Zilla Parishad), District Health Officer and other staff. Civil Surgeon and staff of Civil Hospital, Ahmednagar;
Staff of various PHCs; Chief Executive Officers and staff as well as Medical Officers of all Municipalities and Municipal
Councils; Block Development Officers and staff of the Taluka Panchayats; Staff of the Food and Drug Administration;
National Informatics Centre; Maharashtra Medical Council, Dental Council; Maharashtra Nursing Council; Maharashtra
Board of Ayurved and Unani Systems of Medicine; Board of Homeopathic and Biochemic Systems of Medicine;
Directorate of Health Services; Directorate of Census Operations; Maharashtra State Finance Corporation; Directorate
of Economics and Statistics; Library staff of Gokhale Institute of Politics and Economics, Pune.
Indian Medical Association; National Integrated Medical Association, Association of the Medical Sales
Representatives; numerous doctors; owners of medical stores; distributors of pharmaceuticals, and all our respondents.
AtFRCH
Dr. N. H. Antia for his constant support and encouragement; Aruna Deshpande for her statistical help; Devendra
Dalal and Pratibha Mane for helping out in the field work; Prof. R. K. Mutatkar, Dr. Sujata Rao and Anuradha
Gupte for their suggestions and comments; Shubha Gadkari for editing; Mana Pinto, Gautam Jadhav, Joyeeta Sinha,
Anita Nair, Sushma Joshi, Nitin Tilekar, Rajam John, Rajiv Kulkami and most important Rajesh Ingle for patient
typing and pagemaking; Avinash S. Pandit for his suggestions and comments and undertaking the publication of
the study.
Field Investigators and Coders
Ranjana Netke, Sanjay Bhase, Anil Botre, Chanda Jahagirdar and Sonali Sule.
Research Team
Duggal Ravi
Joshi Ranjana
Kavadi Shirish
Nandraj Sunil
Nirmala Maya
Pawar Jeetendra
Side Manjiri
Foreword
There has been a vast expansion of the health
services in both the public as well as the private sectors
since Independence in terms of infrastructure, manpower,
drugs, equipments and supplies in both urban and rural
areas.
Meaningful planning for the future of our country's
health can only be undertaken provided we know the
present status of the above as well as its distribution and
utilisation.
Unfortunately there is a dearth of comprehensive
information for this purpose. The information presented
in this book is in the form of a preliminary study
undertaken by FRCH to evolve a methodology for similar
studies, which should be undertaken on a larger and
possibly countrywide scale. The Ahmednagar district
represents an average district with urban as well as rural
population. It not only examines the nature of pattern
of investment and expenditure incurred by health providers
in this district but also provides a census of the various
providers in both the public and private sectors.
The difficulties in undertaking such study have also
been highlighted and hopefully will serve as a guide to
others who may undertake such a task. This includes the
lacunae and inadequacies ofthe official data and the mode
of its collection.
It is hoped that this report will stimulate both the
government as well as non-governmental organisations
to undertake similar studies so essential to the undertaking
and more appropriate utilisation of funds as well as
available manpower and facilities.
r
Dr. N. H. Antia
Director
List of Tables
No.
2.1
2.2
2.3
2.4
Title
Taiuka-wise break up of exisiting doctors in comparison with the original list
No. of urban doctors verified through Sample Survey
Validity of sources - status of listed practitioners
A breakup of the doctors status
Page No.
9
9
9
10
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Geographical distribution - GJPs. and specialists
Rural-urban distribution - medical practitioners
Population covered by one doctor
Rural-urban distribution according to system
Distribution in developed and underdeveloped talukas of the district
Average no. of doctors per type of village/town
Availability of specialists services
Bed-provision by private practitioners
Qualification system and bed-provision of employers of nurses
3.10 Qualification-system and bed-provision of employers of compounders
3.11 Qualification-system and bed-provision of employers of paramedics
12
Health Institutions in the District
Rural-urban distribution of hospitals according to bed strength
Geographic distribution of hospitals
Type of management and ownership
Profile of responding health establishments
Services provided
Facilities provided
Personnel
Visiting doctors (sectorwise)
4.10 Rural-urban distribution of pharmacies
24
24
25
26
27
28
28
29
30
31
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
14
14
14
14
16
16
18
20
21
21
32
Geographical distribution of doctors
32
Floorspace according to system of medicine
33
Beds according to system of medicine
34
Average investment of each category according to social geography (in Rs.’OOO)
35
Average investmentof each category according to bed facilities (in Rs.’OOO)
Average investment of each category according to the period of establishment(in RsJOOO) 35
Average investment in various heads for each category (in Rs. ’000)
36
Frequency table for the number of loans
36
Average monthly expenditure of each category according to social geography (in Rs.)
37
5.10 Average monthly expenditure of each category according to bed facilities (in Rs.)
37
5.11 Average monthly expenditure in various heads for each category (in Rs.)
38
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
No.
Title
Page No.
6.1 Public health units
%
6.2 Monthly expenditure of public sector units (1991 - 1992)
6.3 Staff in private health establishments - according to social geography
6.4 Staff in private health establishments - according to bed strength
6.5 Facilities / services in private health establishments according to social geography
6.6 Facilities / services in private health establishments according to bed strength
6.7 Staff in voluntary sector hospitals
6.8 Facilities offered by voluntary sector hospitals
6.9 Investment made in 1981-91 by establishment according to social geography
6.10 Investment according to years of establishment
6.11 Investment according to social geography
\
6.12 Investment according to bed strength
6.13 Investment sources according to bed strength
6.14 Investment sources according to social geography
6.15 Average monthly expenditure according to ownership/management
6.16 Average monthly expenditure according to bed strength
6.17 Average monthly expenditure according to social
geography
40
42
44
44
45
45
46
46
47
48
49
50
52
52
54
55
56
List of Graphs
No.
1
1
2.
3.
4.
Title
System-wise distribution of doctors in the District
System-wise distribution of doctors in India
Doctor to population ratio in Ahmednagar district
Average No. of doctors per type of Village/town
Page No.
13
13
15
16
!
AHMADNAGAR DISTRICT
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District Boundary
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District Headquarters
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30
1
Introduction : Objectives and Study Plan
I
In most developing countries there exists a wide
discrepancy between the actual health situation and the
desired health situation. Comprehensive and effective
health care services which are affordable, adequately
equipped and easily available in adequate number to
those who require it can partly help to bridge the gap.
The lack of universal health care, the poor quality of
health care, the disparities in the health services
available to different groups of people in these countries
reflect not just the wider socio-economic reality but
poor planning, ambiguous policies and inefficient
implemention. The remedy lies in purposeful and
meaningful planning which aims at equitable
distribution of available resources for optimal use. Well
defined policies and full implementation of government
plans and policies would be a major step towards the
creation of a comprehensive health system.
allocations to health and especially in the transfers from
the Central to State Governments. As the funds for
health have begun to decline, the issue of health
expenditure has become important. Available official
data is inadequate and unreliable once again highlighting
the need for creating expenditure database and
understanding health spending.
Since the mid 1980s studies have been carried
out of government expenditure on health care delivery
or on specific national disease control programmes. A
recognition of the inadequacy of information on health
spending initiated studies of private spending such as
that incurred by households. Expenditure incurred and
investment made by health providers for the running
of a health service is an important component of health
expenditure. The present study seeks to enrich the
information base on health expenditure, especially of
the non-government or private sector. The study is
largely an exploratory exercise in understanding and
analysing the nature of investment and expenditure
health care providers.
A major weakness of health planning in
developing countries is the absence of a holistic view
of health care development for want of reliable and
trustworthy data on health services, their size, growth
and distribution. Such a database is essential to
planning. Most governments have shown a singular
lack of awareness and inefficiency in the generation
and creation of such databases. It is an accepted fact
that government data in these countries is not
dependable. In India, for instance, the governments’
data on health service institutions, other than their own,
are poor and at least a decade old. The present study
attempts to show how a health resources database can
be created at the district level.
Objective of the Study
The purpose of this study was to conduct a
comprehensive survey of the nature and volume of
health resources available and accessible to the
population of a district. Analysing the volume and
distribution of health facilities and providers, it was
believed, would help to faciliute an estimate of the total
investment in the health sector at the district level.
The liberalization of the Indian economy has
further opened up the market for private sector health
care. An important fallout of economic reforms has
been that areas such as health which had so far been
accorded low priority are attracting the attention of
policy makers, scholars and activists. There is
recognition that the available information is poor and
that there is need for a reliable database for proper
planning.
The original objective of estimating total
investment for the district was dropped, primarily
because of the constraints experienced in data collection
and the lack of certain data or incomplete data. For
instance, investment figures for public units were not
available, nor were disaggregated expenditures recorded
by agencies concerned. Municipal Councils did give
total health expenditure figures but not the expenditure
per municipal health unit. Hence, the study restricts itself
primarily to looking at the nature and pattern of health
investment and expenditure. The main features of this
investment are analysed.
Under the IMF/World Bank sponsored Structural
Adjustment Programme (SAP) the government begun
to curtail social spending which has affected the health
sector. There is a definite decline in government
1
hospitals in particular, only confirmed the generally
known bias in favour of urban and developed areas. The
report also presents a profile of the practitioners,
qualifications, system of medicine and practice.
Selection of the District
The district of Ahmednagar in the state of
Maharashtra was selected for the study as representative
of a district in India with average socio-economic
development. The selection was based on the CMIE
indices for levels of economic developments of 1980.
(See Appendix A. 1 - District Profile.) The development
index for Ahmednagar was 132 and for Maharashtra,
164, the All India index being constant 100. Although
the development index for Ahmednagar was higher than
the all India index, the district is representative of
the disparate economy and unequal levels of
underdevelopment in the country. This is so because
of the thirteen talukas only five are developed while
the other talukas arc underdeveloped. The former
talukas have managed to progress due to irrigational
facilities, sugar cane cultivation, the setting up of sugar
co-operatives and location of industries. The
underdeveloped talukas affected by lack of water and
drought have been unable to make much economic
progress. It is this disparity within the district which
does not present a correct picture of the level of socio
economic development. The high development index
is more due to the pockets of high level development
in the district. This presents a misleading picture of
the district and hence was considered average for socio
economic development.
The Second Phase : Investment and Expenditure
Study
For the second phase of the study to begin with
a second set of mailed questionnaire addressed to
doctors and health establishments was prepared. The
questionnaire asked for information related to fees from
patients and expenditure incurred on maintaining their
establishment. This questionnaire was only sent to the
respondents of the first round of the postal survey. The
response rate was around 20 per cent. All this
information was then processed by the computer.
Another technique used to gather information
on medical practice was the holding of three workshops
for a few selected practitioners from among the
respondents to the mail survey. The focus of the
workshop was on the setting up of medical practice
- the economics of setting up practice, problems and
constraints encountered in setting up and continuing
practice etc.
Sample Selection and Techniques
For the actual study on expenditure and
investment 137 units (individual practitioners and health
institutions) from six talukas were randomly selected
mainly from our respondents to the mailed
questionnaires. It was decided to have 80 per cent of
the sample from the respondents to the mailed
questionnaire and 20 per cent from the non-respondents.
The First Phase : Mapping Health Resources
Information on health resources was compiled
by scrutiny of official sources and private sources. To
verify the accuracy and reliability of the collected data.
A sub-sample survey was carried out in villages
randomly selected.
The six talukas were randomly selected, keeping
in mind the regional differentials in socio-economic
development. Thus, from the developed talukas Nagar
and Kopargaon were selected, while Akole, Pathardi,
Shrigonda and Shevgaon fell in the underdeveloped
category. Almost all of the various categories of selected
health providers were located in these talukas,
distributed between the rural and urban areas. Nagar
and Kopargaon towns are in the developed talukas of
Nagar and Kopargaon talukas while Pathardi and
Shrigonda are in the underdeveloped talukas of Pathardi
and Shrigonda. Thus, there was an equal urban
representation between the developed and
underdeveloped talukas certain categories of health
providers were not located in the selected talukas and
hence had to be identified and selected from other
Lastly a postal survey was carried out through
a questionnaire mailed to all the listed health providers
requesting the respondents to identify other practitioners
in their locality. This process of preparing a census
of health providers in the districts is discussed in detail
in Chapter 2.
The first part of this report looks into questions
of availability of and accessibility to these health
providers and the nature of the services provided. The
analysis highlights the volume, distribution over sector
(public and private), geographical location and services
available with the health providers for both individual
practitioners and medical establishments. The
geographical distribution of medical practitioners, and
2
i
talukas. Thus, besides units in the above mentioned
six talukas, units in Sangamner and Shrirampur talukas
were also studied. The selected units covered private
practitioners representing all systems of medicine
(qualified and unqualifed), general practitioners and
specialists, and public and private health facilities with
varying bed strength, located in the urban and rural areas
of these talukas. Health personnel categories were based
on their qualifications, system of medicine,
specialization and geographical location - both regional
and urban/rural. One hundred and sixteen were selected.
However, given the poor quality of information or owing
to incomplete data twenty cases were dropped them the
actual analysis. Hence only 96 private practitioners were
studied.
health care provision and expenditure profile. Of the
twenty seven selected health establishments seven were
from the public / Government sub sector, seventeen from
the private subsector and three from the voluntary sub
sector.
The chapters that follow are organised as
below. Chapter 2 describes the process, the methods
and techniques used to create a census of health
providers in Ahmednagar district. Chapter 3 presents a
profile of individual medical practitioners in the district,
their geographical distribution, system of medicine,
graduation and specialisation etc. Chapter 4 describes
health institutions in the district, their geographical
distribution, types of units, types of facilities and
services offered etc. Chapter 5 examines the investment
and expenditure patterns of individual medical
practitioner. Chapter 6 analyses the investment and
expenditure incurred by health institutions. The final
chapter briefly summarise the main findings and makes
relevant comments and suggestions.
Twenty seven health establishments were
selected from the three subsectors, public or Government,
private and voluntary, also by social geography, bed
size and type of services offered. The questionnaire
focussed on historical information about practice or
facility, information on investment and finance,
experience related to raising finance, revenue and current
on
3
Health Resources, Investment
and Expenditure
(A study of health providers in Ahmednagar District)
UNITS ACTUALLY STUDIED
1. Private Practitioners
Area &
System
Talukas
Nagar
Rural__
Urban
Allo
Ayur
Hom
Sp.
Others
Total
Allo
Ayur
Hom
2
6
1
20
0
29
2
2
2
3
1
4
07
4
2
2
03
1
3
3
1
4
4
2
3
2
Akole
Kopargaon
1
1
Pathardi
1
1
5
1
Shevgaon
Shrigonda
01
1
41
Total
Grand Total =
Others Total
06
1
2
11
08
2
3
10
1
12
1
08
01
1
Shrirampur
Sp.
96
Notes :
Allo
Allopathy (General Practitioners)
Ayur
Ayurveda
Hom
Homeopathy
Sp
Specialists (Allopathy)
4
55
Health Establishments
Area
Urban
Talukas
Public
Rural
Pvt.
Voluntary
Public
Pvt.
I
Nagar
Childrens Hospital-/
Municipal Mat.
Home - 1
Hospital - 1
Nursing Home -1
Nursing Homes - 2
Municipal
Dispensary - 1
Akole
Kopargaon
Municipal
Hospital - 1
Ayurved Hospital-/
Allopathy Hospital-3
Hospital - 1
Pathardi
Shevgaon
Maternity Home-/
Nursing Home - /
Rural - /
Well
Utilised
PHC - 2
Hospitals - 2
Rural
Hospital/
Mother
PHC - /
Maternity
Home - 1
Hospital - 1
Shrigonda
Nursing Home - 1
Shrirampur
Poly Clinic - 1
Hospital - 1
Maternity
Hospital - 1
Sangamner
Poorly
Utilised
PHC - /
Cottage Hospital -1
5
Voluntary
2
Mapping Health Resources
This chapter describes the various methods used
to prepare the inventory of health resources in the district.
The techniques used to estimate the volume of health
providers are also described.
3) Mailed questionnaires : The last exercise involved
a postal survey. Questionnaires were mailed to all the
listed practitioners and hospitals to generate information
on providers within their locality.
The second and third techniques were used owing
to the inadequacy of data collected from official and
non-official sources.
Objective of the Study
The aim of the study was a comprehensive
survey of health resources/providers in Ahmednagar
district to determine the volume of health care facilities
and practitioners.
Official Sources of Information
Official Registration with their respective
Councils is a statutory requirement for all qualified
medical graduates who wish to practice. The Councils
are statutory bodies and it is obligatory for them to
maintain updated records of qualified practicing
doctors. Hence, the Councils were the major source
of information regarding medical practitioners in the
district. The five Councils from whom information
was obtained were :
Methodology, Techniques and Sampling
Health resources/providers comprise of all health
personnel and health establishments involved in
providing health and medical services. Therefore to
begin with, definite categories of health providers were
identified, with a view to making them as
comprehensive as possible. The health providers, as
identified, covered
♦
Maharashtra Medical Council (Allopathic)
* Maharashtra Board of Ayurved and Unani Systems
* Health care facilities - dispensaries, hospitals,
clinics, polyclinics, special hospitals, PHCs, sub-centers,
medical stores, indigenous/folk and other non-allopathic
facilities.
of Medicine
* Board of Homeopathic and Biochemic Systems of
Medicine
♦ Maharashtra State Dental Council
♦ Maharashtra Nursing Council
♦ Practitioners - allopathic doctors, indigenous and
other non-allopathic doctors, nurses and all other
paramedics from the private and public sectors in both
urban and rural areas.
From the Council directories/registers, 1887
doctors were listed.
The exercise involved the listing of all health
care providers in the district by tapping all known
official and non-official sources. Three techniques were
used for listing:
In addition, information on private practitioners
and doctors working in public health services was
recorded through the District Health Office, Civil
Hospital, Medical Officers of Municipal Councils and
Cantonment Hospital and the Extension Officers of
Health at Panchayat Samitis. Lastly, information on
the total number of health professionals was also
collected from the National Informatics Centre, Pune.
1) Collecting information from official and non
official sources: Information gathered from these
sources, for both health personnel and health
establishments, was cross-checked, compiled and then
classified. Classification was done mainly on the basis
of social geography, system of medicine, qualification
and sector.
The major sources of information on health
establishments were: the “Directory of Hospitals in
India (1988)** published by the Health Ministry,
Government of India, and the lists provided by the
District Health Officer, Municipal Councils and
Panchayat Samitis.
2) Sample survey: To check the validity of these data
and specifically the sources, a sample check was
conducted.
6
4
The office of Food and Drug Administration
provided a list of medical stores and licensed drug sellers
in the district.
nursing homes under the Bombay Nursing Home Act,
is not complied with by medical practitioners,
particularly so in rural areas. The Medical Officer of the
Ahmednagar Municipal Council confirmed that the
legally required registration was not being complied
with and that only 25 per cent of privately run health
units had bothered to register. Only the Shop and
Establishment Departments of the Municipal Councils
of Shrirampur, Sangamner and Kopargaon, however,
had lists of registered doctors and hospitals in their
respective areas. The information from these lists was
however, neither complete nor adequate and hence not
fully reliable.
Non-Official/Private Sources
Information was also gathered from private
sources. The sources included the “Medical Directory
Ahmednagar District”, published by the Maharashtra
Sales and Medical Representatives Association,
Ahmednagar Unit in 1986, for private circulation.
Directories published by some pathological laboratory
owners, pharmacists and medical associations in talukas
like Shrirampur were also used. In addition to this,
membership lists of the local branches of Indian Medical
Association (IMA), National Integrated Medical
Associations (NIMA) and other taluka-level associations
were sought. Also, along with distributors of
pharmaceuticals and drugs, the associations of medical
stores and pharmacies at both the district and taluka
levels were tapped. The former mainly provided
information on medical stores. The private and public
sources (non-council) elicited the names of 1773 doctors.
The overall impression was that the non-official sources
and non-council lists were more reliable (though not
necessarily exhaustive) since these lists contained names
of doctors who were actually practicing in the district.
All other official sources gave lists that were
either informally prepared for us or were prepared for
some other purpose with little concern for accuracy.
The exception was the Ahmednagar Municipal Council.
The Health Department of this Council had an updated
list of general practitioners, consultants and hospital
owners in Ahmednagar city. The Chief Medical Officer
has undertaken to prepare such a list almost every year.
The ^Directory of Hospitals in India’” a government
publication) was also found to be most inadequate
especially regarding units with a small bed strength.
A possible explanation for this could be that since
most nursing homes do not register with Local Boards
as required under the Bombay Nursing Home Act, they
remain officially non-existent. The directory depends
entirely on official sources. Hence, the listing of private
medical establishments encountered the same problem
as in the listing of medical personnel. Information on
the number of beds and facilities available, types of
establishments (general/special hospitals, nursing
homes, dispensaries, clinics) and ownership was also
not available or incomplete for most hospitals in these
published sources. Data gathered from the sources other
than the Council records was not always accurate as
far as qualifications and names were concerned.
Limitations of the Sources
Since none of the Councils had updated the
published directories of the registered medical graduates
till 1990, their unpublished registers had to be referred
to. From the directories and registers, doctors having
their professional addresses (if available) or residential
addresses or both in Ahmednagar district, were listed.
The Allopathic Council does not specify whether
the addresses of doctors are residential or professional.
The Ayurvedic Council registers only residential
addresses. The Homeopathic and Dental Councils give
both professional and residential addresses but not all
doctors have registered with professional addresses even
for these Councils. As a result, in the case of a majority
of doctors from these four Councils, only the residential
addresses are known. This makes it difficult to identify
or trace doctors who have either emigrated out of or
immigrated into Ahmednagar district and not intimated
their change in residence: or. doctors who practice in
Ahmednagar but reside in neighbouring districts. Visits
to the offices of the Civil Surgeon, DHO, Panchayat
Samitis and Municipal Councils also revealed that the
obligatory registration of practice, especially for the
Organization and Processing of Data
Each list was entered into the computer and a
database of the practitioners was constructed. Whatever
information was available about doctors - address, sex,
degree, registration number, year of qualification,
university etc. - under each list, was included.
Subsequently, all the lists were tallied and thoroughly
checked to remove errors and repetitions. A similar
exercise was carried out for hospitals and nursing
homes. A list of pharmacy shops was also compiled.
An indication of the inadequacy and unreliability
7
gathered from the central or the PHC village itself. In
cases where the centre had shifted to the PHC village,
the village clusters also changed slightly. After the
Parner experience, only three village clusters in each
of the remaining three talukas were surveyed. Thus
instead of 16, our sample consisted of only 13 village
clusters with 5 villages each, making a total of 65
out of altogether 1503 villages in the whole district.
of the Council lists was seen from the fact that only
604 of the 1887 doctors who had registered with the
Councils were identified amongst the 1773 practitioners
listed from other sources. It was also found that names
of about 1170 of the 1773 practitioners, having
Ahmednagar addresses, could not be located in the
Council registers. Cross checking was an arduous and
time consuming task. After going through the whole
process, a single master list of medical practitioners
from Ahmednagar district was compiled. All
duplications were deleted from the list, giving a final
total of 3059. Given the limitations of the exercise
carried out, we decided to undertake a sample survey
with a view to determine both, the reliability of our
sources and validity of available data. The sample survey
had also, as one of its objectives, the identification
of non-qualified and non-conventional medical
practitioners who could not be listed from the earlier
mentioned sources.
Urban Sampling
The two towns, Nagar and Shrirampur were
automatically selected, being the only urban centers
among the targeted talukas. These towns also fell in
the categories of high and low concentration of doctors
respectavely in the urban areas of the district. Various
difficulties were encountered in the urban survey and
a different approach was adopted. Physically cross
checking 836 and 184 doctors in Nagar and Shrirampur
respectively was not possible unless a ward-to -ward
survey was done. Instead, we decided to approach
medical stores. Prominent areas in Nagar and
Shrirampur were marked. A centrally located medical
store in each locality was identified. Ten medical stores
in Nagar and four in Shrirampur were accordingly
selected. Names of doctors in the respective locality
were listed with the help of employees/owners of the
medical stores. (See Table 2.2.)
The Sample Survey
The second technique involved a sample check
in over 65 villages and 2 towns in 4 talukas.
Sampling
Sampling was based on rural-urban and regional
(developed and under-developed) differentials in the
distribution of health resources and on the doctor
population ratio (high, average and low). Accordingly,
the talukas of Nagar, Shrirampur, Parner and Akola
were selected. The last was selected specifically for
the presence of a sizeable tribal population.
Questionnaires
The main objective of the questionnaire was to
seek information on medical practitioners in the locality
with a view to counter-checking our list. However,
before enquiring about the health providers within their
locality, we planned general interviews with doctors,
paramedics, folk healers and with the lay community
in order to establish our credentials and develop a good
rapport with them. The questionnaire was pre-tested
through a pilot survey in Purandar taluka of Pune
district. The interview schedules began with background
information regarding the villages, families,
occupations, amenities available in their areas, disease
patterns, problems in giving and receiving medical care
etc. Only towards the end did we enquire about the
health personnel in that area.
Rural Sampling
Villages from the selected talukas were classified
as those having high, average and low doctor-population
ratios and those villages having no doctors. Sixteen
villages were randomly selected in this fashion. Four
villages within a 5 km. radius of every selected village
were included, to form village clusters, for a doctor’s
area of operation extends to the adjacent villages as
well. Thus village clusters rather than isolated villages
became the basic units for the survey.
Validity of Information Sources
In the first round of the survey in Parner taluka
all villages in a cluster were visited. Subsequently,
in the remaining sample talukas the strategy was
changed to cover only the central or PHC village within
each cluster. This was so since it was felt that the
medical information about the whole cluster could be
The fact that only 72 out of the 127 listed doctors
actually practised in the areas that they were expected
to be practicing in, exposed the inadequacy of our
sources of information, in particular the Council
8
4
1
4
directories. (See Table 2.3.) Of the remaining 55 doctors,
some had shifted to other places, some had retired or
expired while others could not be traced at all. In all,
42 new doctors practicing in the sample areas were added
to our list. Out of these 42 additional doctors, about
11 doctors came from the same district and had already
been included in our inventory, but with different
addresses. We could not determine whether those who
had shifted or were untraceable were practicing
elsewhere in the same district.
were untraceable (12.8%) was very high. Among the
Medical Councils, the Board of Homeopathy and
Biochemic Systems of Medicine provided a
comparatively more complete and valid list of doctors.
It was information acquired from informal sources that
proved to be more accurate than that gathered from
various Councils and Boards.
Taiuka-wise assessment of the sample list
For Parner taluka, which had very few doctors,
our estimation was most accurate, whereas for
Shrirampur, with more doctors our estimation was least
accurate. In both the talukas there were more doctors
than those listed . But on an average the list of
practicing doctors fell short of the original sample list
(See Table 2.1). During the sample check the team
experienced great difficulty in identifying and locating
folk practitioners. Often, community members were
reticent and would not talk about them; at times we
were even laughed at, saying that such practices were
no longer prevalent; at other times persons so identified
when personally met, denied that they practiced folk
medicine. Practitioners of traditional medicine
(Ayurveda/Unani) were also difficult to locate , since
the practise of this medicine as a hereditary or caste
profession appeared to have died out. Against the
background of difficulties encountered in the first two
techniques, we decided to mail questionnaires to the
listed doctors and asked them to provide information
on the fellow practitioners in their locality or within
their knowledge.
The actual number of doctors practising in the
sample areas was thus calculated at 114. (See Table 2.1.)
Out of the 114 practising doctors, only 33 had registered
with their respective Medical Councils with their current
addresses. The percentage of doctors who had shifted
from their original residence (26.4%) and of those who
Table 2.1
Taluka -wise break up of exisiting doctors in
comparison with the original list.
Sample Taluka
No of Doctors
Original List
Verified List
20
30
66
22
28
53
Nag ar
Akola
Pamer
Shrirampur
Total
114
Table 2.2
No. of urban doctors verified through Sample Survey
Town
No.of Doctors
No.of Doctors No.of Doctors
originally listed Med.store list Cross checked
+ Additions
A'nagar
836
140
122+ 18
Shrirampur
184
82
Postal Survey
A postal survey was carried out by mailing
questionnaires to all the listed health providers (3059),
and to 274 hospitals primarily in the private and
53+ 29
Table 23
Validity of sources - Status of listed practitioners
Source_____
Allopathy
council
New
Indian Systems
council
Taluka
1 *
2 #
____ !___
A’nagar
Akola
Earner
Shrirampur
01
00
02
01
03
02
00
06
04
02
02
11
00
02
06
15
Homeopathy
council
J_
2__
01
00
02
03
04
01
11
10
Total
04
36%
11
64%
19
45%
23
55%
19
61%
2___
Notes : Status
1. * existing 2. # non- existing
9
12
39%
Dentistry
council
Other
J
00
01
00
00
2
00
00
01
01__
00
0
02
100%
40
85%
1
02
11
14
13
2
01
01
01
04
07
15%
03
06
06
17
32
sectors were covered. Nearly 92 per cent were from the
latter sector. Around 860 health establishment including
274 hospitals (with bed strength ranging from 3 to 200
beds), PHC’s, sub-centres etc. were also listed, while 565
medical stores were found to be functioning in the
district.
voluntary sectors, very few were from the public sector,
thus attempting to cover the whole district. Besides
seeking information regarding their practice and the
delivery of health care in their area, family background,
medical education, charges, utilisation of their services
the respondents were also asked to identify other
practitioners in their vicinity. The questionnaire was
aimed at verifying the information gathered during the
sample check exercise and field trips, and generating
information other than that gathered during the field
trips. An incentive was held out through these
questionnaires as a means for attracting a positive and
early response from the doctors. This incentive was
in the form of workshops to be organised by FRCH
in Ahmednager for the responding doctors.
From both the surveys, the status of 1164 doctors
(294 non- existing and 870 existing) could be
determined, leaving the status of 1895 (62%) doctors
undecided. In the total of 870 practicing doctors
(determined through the study), the names of 209
doctors were added as a result of both the surveys.
After adding and deleting from the final list as per
our information, we found that the original list of 3059
doctors was overestimated by a mere 3 per cent. There
was still the possibility of a certain number of doctors
being inadvertently left out by us and hence, the number
3059 was considered a fairly reliable figure of practicing
doctors in the district.
Response to Postal Questionnaires
Out of the 274 hospitals to which the
questionnaires were sent, 90 replied and we were able
to add the names of around 15 more hospitals and
delete a few. Out of the 3059 doctors to whom the
questionnaires were mailed, 460 (15%) replied to us.
Eight per cent (249) of the questionnaires came back
Through the various techniques used we were
able to determine the volume of health resources in
the district. This data base of health resources for the
district may be considered as fairly reliable. We
managed to overcome most of the inadequacies in the
official sources and have been able to show that number
of health personnel and health units exceeds those in
the official sources. In the process we have been able
to expose the specific inadequacies in official sources
and the drawbacks in official enumeration of health
resources. Here the attempt was also to delineate an
approach for determining the size of health resources
within a specific territorial and administrative unit.
Table 2.4
A breakup of the doctors status
Doctor’s Status
No. of Doctors
% of Total
Shifted
retired
Expired
Not traceable
14
10
09
216
(5.6%)
(4.0%)
(3.6%)
(86.7%)
An important constraint in conducting an
exercise of this kind covering a large territory is that
of logistics. Such an exercise can be carried out only
in a district or a smaller territorial unit. Yet, it may
be said that in spite of the various limitations and
constraints, the FRCH team was able to prepare a fairly
reliable inventory of health providers in the district
which also enabled them to better understand the
distribution pattern of medical personnel according to
the sector and system of medicine. Keeping in mind
the various limitations encountered by the FRCH team,
other researchers can improvise upon the above
described approach by improving the techniques and
better dealing with local conditions.
unopened because the doctors concerned had either
shifted, expired, retired or were untraceable. (See Table
2.4.) We received 177 new names of individual doctors,
not recorded elsewhere in our list. During our subsequent
tours of the district a number of doctors who had not
replied, informed us that the questionnaires reached them
only after the last date for sending replies; otherwise,
the response rate would have been better.
Findings
The original list was cross-checked with lists
prepared through the sample check and postal survey.
All duplications were taken care of. The final list
showed 3059 doctors (qualified and unqualified) located
in urban and rural areas, representing all systems of
medicine. Doctors from both the public and private
□□
10
I
3
Health Manpower In The District
The chapter describes and discusses the nature
and volume of health personnel in Ahmednagar district,
as regards their distribution systems of medicine and
geographical areas of the district. Also some issues
arising from inaccessibility of treatment for those
seeking it. In the process, answers to some of the
questions raised in Chapter 1 will be sought.
allopathic doctors has risen. In the absence of any
significant increase in the employment opportunity,
there was further increase in the volume of selfemployed practitioners (Jesani A.. 1993). There were very
few large health units in the private sector in the district
which offered employment opportunities to doctors.
Though the employment opportunity is very slim in
the private sector, practitioners are reluctant to join the
public sector which is a problem discussed in the Five
year plans as also by various Committee and
Commission reports. In India a mere 13 to 15% of all
doctors were estimated to be employed in the public
sector (Jesani A., 1993). In the district this proportion
was 7 per cent, out of which, 151 were MOs of PHCs,
23 were amongst the staff of the civil hospital, and 38
were the MOs of the municipal hospitals and
dispensaries, the rural and cottage hospitals.
The survey shows that the total of 3059 doctors
in the district as against total district population meets
the Bhore Committee standards. There was one doctor
to serve a population of 1099. And yet there were
communities to whom medical care was both
unavailable and inaccessible. These 3059 doctors were
both qualified and non-qualified practitioners of modem
and traditional systems. The first section of this chapter
gives information on them. The survey also attempted
to generate information about paramedical personnel;
but. this was difficult, due to those working in the
private sector. An attempt was made to provide some
information about paramedical personnel in the district.
This percentage of public sector employment
could be higher as information about the public
employees in the district may not be accurate.
Information on the medical staff of the central and
state government units (such as the railway, police and
prison hospitals) could not be gathered. Secondly, the
list of PHC, MOs given by the District Health Office
was not updated. The State assembly was informed that
in Ahmednagar district, 92 posts of MOs (the highest
in the state) in 82 PHCs were vacant. (Times Of India,
1st Dec. 1992). Each PHC is supposed to have two
medical officers., one each of class one and class two
respectively.
Medical Practitioners in the District
The information was drawn from the census
exercise discussed in Chapter 2. For enumerating quality
of services rendered, the information is drawn from 474
responses to the postal survey which will be discussed
sector-wise, system-wise and sex-wise along with the
distribution of specialists.
Sector-wise Distribution
The responses to the mailed questionnaire gave
more information on the employment trend amongst
practitioners of all systems in the public and private
sector as seen in the following sections.
Out of total of 3059 doctors identified in the
district, 93% were in the private sector and 7% in
the public sector. The private sector is basically made
up of individual self-employed practitioners providing
medical care through dispensaries, clinics, polyclinics
and even small bedded nursing homes. The majority
of them were general practitioners with a small
percentage of specialists. The situation in the district
was similar to the all India scene. In India, according
to an IAMR study in 1963-64, all doctors in the private
sector, (88.4%) were self employed. Even in the 1990s
the percentage was the same. With the rapid increase
in medical colleges, especially private and of nonallopathic systems of medicines, the turnout of non-
General Practitioners and Specialists
The lack of employment opportunities is also
reflected in the higher proportion of general
practitioners in the private sector. We have assumed
that the graduate degree holders of all systems are
general practitioners and post-graduates are specialists.
Table 3.1 shows a higher proportion of
specialists amongst urban private practitioners whereas
11
Table 3.1
Geographical distribution - G.Ps. and specialists
General
Practitioners
Specialists
Qualifications
not known
Urban
77%
13%
9%
Rural
85.5%
1.8%
11.9%
E>i strict
81.9%
8.1%
10%
practitioners (0.1%) was smaller than expected. Published
sources do not list them and the State Government’s
decision in 1991, to ban their practice perhaps made
community sources wary about passing on information
regarding them. According to the DHO, the number of
non-qualified practitioners in Ahmednagar district was
197, though the actual list was never shown to us. We
were informed the names had been passed on to the
police for action. Information whether any action was
actually taken and cases filed was not given to us. The
information about number of non-qualified practitioners
may not be accurate as it was obtained by getting all
private practitioners in a PHC area to submit their
professional degree/diploma certificates at the PHC. No
specific and carefully planned method was used to
identify non-qualified practitioners. Hence, the number
may be even higher than stated. The CMO of
Ahmednagar Municipal Council informed us that once
the process of identification began, several non-qualified
practitioners fled the city.
in rural areas it was quite negligible. The percentage
of those whose qualifications were not known was higher
in the rural areas. We assume that most of these were
general practitioners. Other studies have shown that
specialists generally do not set up practice in rural areas
owing to the absence of any infrastructural facilities and
modern amenities.
There were 234 specialists ( 8.1% of total 3059)
in the district. Amongst the 234 specialists in the
district, 22% were gynecologists, 20.5% were surgeons,
12% were physicians, 10% pediatricians, 7%
ophthalmologists and orthopaedics together 4% ENT
specialists, 2% psychiatrists, 6.5% were others (such as
radiologists, pathologists, cardiologists, plastic surgeons
etc.)
Sex-wise Distribution
From amongst 3059 practitioners information
regarding gender was available for 2781. The Gender
distribution for the 2781 doctors, showed 2335 (84%)
were male and 446 (16%) were female. This corresponds
to the national pattern. In 1977 amongst the doctors
registered with the Medical Council of India, 81% were
male and 19% were female (Bang R.,n.d). Of the total
male doctors, 93% were general practitioners and 7%
were specialists, while 88% of female doctors were
general practitioners and 12% specialists. The proportion
of female specialist doctors in the district total was 234
specialists (21%).
The following discussion of the system-wise
distribution of the doctors shows a higher proportion
of non-allopaths. These non-allopaths have virtually
none or limited employment opportunities in
government/public health institutions. In the private
sector the opportunities are also limited and, in private
hospitals, their status is secondary with low salaries.
The absence of employment opportunities for the nonallopaths explains the high percentage of general
practitioners amongst this category.
Geographical Distribution of Medical Personnel
The availability and accessibility of health
personnel depends on their number and their
distribution across the geographical areas. So far we
have discussed the nature of volume of medical
personnel in Ahmednagar district The following data
about their geographical distribution, will explicitly
confirm the nature of inequalities in availability and
accessibility of health care services to the population
in both the rural and underdeveloped areas and the
urban and developed areas.
System-wise Distribution
Graphs 1 and 2 show that the percentage of nonallopathic doctors are almost identical at the district
and the national levels.
As seen in graph 1, the high percentage of nonallopathic graduates explains the high percentage of
general practitioners. Along with these non-allopaths,
728 of total 959 allopaths (76%) with only graduate
degrees. A majority have been assumed to be in general
practice considering that employment both in the public
and private sector is limited.
In the district, the percentage of non-qualified
12
*
Graph 1
System-wise Distribution of Doctors
In the District
42%
*
H%
16%
5.9%
1$®
Allopathy
1.5%
Ayurveda
_________
Homoeopathy Dentistry
33%
—
0.1%
RMP
Un-qualified Qualifications
not known
Graph 2
System-wise Distribution of Doctors
*
In India
41.3%
40.5%
i
■’
■
16.9%
.<
■
_______
Allopathy
_________
Ayurveda
0.2%
r
Homoeopathy
13
i
Dentistry
persons to one doctor while in the rural areas it was
1883 persons to one doctor. Thus, while the difference
in urban-rural distribution of doctors appeared to be very
small, seen in terms of doctor-population ratio, this
disparity was very wide.
Table 3 J
Rural-urban distribution - medical practitioners
Taluka
Urban (%)
Rural (%)
Total
Ahmednagar
(district)
Nagar
Shri rainpur
Kopargaon
Sangamner
Rahuri
Pathardi
Newasa
Akola
Shrigonda
Pamer
Shevgaon
Karjat
Jamkhed
1556 (50.9)
1501 (49.1)
3056 ♦
836 (84.7)
184 (52.8)
189 (58.5)
193 (65.9)
89 (40.3)
36 (23.2)
150 (15.3)
163 (47.2)
134 (41.5)
100 (34.1)
132 (59.7)
119 (76.8)
138 (100)
127 (100)
80 (73.4)
105 (100)
95 (100)
85 (100)
72 (100)
986
347
323
293
221
155
138
127
109
105
95
85
72
29 (26.6)
Disparity also existed between the developed and
under-developed regions of the district. About 71%' of
total doctors were located in five developed talukas
and only 29% were located in the eight underdeveloped
talukas. In the five developed talukas taken together,
one doctor served 812 persons. In the eight under
developed talukas a population of 1806 was served by
one doctor (Tables 3.2 & 3.3). The same disparity was
observed in Andhra Pradesh where two developed
districts with population of 7,968 and 8,051 were served
by one doctor each and two backward districts with
populations of 10,994 and of 9,408 were served by one
doctor each respectively. (Baru R., 1993).
(* ThcTaluka and/or social geography of 3 doctors
could not be identified)
System wise Geographic Distribution
Table 3.4
Doctor-Population Ratio
Distribution in developed and underdeveloped
talukas of the district
According to the 1981 census, urban areas had
58.8% of the doctors and rural areas had 41.2% of the
total doctors in the country (Jesani A., 1993). Of the
3059 doctors from the district, 51% doctors were located
in urban areas where only 16% of the district population
resides whereas 49% (apparently slightly less) of the
doctors were in rural areas with 84% of rural population.
In the urban areas population to doctor ratio was 343
Developed
Talukas (%)
Allopathy
Dentistry
Indian systems
Homeopathy
RMPs and Non
qualified
Table 33
♦ Population covered by one doctor
Taluka
Urban
Rural
Total
AHMEDNAGAR
(District)
Nagar
Shrirampur
Kopargaon
Rahuri
Pathardi
Sangamner
Jamkhed
Akoia
Shevgaon
Newasa
Parner
Shrigonda
Karjat
343
18S3
1099
265
430
467
604
542
253
1735
1585
1848
1504
1394
3046
1653
1739
1791
1973
2035
2671
2160
488
971
1037
1141
1196
1207
1653
1739
1791
1973
2035
2157
2160
76.5
98
68
71
23.5
2
32
29
65
35
Table 3.5
Rural-Urban Distribution According to System
Urban %
738
Under-Developed
Talukas (%)
Allopathy
Dentistry
Indian systems
Homeopathy
RMPs and
Non-qualified
Rural %
District
India
District
India
63.0
91.5
48.0
39.0
72.8
81.5
51.95
36.3
37.0
8.5
52.0
61.0
27.2
18.5
51.95
36.3
38.0
62.0
Source : India - 1981 Census GO1 District figures
Refer graph 1
Table 3.4 shows higher proportion of doctors
of all systems in the five developed talukas. Allopathic
and specialized services like dentistry were highly
(* 1991 Census population used & talukas ranked
by last column)
14
Graph
3
Doctor to Population Ratio in Ahmednagar
Urban Area
AKL
JKD
KJT
KPG
NGR
NWS
PRN
900—
800—
n
700—
District
Akola
Jamkhed
Kaijat
Kopergaon
Nagar
Newasa
Parner
~ 3000
pro
Pathardi
RHR
SGD
SMG
SRM
SVN
Rahuri
Shrigonda
Sangamner
Shrirampur
Shevgaon
~ 2700
-2400
- 2100
600—
~ 1800
a
o
500-
1500 U
O
Q
400—
“■1200
a:
o
300900
Q
200600
100-
o:
a
a.
300
O
■
100-
b
z
□□
u-
-300
Q
a
a:
a
-600 >
o
o
200—
300—
- 900
- 1200
u
PTD
RHR
SRM
z
- 1500 2
JKD
NGR
_
NWS
KPG
AKL
- 1800
SVN
£
LJ
PRN
-2100
KJT
-2400
SGD
Rural Area
SMG
F
15
!□
-2700
Key
I Population in 000s
-3000
I Number of Doctors in 00s
-3300
concentrated in the developed talukas in general and
in urban areas in particular as seen in Table 3.4 and
Table 3.5. The proportion of non-allopathic doctors,
RMPs and non-qualified practitioners was much higher
in rural areas. As is seen in Table 3.5 figures for
Ahmednagar district more or less match national figures.
Table 3.7
Availability of specialists services
Urban (%)
Rural (%)
[Percentage in Brackets]
General Surgery
Gynecology
Paediatric
Dermatology
General Medicine
Anaesthetic
An additional aspect of the location of health
procedures is the manner in which private providers
concentrate where public health services also exist.
Developed regions and urban areas tend to have a
concentration of health care services - both public and
private. It has also been observed that the private sector
tends to be concentrated in areas where public facilities
already exist. The private sector, utilising to its own
advantage the dissatisfaction of the general populace
with public facilities is thus assured of a large clientele.
Table 3.6
No.
Type of village/town
Under developed
Talukas
No. of
Villages/
Towns
Doctors
No. of
Villages/
Towns
Doctors
No. of
Pvt.
No. of
Pvt.
1
Towns with Civil Hospital and/or
Municipal Facilities
5
1428
0
0
2
Towns/Villages with Rural
Hospital
3
115
9
287
3
Villages with PHCs
37
233
39
273
4
Villages with Sub-centres
182
284
240
237
5
Villages without any Public
Facilities
324
163
673
107
Of the 234 specialists, 206 (88%) worked in
urban areas and 28 (12%) in rural areas. Out of the 234
specialists 214 (91%) worked in the five developed
talukas while a mere 20 (9%) worked in the eight
underdeveloped talukas.
Table 3.7 gives comparative availability of
essential specialized services in urban/rural areas and
shows that in rural areas important services as of ENT
specialists, ophthalmologists and orthopaedics were not
available at all.
Distribution of Women Doctors
The 446 female practitioners recorded in the
district form 16% of total practitioners. Only 116 (26%)
of total female practitioners worked in rural areas. Their
proportion in underdeveloped talukas was even smaller.
Only 80 (18% of total women doctors) worked in the
underdeveloped talukas. There were a total of 50 female
specialists in the district. Of these 5 (10%) work in
rural areas, 3 were gynaecologists, 1 a skin-specialist
and 1 an anaesthetist. Again of 50 female specialists,
11 (22%) worked in underdeveloped talukas. Only 3
(11%) of 27 female gynaecologists in the district worked
in rural areas and 2 (7%) in underdeveloped talukas.
Graph 4
Average No. of Doctors per type of Village/town
A
285.6
□
A
G
E
38.3
NO.
□
OF
31.9
D
O
C
T
O
R
S
7
□
Profile of the Respondents
6.3 —
Out of 474 respondents, 311 (66%) were from
the developed talukas and the remaining 163 (34%)
from the underdeveloped talukas. Of these 474
respondents 198 (42%) were urban based while the
1.6
0
1
II
2
48
51
23
12
28
14
The Distribution of Specialists
Ahmednagar has 13 talukas with five of these falling
in the developed category and seven in the under-developed.
The district has 10 towns and 1503villages. An attempt was
made to identify the location of private doctors against public
facilities in the towns and villages of the district Graph 4 and
Table 3.6 indicate the tendency of doctors to set up practice
in towns/villages where public services already exist
V
E
R
13(93)
13(27)
7(14)
2(9)
1(8)
2(7)
1(7)
It was observed that villages having no or
limited accessibility to public services also had the least
number of private doctors. Many private doctors, when
not located in a town/village with public facility, were
usually based in a neighbouring village within a radius
of five to ten kilometers, which was also the area covered
by a PHC. The villages falling outside the periphery
of a PHC area had thus, no immediate access to cither
public or private health providers.
Average no. of doctors per type of village/town
Developed talukas
35(73)
44(86)
21(91)
11(92)
26(93)
Total
0.5
IIII 11^ n
3
4
TYPE OF VILLAGE / TOWN
0.2
5
16
remaining 276 (58%) came from the rural areas.
Male respondents from amongst them numbered
429(90.5%) and the female respondents 45(9.5%).
The average age of the respondents was 40
years. The degree holders amongst them were 264 in
number (56%), diploma holders 137 (29.5% most of
them had done earlier diploma courses of Ayurveda, like
GFAM, MFAM, etc. and 21 had done postgraduate
diploma courses for specialization), 52 had some
certificates, 2 had both degrees and diplomas for
specialization, 11 had degrees and certificates, 7 had
diplomas and certificates.
Out of them 69 (14.6%) were specialists while
404 (85.2) were general practitioners.
Of the 474 doctors 132 (27.8) were allopaths,
69 of them being general practitioners and the remaining
63 specialists. The number of pure Ayurveda degree
holders was 147 (31% of the total) of which 3 had done
specialization. The integrated course of Ayurveda and
allopathy (BAM & S) was studied by 74 (15.6%) of 474
doctors and of these one was a specialist. There were
90 (19%) homeopath degree holders, out of which 2
claimed to have done some kind of specialization.
Dentists who responded were 6 (1.3%) in number. There
were amongst the respondents 18 (3.8%) RMPs, 4 (0.8%)
who had qualified in two systems (2 in allopathy and
homeopathy; 2 in ayurveda and homeopathy) and 3
(0.6%) had certificate of some non-recognized systems.
allopathy, Ayurveda and homeopathy and one practiced
allopathy and Ayurveda.
Of the 18 RMPs, one practised allopathy, 3
Ayurveda, 1 both Ayurveda and allopathy and 12 had
not mentioned their system of practice.
Of the 474 respondents 432 (91.1%) had their
own practice, 11 (2.3%) were employed in the private
sector, 22 (4.6%) were employees in the public sector
and 9 (2%) were employed by NGOs.
Of (he 132 allopaths 108 (81.8%) were engaged
in private practice while of the 221 Ayurveda graduates
(pure and integrated) 205 (92.8%) were private
practitioners. Employment was available more to allopaths:
24 (18.2%) were employed - 4 at private practitioners, 15
in government service, and 5 with NGOs, while of Ayurveda
doctors 16 (7.2%) were employed - 5 at private practitioners,
7 in public sector, and 4 with NGOs. The other practitioners,
homeopaths, dentists and RMPs were completely dependent
on private practice.
Of 432 private practitioners, 140 (32%) doctors
provided indoor facilities. The average bed capacity of
these 140 units is about 8 beds. Of 108 allopath private
practitioners, 58 (54%) provide indoor facilities; on an
average each one had about 11 beds.
Of 205 Ayurveda doctors (of pure and integrated
course) units, 51 (25%) had indoor facilities with average
bed strength of 6 beds.
Of 89 homeopaths having their own practice.
25 (28%) provided bed facilities with average strength
of 5 beds.
The majority of the 429 male respondents were
Ayurveda graduates (pure and integrated courses together
- 205 i.e 47.8%) allopaths were 111 (25.9%),
homeopaths 85 (19.8%), dentists 4 (0.9%) RMPs 17 (4%)
and others of (1.6%). On the other hand of the 45 female
respondents majority were allopath doctors - 21 (46.7%),
followed by Ayurveda graduates - 14 (31.1%), 5 (11%)
homeopaths, 2 (4%) dentists females and 1 RMP. Of
the 132 qualified doctors in allopathy, 5 said that they
practiced Ayurveda and homeopathy also. The extent
of cross-practising was however higher amongst the nonallopathic graduates. Of 147 Ayurveda degree holders
13 (8.8%) said that they practised only allopathy, while
83 (56.5%) practised both allopathy and Ayurveda, 3
practised all the systems and 1 practices homeopathy.
Of 17 RMPs, 4 had bed facilities, each having
on an average 3 beds.
Those practicing pure Ayurveda (49) or pure
homeopathy (32) on an average held a negligible bed
strength. Thus bed facility was basically provided by
qualified allopaths and non-allopalhic doctors practicing
allopathy.
Issues Arising from Unequal Distribution
As discussed above, the volume and distribution
of medical professionals in the district confirmed the
bias towards developed and urban areas. Information on
characteristics of these services gathered from the postal
survey and the workshops in the district show how
unequal distribution of services was the result of
economic factors as also other socio-political and cultural
factors. All these contributed to make the health services
inequitiable in the provision of health care.
Out of the 74 graduates of integrated Ayurveda course,
4 practiced complete allopathy and while 3 practised. Ayurveda
the remaining 67 practised both allopathy and Ayurveda.
From amongst the 90 homeopath graduates 16
(17.8%) practised only allopathy, 31 (34.4%) practised
only homeopathy and 36 (40%) practised allopathy and
homeopathy both. Of the remaining 4, 3 practised
All these factors in composition were reflected
17
Table 3.8
Bed-Provision by private practitioners
in the choice made by qualified and specialist
professionals to practice in urban and developed areas,
the employment opportunity available to graduates
from different systems, the high proportion of cross
practice and the demand for allopathy.
Dominant Private Sector
The mailed responses to questionnaires also
throw some light on the employment pattern according
to the systems of medicine. Of a total of 474 respondents
432 (91.1%) had their own practice, 11 (2.3%) were
employed in the private sector, 22 (4.6%) were
employees of public sector and 9 (2%) were employed
in the voluntary sector. But when classified according
to system, it was found that of 132 allopaths 108 (81.8%)
had their own practice while of 221 Ayurveda graduates
(pure and integrated courses), 136 (62%) were private
practitioners. It can be said that allopaths have more job
opportunity as 24 (18.2% of total 132 allopaths) were
employed - 4 with private practitioners, 15 in government
services, and 5 with the voluntary sector, while only 16
(7.2% of total 121) Ayurveda doctors were employed - 5
with private practitioners, 7 in public sector, and 4 with
the voluntary sector. The homeopaths, dentists and, of course,
RMPs who responded had their own practice.
Average Bed
strength
Systems
Total
Those having
indoor facilities
Allopathy
Ayurveda
Homeopathy
RMP
108
205
89
17
58 (54%)
51 (25%)
25 (28%)
11
6
Total
432
140 (32%)
8
5
aggravated when attempts are made to legitimize cross
practice. Inspite of the decision of the Supreme Court
over-ruling the verdict of Kerala High Court allowing
allopathic practice by non-allopaths, the Maharashtra
government issued an order on 25th November, 1992,
allowing Ayurveda graduates to practice allopathy.
Another issue involved is that of economic
pressures and market competition forcing non-allopalhic
practitioners to submit to cross practice. The
participants at the workshops held in Ahmednagar
district for both rural and urban practitioners of all
systems cited that an allopathic medicine gives a quick
relief to the patients. Therefore, there is a great demand
for allopathy especially in rural areas, where people
cannot afford to lose their working days because of
illness. Because of this demand, non-allopathic doctors
lack opportunity to prove the efficiency of their
particular system of medicine.
With rapid increase in the private sector in the
seventies and eighties the attraction of setting up private
practice became so strong that qualified allopaths are
unwilling to accept government services. Perhaps this ground
reality influenced the Health Minister of Maharashtra to
declare that government was thinking of creating posts of
class III Medical Officers to be filled-up by the degree
holders like Ayurvedacharya, Ayurvedateertha, etp. to attract
doctors to rural services (Sakai, 1993). This is a fairly
distorted form of the proposed and planned integration of
indigenous systems into public health services.
This demand for allopathy, for injections,
for saline, from the people has encouraged
commercialization of the profession. The profit making
attitude developed by market demand has resulted
in over-medication, unnecessary hospitalization etc.
Table 3.8 gives the comparative bed-holding
capacity of the doctors of all systems.
Demand for Allopathy
Those who have said that they practice pure
Ayurveda (49) and pure homeopathy (32) on an average
held a negligible bed strength. This meant that qualified
allopaths, most of them being specialists, provided
indoor facilities (the extent of over-medication,
unnecessary surgeries and uncalled for hospitalization
by them cannot be decided by this study, hence is not
discussed here) and non-allopaths practicing allopathy
provided bed facilities, owing to the ‘demand’ for
allopathy.
The haphazard and adhoc attitude of the
government towards the development of alternate
systems has caused degeneration of Ayurveda, Unani
and Homeopathy, which is reflected in the extent of
cross-practice done by non-allopaths. There is a clear
gap between the policy rhetoric on alternative medicine
and implementation of the declared policy.
A majority of non-allopaths engaged in cross
practice, either completely or in combination with their
own system. This was explicitly reflected in the mailed
responses and discussed earlier under profile of
respondents.
This demand for allopathy and the legitimacy
offered to the non-allopaths (by masses who ask for it
and by the government which legalised it) has
encouraged the tendency to seek any valid or even
The issue of cross-practice is a complex one.
The threat to development of alternate systems is
18
suspect and doubtful degree holder to start private
medical practice, basically in allopathy. This explains
the spurt of non-allopathic medical colleges in the
district over the last few years. To set up a non-allopathic
medical college is much easier than setting up an
allopathic medical college. The non-allopathic medical
education is in demand because it is cheaper than
allopathic medical education but in no way a hindrance
to allopathic practice and money-making. If in the name
of demand for allopathy, these non-allopaths practice
allopathy, this is another important issue to be
considered.
competitive and rural students suffer several
disadvantages as compared to their urban counterparts
in this competition. Non-allopalhy courses therefore
offers and becomes the choice for rural students who
wish to acquire a medical degree. Acquiring a medical
degree becomes the goal and not acquiring knowledge
of a particular system of medicine out of faith and
desire to practice that healing system.
The more practical reason mentioned for this
tendency was related to the economics involved. In the
towns with the availability of allopathic practitioners,
the demand for non-allopathic doctors, practising
allopathy was relatively low. In the urban areas their
status would always remain second to that of allopathic
doctors. Non-allopaths work in urban institutions for
a short duration, gain experience in allopathic
treatment. On the basis of this experience gained, they
return to their rural homes to practice allopathy, which
ensure a certain status and prestige. They also have
the advantage of family contacts to carve out their
clientele. They have the additional advantage of
supporting their income from agriculture or other
inherited businesses. Considerations such as ancestral
or agricultural property do not appear to compelled
allopathic graduate to return to their rural homes and
set up practice. This appeared to be so because of the
confidence they had in their own system and the demand
for and prestige attached to it. Non-allopaths appeared
to lack that kind of confidence. In addition, most people
have little knowledge and awareness of the alternative
systems, even of traditional systems as Ayurveda and
Unani. Their own faith in the healing potential of the
alternative systems is limited because of the slow process
and long duration taken for treatment. Allopathy ensures
quick relief. For daily workers who perhaps constitute
a large sector of rural potential this is important.
Various studies have demystified the claim of
natural cultural affinity for indigenous medicine and
the demand for allopathy since its introduction in India.
The reasons for this demand might be in the natural
tendency of accepting everything that the clite/ruling
class pursues as best or the perceived successful
development of allopathy as a science against Ayurveda
or in the ineffective policy-making and policy
implementing regarding health manpower, medical
education and the distribution of services.
Urban/Rural Preference
In the workshops held for doctors in Ahmednagar
district this issue of preference of allopathic
practitioners for urban areas and of non-allopathic
practitioners for rural areas was discussed. The allopaths
with rural and semi-urban family background speaking
on their preference for urban areas cited reasons such
as the rise in their material expectations corresponding
with those of their urban colleagues, knowledge of their
market potentials in urban areas and that a high standard
of living unavailable to them in the rural areas, within
their reach in urban areas. Non-allopathic practitioners
complained about the poor standards of educational
facilities available to them as compared to those
available to allopathic colleges. The accommodation,
mess and teaching facilities, they said, are so poor that
as soon as a student gets his degree he preferred to go
back home, even if it was in the rural area.
The demand for allopathy from the masses and
an unequal distribution of qualified and specialists
services in urban areas has created a ready market in
urban areas. This was reflected in the proportion of
doctors visiting surrounding villages to carve out the
clientele. In a week only 30% of 182 private urban
doctors regularly visited other villages that too at the
most one-or-two surrounding villages. As against them,
89% of 250 private rural practitioners visited other
villages and quite a few of them visited upto 5 villages
only. Again when 60% of urban private practitioners
go for home visits almost 85% of rural practitioners go
for house visits. On an average urban practitioner was
available for 8 hours in a day and rural practitioner was
available for 10-11 hours a day.
For many, training in non-allopathy medical
course was a second choice. It was not because of faith
in the inherent soundness of the alternative system that
they chose to study it. Unable to get into allopathy
colleges and because of expensive education in these
colleges, they opted to join non-allopathy courses.
Rural background, socio-economic background, lack of
efficient educational facilities and proper coaching all
combined to become constraining factors in the entry
to allopathy colleges. Entry into these courses is highly
19
along with the medical personnel. By paramedics we
meant the vaccinators, innoculators, medical assistants,
dental assistants, pharmaceutical assistants, nurses,
auxiliary nurses midwives, traditional midwives and
health visitors.
The average weekly OPD of the practitioners
of allopathy both qualified and non-qualified (157.2)
was much higher than that of the practitioner of pure
Ayurveda (126.6) and of pure homeopathy (93). The
non-qualified practitioners of allopathy were all those
who practised allopathy without any formal training.
When we undertook our survey of the district
we realised that this section being not organized, their
volume in private sector was difficult to estimate. The
Socio-Economic Review of Ahmednagar District for the
years 1991-92 gives the total number of qualified nurses
as 833 in the district. The information has to be read
with caution as the same source gives the figure of
doctors and Vaidyas together from the district as 265,
whereas our census covered 3059 doctors of all types.
The only source for any information on them as far as
the private sector was concerned, was through their
employers. This was done through the mailed
questionnaire.
The percentage of practitioners of allopathy
without any formal training amongst pure Ayurveda and
homeopathy degree holders in urban and rural areas
(64.0% and 65.9% respectively) differed by only about
1.9%. But the proportion of qualified practitioners being
much higher in urban areas than in rural areas
inaccessibility to proper allopathic treatment was much
higher in rural areas.
Health of Rural Women and Health Personnel
According to one study in rural Maharashtra,
about 92% of the women observed, suffered from one
or more gynaecological or sexual disease and on an
average each woman suffered from 3.6 diseases (Bang
R.n.d.) But health care needs of women do not get
adequate medical attention, more so in rural areas
because of other social problems and cultural taboos.
Say Khan and Patel in *Access to Health Care “Health
planners do not realise that the subordinate status of
women in Indian society prevents them from accessing
health facilities as the men”. (Khan M. and Patel B.
1993). In a study conducted at Safdarjung Hospital in
Delhi male admission was 65% and that of females was
35%. According to other study reports this ratio varies
from 2.1 : 1 to 1.3 : 1, the latter being in the south.
Paramedical in Private Sector
Quite a few respondents to the postal survey
gave some information on their paramedical staff. Since
the responses were not controlled, and further queries
were out of question, any details or further classification
as was expected earlier was not available. Hence the
responses detailed only nurses, compounders and other
paramedics. What these other paramedics meant was
difficult to define. Secondly, the qualifications of the
staff employed were not given. The nurses in the
responses could be midwives, traditional ayahs or dais.
The compounders could be helpers, assistants or
attendants.
The Nurses
Part of the problem of women’s inaccessibility
to health care arises out of cultural values of a
conservative rural society. Women patients would prefer
to be treated by women doctors. But women doctors
are few in number overall and far too few in the rural
areas. This small group of women professionals are
hardly able to provide their services where they are
most needed. A substantial increase in the number of
lady doctors and their proper distribution will perhaps
help to achieve better health status for women in the
rural areas.
Of 474 respondent doctors, 432 were selfemployed practitioners. Of these 432 practitioners 36
Table 3.9
The qualification system and bed-provision of the
employers of nurses
PARAMEDICAL PERSONNEL
The census was to cover all those who were
engaged in the delivery of health care services.
Accordingly, the paramedics who physically or directly
provide their services and were in immediate contact
with health care, were obviously the object of the census.
Beds
0
1
7
3
4
Total
Allopathy
Pure
Ayurveda
Homeopathy
Dentistry
Integrated
Ayurveda
RMP &
Others
1
3
6
10
1
21
0
1
1
1
2
3
1
Total
20
1
1
2
3
5
1
£
5
6
4
2
12
11
2
36
had employed nurses in their institutions of which 20
were in urban areas and 16 in rural areas.
Of the 20 urban doctors, 10 had employed one
nurse each, five had employed three nurses each, 1 had
employed four nurses and there was a lone instance
who claimed to have employed nine nurses. Three
respondents did not mention the number. Of the 16 rural
doctors, 12 employed one nurse each and one each
employed 2,3 and 4 nurses respectively. One doctor did
not mention the number of nurses employed. That meant
17 urban doctors employed 36 nurses, and 15 rural
doctors employed 21.
Table 3.9 shows the system of qualification
of doctors who have employed the nurses and the
number of beds they provided.
Table 3.9 also shows there were 5 doctors who
had employed nurses in spite ol not having any indoor
facility.
It has to be kept in the mind that the
qualification and the definition of the term ‘nurse’ is
not known.
0
Allopathy
7
Pure Ayurveda 18
Homeopathy
11
RMP
1
Integrated
Ayurveda
10
Total
47
1
2
3
6
12
6
6
6
5
5
1
2
4
3
30
19 [
4
6
Total
18
2
104
Of 432 self employed respondents, 43 doctors
staled that they employed paramedics other than nurses
and compounders - 26 in urban areas and 17 rural areas.
Of the urban doctors 12 employed one
paramedic each, 4 employed 2 paramedics each, 4
employed 3 paramedics each and one each employed
4, 6 and 8 paramedics respectively. Three doctors did
not mention the number of paramedics employed by
them. Of the 17 rural doctors, 5 employed one paramedic
each, 4 employed two paramedics each, 1 employed
thrice paramedics, 4 employed four paramedics each,
1 each employed five and six paramedics respectively,
while one did not mention the number of paramedics
he employed. Thus the 23 urban doctors employed 50
other paramedics and the 16 rural doctors employed 43
other paramedics.
Table 3.9 shows that majority who employed
nurses were allopathic practitioners having bed care
facility. But non-allopathic doctors with or without
indoor facility also employed nurses. As far as
compounders were concerned, as seen in Table 3.10
majority of them were employed by those who were
qualified in Ayurveda and did not have indoor facility.
It seemed that all those (regardless of their system of
25
35
23
3
1
Other Paramedics
Table 3.11 gives the system of qualification of
doctors who employed the paramedics other than nurses
and compounders and the number of beds provided in
their facilities.
Table 3.10
Qualification-system and bed-provision of the
employers of compounders
Beds
Table 3.10 shows the system of qualification
of doctors who have employed compounder and the
number of beds provided by them.
The Compounders
Table 3.11
Qualification-system and bed-provision of the
employers of paramedics
Of 432 self employed practitioners, 104 had
employed compounders. Of these doctors 41 practiced
in urban areas and 63 in rural areas. Of the urban doctors,
thirty employed one compounder, seventeen 2
compounders and one each employed 3 and 5
compounders respectively. Two did not mention the
number of compounders employed. Of the rural sixty
three doctors, 54 employed one compounder each, six
employed 2 each and two employed 4 each. One doctor
had not mentioned the number of compounders he
employed. Thus, 39 urban doctors employed 52
compounders and 62 rural doctors employed 74
compounders.
Beds
0
1
2
3
Allopathy
Pure
Ayurveda
Homeopathy
RMP
Integrated
Ayurveda
5
10
10
1
2
2
5
1
2
1
1
1
2
9
3
Ts
10
Total
21
4
Total
26
7
2
3
5
3
43
A full-fledged working 30-beds rural hospital,
at Pathardi had the following paramedical staff
sanctioned as on 31st December, 1993 : Compounder,
lab technician, nurse and x-ray technician one each in
class III cadre and X-ray assistant and cab assistant one
each in cadre IV.
qualification) and who do not have indoor facilities,
employed compounders, rather than other staff. All others
having indoor facilities, mainly employed nurses and
other paramedics. The reasons were obvious. Most of
the former dispensed medicine and therefore required
compounders, whereas nursing staff was required more
for the latter category of doctors.
Generally, in the PHCs paramedical staff consists
of one compounder, one health assistant, one nurse
midwife, four attendants and one ANM. Each subcentre
has one ANM. Within a PHC area, there can be about
20 trained dais and about 35 CHVs depending on the
exact number of villages covered by the PHC. During
the sample check study it was found that each village
has at least one untrained or traditional dai.
Paramedics in the Public Sector
The paramedics in the public sector were
employed in facilities run by central government, state
government and local bodies. They were known to work
in the following institutions :
District Hospital
Rural Hospitals
Primary Health Centres
Subcentres
Dispensaries run by local bodies
Hospitals run by local
bodies/cottage hospitals
Dispensaries run by
state government
Railway Hospital
Other Central Government
Hospital
Prison Hospital
Police Hospital
1
12
87
A Cottage Hospital of 50 beds at Sangamner
jointly run by the State Government (through the Civil
Hospital) and the municipal council, had 2
compounders, one x-ray technician, 1 lab technician,
7 nurses, 6 aayahs, 7 wardboys, 1 vaccinator, on daily
wages 2 male and 3 female nurses.
485
6
5
The volume of paramedics in the public sector
was thought to be easier to determine but neither through
personal contact or the structured questionnaires sent
to both the Civil surgeon and the District Health Office
(DHO) could we elicit this information. Hence, the census
was not very successful as far as paramedics were
concerned in both public and private sectors.
3
2
2
1
1
The total paramedical staff working in these
institutions consist of nurses, nurse midwives, auxiliary
nurse midwives, compounders, health assistants, health
workers, etc. The total staff strength of these'institutions
could not be made available.
In conclusion it may be said the pattern of health
services in the district corresponds to the already known
pattern, namely the dominance of the private sector
particularly so of private individual practitioners in the
delivery of medical care; the concentration of health
personnel in urban areas and developed regions;
rampant cross-practice amongst non-allopaths; and non
availability of specialized medical care in rural areas.
In the district hospital, at Ahmednagar there
were about 100 nurses employed-in various capacities,
one pharmacist, three X-ray technicians and
compounders were working in the same hospital. This
information was unofficially collected from some staff
of the district hospital. The Civil Surgeon after persistent
requests made available only the list of medical
personnel of the hospital.
22
4
4
Health Institutions In The District
Diverse types of health care are delivered to the
people by various providers operating in the health care
system. One of these is institutional care. Treatment
provided in the confines of institutions for a certain
duration is of a domiciliary character and is also
referred to as hospitalization or indoor care. Treatment
in these institutions could be for the purpose of
examination and diagnosing the illness, curing,
recuperating, maternity and related purposes among
others. Institutional care can also be ambulatory care
but our concern is more with institutions offering patient
care.
provide specialized service in any one of the specialties,
but many of them provide more than one speciality.
These services include maternity, medical termination
of pregnancy (MTP), gynecology, orthopaedic,
ophthalmic, ear-nose and throat, paediatric baby care
and new bom center, intensive care unit, day care and
other types of general services and surgical services.
Single specialty institutions that provide services only
for certain illness or specialty e.g. maternity, paediatric,
ENT hospital etc.
The Present Study : Health Establishments
In India health care in the public sector is mainly
provided through a network of various teaching, non
teaching, district level three-tier health system with
its civil hospitals, rural/coltage hospitals and primary
health centres and certain specialty hospitals meant for
specific illness such as tuberculosis, leprosy, mental etc.
and maternity homes. In addition to the above the state
provides health care for its employees through the
Central Government Health Scheme (CGHS) and for
the organized sector employees through its own
hospitals. Other ministries and department of the
government like defence, railways, police etc. have their
own hospitals and other health units that provide care
to their own personnel.
The first modern hospital to be set up in the
district was the Ahmednagar Civil Hospital. Il is
difficult to ascertain the exact date of its establishment
since two different sources state two different years,
1877 and 1882 respectively. However this difference in
dates is of small importance. Besides the Civil Hospital,
the district had three grant-in-aid dispensaries at
Sanagamner (the present cottage hospital), Nevasa and
- Shevgaon. Dispensaries with indoor facilities were also
available at Pamer, Akola, Mirajgaon and Jamkhed.
Christian missions the foremost being the American
Mission were very active in the district from the late
19th century. They too set up 2 medical dispensaries
to begin with, which were later converted into hospitals,
one at Rahuri in 1880 and another in Ahmednagar in
1904. Since then the number of Christian mission
hospitals in the district has gone up to six.
Private health sector institutions also provide
indoor care. These may be broadly classified on the
basis of their (i) bed strength, (ii) ownership and (iii)
services and facilities provided. Bed strength may vary
from 5 to 200 beds - even more at times. Bed strength
may indicate the nature of facilities and services
provided by the health units. As for ownership there
are corporate hospitals set up by corporate bodies as
a business venture: then there are private industrial/
plantation enterprises who have their hospitals to
provide medical care to their employees; and there are
voluntary and private charitable trusts hospitals. In India,
as in several other countries, a substantial component
of private health establishments consists of those owned
by private individual practitioners singly or in
partnership.
In the post independence period, the number of
government aided and government hospitals and
dispensaries went up from 16 in 1951 to 38 in 1957.
These 38 facilities had 165 beds offering medical care
to 7000 indoor patients and ambulatory care to 2.15
lakh outdoor patients per annum. In 1970, the number
of public and public aided health units showed 14
dispensaries, 4 hospitals, 5 health centres and 20
primary health centers and the availability of 650 beds.
Domicialary care and ambulatory care was made
available to 55062 and 427407 patients respectively
per annum through these health establishments. These
health institutions off^ed. employment to 103 doctors,
16 Vaidyas and 223 nurses. In 1971 there were a total
of 752 health establishments in the district. Of these
535 were rural based (employing 1346 personnel) and
The services provided by the health care
institutions are varied. There are some hospitals which
23
the basis of bed strength of the 605 health units, 494
health units had no beds, while 111 health institutions
offered indoor care. But of the latter, 87 were PHCs
which offered limited indoor care and five offered
medical care both domiciliary and ambulatory to only
defined groups of people e. g. military employees and
their dependents or railway employees and their
dependents. Only 19 public institutions were available
to the large general population offering institutional
or indoor care. Out of the 19 public hospitals, 7 were
in the urban area and 12 in the rural areas.
217 (employing 1217 personnel) were located in urban
areas. Sectorwise disaggregated figures were not
available.
In the present study 860 health institutions in
the district including 366 institutions having bed
facilities were recorded from all the available sources.
These included private dispensaries/ clinics with as few
as three beds, private hospitals and nursing homes,
rural hospitals and comparatively bigger public,
voluntary and missionary hospitals, and government
PHCs and sub centers. A total count of all health
Of the 366 institutions with beds, 225 were in
establishments showed that in the public sector alone
the
private
sector. 111 were public sector units and 11
there were in all 605 health units, including PHCs, sub
belonged
to
voluntary and missionary sectors. The
centres and units run by the Central, State Governments,
sources
could
not give information about ownership
Zilla Parishad and Municipal bodies. In Ahmednagar
for
the
remaining
19.
district the public sector health network consists of units
as shown in Table 4.1
The information about type of services offered
Table 4.1
was
not
available for about 82 of the total hospitals.
Public health institutions in the district____
Of the 82, 57 are general hospitals, 11 belonged to the
1
District hospital
public sector, 4 to the voluntary and 42 to the private.
12
Rural hospital
According to information gathered, 74 were maternity
87
PHCs
homes, 5 in the public sector, 1 was a voluntary unit
485
Subcentres
and 68 were private. Psychiatric, orthopaedic, ENT and
6
Dispensaries run by Municipal Councils
opthalmic services, surgical and specialized services
6
Hospitals run by local bodies
for treatment of leprosy, cancer, heart-diseases, TB and
(including one by Cantonment body)
■ other infectious diseases were provided by the remaining
3
Dispensaries run by Zilla Parishad
62 institutions. All services general and maternity care
1
Military hospital
were provided other than by private practitioners (91%).
2
Railway hospital
The remaining (9%) services were provided by the
1
Prison hospital
voluntary sector.
1
Police hospital
According to available information, 16% of
605
Total
_____________________
general hospitals and 7% of maternity homes were run
by non-allopathic doctors.
Of the 605 public health establishments 587 were
located in rural areas and 18 were urban based. On
Table 4 J
Rural-urban distribution of hospitals according to bed strength
Bed-strength
Upto 10
11-20
21-30
31-40
41-50
51-100
101-150
151-200
Above 201
Total
Number of Hospitals
______ Urban_____
56
33
7
4
1
2
4
3
Number of Hospitals
Rural
56
1
7
f
2
11 (91%)
no (91%)
24
Total
34
14
4
1
2
.... .5 ....
- 3
2
121
Of the total hospitals especially those in the
private sector 74% were located in urban areas and 26%
are located in rural areas. As with the case of health
personnel bias was towards the urban areas in developed
taluka. About 70% of hospitals were concentrated in
urban areas of the 5 developed talukas. Remaining 30%
were spread throughout the rural areas of the district
and two urban centres of the underdeveloped talukas
(Shrigonda and Pathardi).
the pre-independence period, one of them dating back
to 1917. Two each of the units were from the voluntary
and public sector respectively and 1 was from the private
sector. Between 1946 to 1969, 12 units were established,
between 1971 to 1980, 24 units were established and
between 1983 to 1991 40 units. The national trend
in the post independence years showed growth in the
private sector. Expansion of private health units can be
noticed at the National level also. In India, during 1974,
16% of the health institutions and 21.5% of the hospital
beds were in the private sector. This proportion
increased in 1990 to 57.95% of the hospitals and
29.12% hospital beds. (CBHI, various years).
While 366 institutions were known to have beds,
data on bed strength was available only for 121 of
the total listed health units, of which 92% were from
urban and only about 8% are from rural areas. If we
look at the bed-strength of these 121 hospitals, we find
that 90 (74%) of them were smaller hospitals having
beds upto 20. But again 99% of these health units up
to 20 beds were located in urban areas.
The trend corresponds at both the national and
district level. The private sector increased from the
seventies onwards and in the eighties witnessed rapid
growth. Out of 40 institutions established between 1983
to 1991, 38 were from the private sector.
There were two hospitals having beds above
200, and both of them were in rural areas. One was a
TB sanitorium in Arangaon, at 6 km from Ahmednagar
town and the other was Pravara Medical Trust’s Hospital
at Loni, a semi-urban place.
Out of the 90 health units that responded, 75
were from the private sector, 8 from the’voluntary /
Non Governmental Organization (NGO) sector and
7 from the public sector. The account that follows
describes and analyses the information elicited from
these 90 respondents.
Thus by its increased presence the private sector
became dominant during the seventies and eighties.
One of the foremost reasons was the economic policies
followed by the Government whereby the private sector
could enlarge unhindered. There was a general
undermining of public health services due to deficiency
of funds for health facilities in rural areas. Between
the years 1985 and 1991 the ratio of national
government expenditure on health as percentage to total
government expenditure halved from 6.3% to 3.68%.
(George A. 1993) The State took up the responsibility
of preventive and promotive health care services and
left the curative care which was the main need of the
people largely in the hands of the private health sector.
The demand of the people from rural areas was more
for curative services; instead primary health care was
thrust upon them which ultimately became a instrument
for pushing family planning services.
Of the 90 respondents, 5 hospitals were from
The findings with regard to the locations of the
Profile of the Institutions
Questionnaires were mailed to 274 health
establishments, which excluded PHCs and subcentres,
identified during the survey. Of these 90, i.e 32%
responded.
Table 43
Geographic distribution of hospitals
Urban
52
5
2
Private
Voluntary
Public________________
Developed Talukas
Under developed Talukas
Total Hospitals
25
Rural
Total
23
75
8
__ 7__
3
5
5
57
2
6
62
28
59
31
90
Table 4.4
Type of management and ownership
Management
Private
sector
Individual Proprietorship
Partnership
Trust/Society
Private industrial Enterprise Ownership
Government
70
Total
Ownership of premises
Voluntary
sector
Public
sector
3
1
1
8
7
75
Private
8
Voluntary
Owned
Long Term Lease
Rental
Any Other
61
1
12
1
6
Total Number of health units
75
8
7
Public
4
2
3
hospitals in the district was that 57 hospitals were
located in the developed talukas, bulk of them in urban
areas. Ahmednagar and Kopargaon talukas alone
accounted for 38.88% of the hospitals in the district.
This corresponds with a study conducted in Andhra
Pradesh which found that the highest concentration of
hospitals and nursing homes were in the towns and
cities of the advanced districts. Even in the backward
districts they were restricted to major towns (Rama Bare,
1993).
7
the Andhra Pradesh study which observed that NGO run
health institutions tend to be located in developed districts
and within them in developed tehsils (Rama Bare, 1993).
The findings with regard to the type of
management/ownership (Table 4.4) revealed that among
the private hospitals. 70 were owned by individual
■ proprietors, 3 were run on partnership basis, one was
run by a Trust and one by an industrial enterprise.
The high number of individual ownership of hospitals
appeared to be due to the increasing number of doctors
passing out from the medical colleges and limited
employment opportunities in the public and private
sectors. In the public sector opportunities were available
but primarily in the rural areas. Most allopathy doctors
were reluctant to join government health units in the
rural areas. In the private sector - including voluntary
- large hospitals with employment potential were very
few. In the last decade and a half banks and government
institutions such as the MSFC (Maharashtra State
Finance Corporation) have begun to offer financial loans
for setting up nursing homes/hospitals. As a result, it
attracted doctors towards establishing their own health
units with indoor facilities. Growing competition forced
doctors desirious of attracting as large a clientele as
possible to offer as many services as possible. New
developments in medical technology facilitated the
expansion of specialized medical care, and given the
financial constraints of the government sector, health
units offering such care came up primarily in the private
sector.
The present study also shows that out of the
75 hospitals in the private sector 52 were located in
urban areas. The private sector functions in areas where
there is a paying capacity. The growth of the private
sector in health care is directly related to the level
of economic development. This link is logical because
it is the economically developed areas which not only
provide the market for these services but also the surplus
to invest in commercial enterprises (Rama Bare, 1993).
With regard to the location of voluntary sector
hospitals in the district 5 of them were located in urban
areas, again in the developed regions. A study conducted
by the Foundation for Research in Community Health
(FRCH) found that 34% of the NGO projects working
in health care were located in districts with above
average socio-economic development, 36% in districts
with average development and 30% in districts with
below average development. Majority of the NGOs
prefer to locate where infrastructural facilities are better
developed (Jesani A, 1986,). That this was a trend
common also to the voluntary sector was confirmed by
The trend towards establishing private health
26
Table 4.5
Profile of responding health establishments
Sector
Geographical Distribution
Pvt
NGO
Pub
Total No. of Units
75
8
7
Total No. of Beds
1085
906
14
Avg floor space (sq.ft.)
Urban
Rural
Total
286
1738
539
2277
113
41
29
17
24
2068
29678
4643
5196
9570
4723
Avg No. of OPD cases p.m
805
2802
1791
998
1174
1059
Avg no. of admissions p.m
70
221
144
94
80
89
Avg days of stay
5
5
13
7
5
6
Avg occupancy rate
142
187
82
145
157
148
Avg no. of beds (per hospital)
units was evident as seen from private ownership of the
premises. Out of a total of 75 private hospitals, in the
case of 61 the premises were owned by individual doctor
proprietors and only in the case of 12 hospitals were
the premises rental. The information on type of
management and ownership of the premises clearly
establishes the trend amongst many medical
practitioners of setting up and constructing their own
hospitals/nursing homes. Hospitals, the voluntary sector
were registered either as Trusts or under the Cooperative
Societies Act since the primary concern of this sector
was to reach out to the poor and the underpriviledged
for whom quality medical care was often financially
inaccessible. Out of the seven public hospitals that
responded five of them were run by the State
Government and two by municipalities.
Services and Facilities Provided by Responding
Health Establishments
There were a total of 2277 beds in the district
amongst the hospitals that responded. Three fourths
of the beds were in the urban areas, most of them
in the developed talukas of the district. There were
a total of 904 beds amongst the 8 voluntary sector
hospitals, the seven public sector hospitals totalled 287
beds and the private sector accounted for 1085. Although
at the all India level the growth in private hospitals has
been tremendous, the increase in number of beds has
been very modest. Bed strength in the country in private
sector increased from 21.5% of the total in 1974 to
merely 30% of the total in 1988 (Jesani A., Anantharam
S., 1993). In Ahmednager District amongst the 90
responding health units the average bed size was 14
Few studies have been conducted of the services
and facilities provided by hospitals from the private
and voluntary sector. Several studies are available on
the hospitals in the public health sector. Data and
information with regard to the functioning of private
and voluntary sector is not forthcoming. Figures
regarding cases treated, diagnosis, type of treatment
provided, amount charged etc. are not easily obtainable
from private hospitals and nursing homes. In the present
study since information was collected through a mailed
questionnaire, there were limitations to the data with
regard to the services, facilities and staffing and
qualification of the staff. There were no physical
verification of the various claims made in terms of the
iii private hospitals while in the voluntary and public
sectors it was 113 and 41 respectively. Though the total
number of beds in the private sector were more, in terms
of beds per hospital, the average is small. This trend
is explained by the fact that small nursing units
expanded rapidly in the private sector while hospitals
with a large number of beds, requiring large capital
attract less investors. Corporate hospitals with a sizeable
number of beds and state-of- the-art technology are a
phenomenona common to the metropolitan cities of
India. The majority of the privately owned health units
were small nursing home with bed strength ranging from
three to thirty beds.
27
%
Table 4.6
Services provided
Geographical Location
Sector
Pvt
NGO
Pub
Devi
Undevl
Urban
Rural
Total
Gen. Medicine
Gen. Surgery
Maternity
MTP
Cardiac
Opthalmic
Orthopaedic
Paediatric
ICU
ENT
Infe Diseases
Others
48
33
46
26
15
18
20
37
3
20
21
4
7
7
7
4
3
5
4
7
2
2
5
2
5
3
6
6
3
4
2
5
0
1
5
2
30
29
34
23
14
14
21
30
5
16
14
7
30
14
25
13
7
13
5
19
0
7
17
1
32
30
37
25
15
16
22
33
5
16
17
7
28
13
22
11
6
11
4
16
0
7
14
1
60
43
59
36
21
27
26
49
5
23
31
8
Total Hosp.
75
8
7
59
31
62
28
90
distribution across the three main sectors, and social
geography indicating the availability non-availability
of these to urban and rural population. The presence
of some health units offering certain services does not,
however, mean the services were also accessible to the
population.
facilities available and services offered. Inspite of the
limitations, the study does contribute in terms of
understanding the general trend.
As observed earlier the services offered by
hospitals vary. There were some hospitals which
provided specialized service in any one field, but many
of them provide more than one specialised service. These
services broadly fall under surgical and medical
services.
More than half of the private hospitals provided
services in general medicine, surgery, maternity and
paediatric care. Less than a quarter provided services
in cardiac, opthalmic, orthopaedic, ENT and infectious
diseases. Only three of the 75 hospitals provided
services for Intensive Care Unit Among the seven public
Table 4.6 gives information on the services
provided by the responding health institutions.
Table 4.7
Facilities provided
Geographical Location
Sector
Pvt
NGO
Pub
Devi
Under Devi
Urban
Rural
Total
Minor OT
Major OT
Labour Room
X-ray
Fluoroscope
Rout Path
Special Path
Anaesthesia
ICU
Ultra-Sono
SPL Dign Test
Any Other
40
40
42
32
9
33
6
30
4
6
2
6
5
7
7
7
1
7
0
7
2
0
0
1
4
4
6
3
I
6
2
4
0
0
0
0
34
42
38
30
7
33
5
31
2
7
17
9
21
12
4
13
1
10
0
0
1
0
31
40
35
27
6
31
5
30
6
6
2
7
20
11
24
15
5
15
1
11
0
0
I
0
51
51
59
42
11
46
6
41
6
6
3
7
Total Hosps
75
8
7
62
28
59
31
90
6
6
28
Table 4.8
Personnel
Sec or
Category
Pvt
NGO
Public
Total
Full/Part time RD
Visit/Atth Doc
Qualified Nurses
ANMs
Paramedics
Pharmacist
X-ray Technicians
Lab-Technicians
Others
104
172
68
49
114
2
3
12
284
39
32
34
48
22
5
15
10
107
16
17
32
12
15
2
0
0
59
159
221
134
109
151
9
8
22
450
Total
808
302
153
1263
1
hospitals that responded six hospitals provided care for
maternity and Medical Termination of Pregnancy
(MTP), five of them for general medicine and paediatric
respectively. Merely three hospitals provide services
for surgery, two for orthopaedic and one for Ear, Nose
and Throat (ENT). In the NGO sector the provision
of services followed a similar pattern as that of the
public sector. Out of eight NGO hospitals, three had
services for cardiac care and two provided services for
ICU and ENT services respectively. Most specialized
services are available in the private/NGO sector which
are mainly based in the developed talukas and urban
areas. No ICU service is available in the% rural areas
or underdeveloped talukas. The cardiac, paediatric and
ENT services are available to a limited degree in rural
and underdeveloped areas. General medicine and
maternity homes are commonly available in the rural
and underdeveloped areas. There are services that are
commonly in demand. Institutional delivery has
gradually increased over the years.
of ICUs were available only in the urban areas of
developed talukas. Out of the five hospitals providing
ICU’s three were from the private sector and two from
the NGO sector. Facilities for anaesthesia were available
in forty one hospitals, were in private and in urban areas
of the developed talukas. Same was true of x-ray
facilities. Six hospitals providing facilities for ultra
sonographies were in the private sector located in the
urban areas of the developed talukas. Same was also
the case with facilities for special diagnostic facilities.
There were two hospitals providing special diagnostic
facilities both of them in the private sector located in
urban areas of the developed talukas.
Personnel in the Hospitals
Health care delivery being a labour intensive
service the presence of trained personnel in the hospitals
is an important determinant for the provision of medical
care. There are diverse categories of health personnel
broadly classified by their qualification or even lack
of qualification. Among the qualified personnel training
could be in the various systems of medicine as amongst
doctors or for the services and role they are expected
to perform. There are doctors, nurses, paramedics,
pharmacists, various types of technicians to handle
equipment and conduct various tests and the other
supportive staff like ward boys, ayahs, receptionist,
typist, security personnel etc.
Table 4.7 shows distribution of facilities over
sector and social geography. The table shows clearly
the technology approach even high technology base of
private medical care. Evident also is the urban /rural
and developed/undeveloped differential in terms of
services and facilities available. Orthopaedic services
were provided by twenty six hospitals, twenty two being
were located in urban areas. Out of the twenty one
hospitals providing cardiac care, fifteen hospitals were
in urban and the rest in rural. Out of 6 hospitals where
facilities for special pathology were available, five were
in urban areas of the developed talukas. The services
Questions regarding the staff strength and type
of various personnel elicited information enumerated
29
Table 4.9
Visiting doctors (Sectorwise)
Pvt
NGO
Public
Total
Gynaec
Paediatric
Ortho
ENT
Surgeon
Physician
Pathologist
Eye/Optho
Anaesthesia
Dentist
General Medicine
Cardio
Neuro
Any Other
Not MBPS
26
18
12
22
26
15
2
16
19
5
15
5
2
20
1
3
1
2
1
5
0
0
3
2
0
2
4
0
3
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
29
19
14
23
31
15
2
19
21
5
17
9
2
23
3
Total
204
28
0
232
in Table 4.8. The table shows distribution of various
categories of personnel across sectors. Private hospitals
tend to depend more on visiting/attached doctors to
provide medical care than on fulltime employed doctors.
Most often private nursing homes offer specialized
medical care through these visiting/attached doctors.
Few small size private health units offering domiciliary
care employ resident doctors.
Few qualified nurses appear to be employed in
these private units, except perhaps those in the voluntary
sector, where some professionalism appeared to exist. Thus
as far as trained personnel requirement were concerned,
private hospitals fell very short of the requirement Majority
of them employed unqualified staff.
There appeared to be no corresponding link
between the availability of certain facilities/services and
the employment of trained medical personnel in the
provision of these services. Thus, while thirty two
private hospitals provided X-ray facilities only three
had X-ray technicians. There were only twelve lab
technicians for routine pathology offered by thirty three
of the private hospitals in the study. In the voluntary
sector run hospitals, the situation appeared to be better
with seven providing X-ray facilities and having the
services of five X-ray technicians. There were ten lab
technicians in the seven hospitals providing routine
pathology. In the public hospitals there were no X-ray
technicians in 3 hospitals inspite of the availability of
this facility. The same was the case with the various
pathological facilities. This can be explained by the
common problem faced by all public/govemmental
systems namely redupism and bureaucratic indifference
causing undue delay in the filling up of various
vacancies in these health units.
The availability of the doctor during times of
emergency for the patient is of utmost importance. It
has been observed that most owner-doctors stay in the
hospitals or close to the hospital premises. A second
important observation was that doctors trained in other
systems of medicine administered allopathy treatment
in these hospitals. Various practices prevail in hospital
admissions. Some private hospitals admited patients of
the owner-doctor/s alone. In some hospitals indoor care
was available to patients of consultan ts/specialists
attached to these hospitals or on the recommendation
of general practitioners who have entered into such an
arrangement with these institutions. The present findings
show that most private units choose to have visiting
specialists instead of offering fulltime employment.Of
204 visiting doctors in the private sector twenty six were
surgeons, twenty six gynecologists, twenty two ENT
specialists, ninteen anaesthetists and eighteen
pediatricians. There were only two pathologists, five
cardiologists and two neurologists. Information on
specialization of doctor employees in the public sector
was not available.
Findings : Medical Stores
As a part of listing of health establishments
30
Table 4.10
Rural-urban distribution of pharmacies
Urban
Ahmednagar
(district)
Akole
Jamkhed
Karjat
Kopargaon
Newase
Parner
Patharadi
Rahuri
Sangamner
Shevgaon
Shrigonda
Shrirampur
116
Total
19
135
28
13
22
53
28
13
22
24
36
30
21
38
29
2
37
22
28
34
30
21
47
51
22
30
71
228
331
559
9
35
Total
Rural
16
(Social geography and taluka of 6 pharmacies could not be identified)
medical stores were also listed with the help of the Food
and Drug Administration, Ahmednagar. There were 565
licensed drug-sellers in Ahmednagar district. 416 (71%)
of them were medical stores while the remaining 149
(29%) were grocery shops, stationary stores, cloth shops
and even pan-stalls which were licensed to sell a limited
number of medicines. Insufficient availability of
qualified services discussed earlier explains the presence
of 72% of the latter type in rural areas.
in urban areas while 54% were in rural areas. This fact
needs further investigation, especially the possibility of
drug sellers functioning as unlicensed practitioners, and
a substantially high sale of medicine without prescription
due to non-availability of adequate health personnel in
rural areas.
The above analysis thus closely brings out the
unequal rural-urban distribution of health services,
highlights the inadequacies of official and non-official
records in the enumeration of health institutions and
reflects the lack of any regulation of the private health
sector.
Like doctors and hospitals about 63%.of medical
stores are located in developed talukas. Unpredictably,
out of the total 565 drug sellers about 46% were located
□□
.'A'*
31
—
05607^#'^,. ;
'V
■
>r ■
.
.
5
Individual Health Providers : Investment and
Expenditure
doctor, while one each amongst allopath general
practitioners, Ayurveda and homoeopath practitioners
had formed trusts which owned and operated the unit
from where they provided medical care. Their health
units thus legally and technically under trust
management were in reality controlled and run by the
individual practitioners. The formation of trusts was
more of an attempt to ensure tax benefits and other
concessions on the purchase of medical equipment which
Trusts are entitled to. Amongst the sample of 96
individuals, 26 had started their practice before 1975,
37 during the period 1976-85 and 33 between 19861992.
The chapter examines investment made by
private doctors to set up health units and monthly
expenditure incurred by them towards running these
health units. The attempt is to analyse the nature and
volume of investment and expenditure and to see if any
pattern emerges particular tc the type of health
providers.
Profile of Respondents
Ninty six health providers selected were
classified into five groups,namely, allopath general
practitioners (17), allopath specialists (29), Ayurveda
(24), homoeopath (18) and registered medical
practitioners (8). Ninety-two of the total doctors were
individual proprietors. One practitioner, an allopath
specialist, owned his unit in partnership with another
Table 5.1 shows the distribution of these
individual practitioners across talukas according to urban
and rural location.
Table 5.1
Geographical distribution of doctors
Allo-GPs
Talukas
1
2
3
4
5
6
7
Nagar
Akole
Kopargaon
Pathardi
Shevgaon
Srigonda
Shri rampur
Ayurveda
U
R
U
R
6
2
1
2
2
4
2
3
3
1
4
3
4
2
9
15
U
"r
u
2
2
20
1
1
3
1
1
R
4 •
5
1
1
1
1
2
2
RMPs
Homoeo
Allo-SPs
R
U
2
1
3
1
1
1
4
Total
26
13
3
17
1
7
1
Table 5.2
Floorspace according to system of medicine
Allo-GPs
Allo-SPs
Ayurved
Homoeo
RMPs
Total
up to 500
501-1000
1001-1500
more than 1500
12
15
8
1
5
23
16
2
7
73
Total
17
29
24
FLSPACE
in sq.ft,
3
2
13
1
4
6
8
96
1
32
18
Factors considered for analysis
Majority of the practitioners, including
specialists had units with area less than 500 square feet,
as shown in Table 5.2. This appears so because of mainly
two reasons. The first factor was that a majority over
50% had rented premises. Second, was the fact that a
majority (81 out of 96) did not offer indoor care and
hence had no beds. (See Table 5.3.)
The system of medicine determines the nature
and volume of investment primarily because it can
determine the type of services an individual practitioner
may offer. Since the non-allopathic systems are
essentially non-technology oriented, hardly any
investment is made in technologically advanced medical
Table 53
Beds according to system of medicine
Beds
Allo-GPs
Allo-SPs
Ayurved
U
R
U
U
IF
U
0
10-20
20 and more
T
TT
2?
T
“15
T
u
T
i
2
4
1
3
i
R
14
3
Total
4
13
26
3
9
15
1
17
2
R
Fifteen from amongst the total 96 practitioners
had beds of which 11 were allopath practitioners, 1 an
Ayurveda practitioner and 3 homoeopath practitioners,
as shown in Table 5.3
Homoeo
Total
RMPs
R
“6
81
14
1
6
96
equipment or state-of-the art medical technology.
Ayurveda practitioners and homeopath dispense
medicine, but are not dependent on medical technology
for diagnosis or treatment because of the principles and
approach on which their systems are based. They are
hence, less likely to invest in medical equipment and
more likely to build up an inventory of herbs and of
medicines. The allopath and especially the specialist
are less likely to dispense medicine (though it may be
a common practice in rural areas where access to medical
stores is difficult) but do invest in setting up technology
based diagnostic and therapeutic facilities and services.
Even where non-allopathic practitioners engage in cross
practice there is an inherent limitation to the type of
services they are likely to offer. However, there are
exceptions.
Employment of medical, paramedical or non
medical staff was not common except in the case of
those who provided indoor services. Only 2 allopath
specialists had employed doctors to assist them. Fifty
one per cent of the practitioners did not employ any
paramedical staff. Forty five per cent practitioners
employed upto 5 paramedical workers. Four out of the
total 29 allopath specialists employed about 10
paramedical workers each. Sixty nine per cent of the
practitioners did not have any non-medical staff. The
remaining 31% employed non-medical staff such as
receptionist, office-boys, sweepers.
Secondly, each system, level of qualification
and type of specialisation may demand a specific kind
and hence size of investment, for instance, the
investment likely to be made by an allopathic general
practitioner, an Ayurveda practitioner, a radiologist or
a physiotherapist. It necessarily differs. Over the years
specialisation has grown. New and rapidly advancing
medical technology has become easily available and
accessible. As a result, even the demand for high-tech
treatment has also grown. Along with these factors,
government and public subsidy, and various loan and
financing schemes for purchasing of medical equipment
and setting up medical practice have also been
responsible for higher investments in medical practice.
The above discussed features of the respondents
are important indicators for analysing investment made
and expenditure incurred. However, only the three
factors having an important bearing on the extent, nature
and pattern of the money involved in setting up and
running health units are considered. (1) the system of
medicine in which the particular practitioner had been
trained and; (2) the geographic location of the unit; and
(3) bed strength. Hence for the purpose of analysis the
provision of bed facility, system of medicine and social
geography are considered.
33
expenditure may occur on the interiors, furniture
facilities and technologies to attract clientele.
Moreover, it is observed that training in nonallopathic systems is a second choice amongst students
opting for the medical profession. This happens because
either they fail to meet the minimum qualifying
requirements or because financial constraints may lead
them to choose non-allopathic medical education which
is less expensive. Both the above observations are true
to a large extent about students from rural backgrounds
and the socially and economically disadvantaged classes.
The following sections discuss, first the
investment pattern and then the expenditure patterns. Each
item of investment and expenditure is considered for
analysis. The analysis is restricted to only those respondents
who provided the information and excludes those who did
not. The category, registered medical practitioners', was
not considered for analysis because the number in the
sample was not adequate to draw any definite conclusions.
The geographical location of the unit again
determines the money required to meet, match and fillfill
the market demands in that particular location. The level
of development and urbanization may determine the
volume of investment. In the present Indian context
where gross socio-economic disparities exist between
urban and rural areas the level and quality of education
is also disparate. The rural students aspiring for a medical
profession are often the victims of this disparity. Unable
to get admission to a medical course of their choice they
opt for alternative course. Education in indigenous systems
of medicine or homeopathy offers such an option. Hence,
quite a sizeable number of students of non-allopathic
medicine were observed to have come from rural
background and lower economic class. Education in a less
expensive system of medicine suggests low paying
capacity indicating lower economic class. This in turn
affects the capacity to invest in setting up practice.
Investment Patterns
The investment data were recorded for broad
heads such as building construction, furniture and
renovation, equipments and vehicle. Nearly half the
respondents conducted their practice from rented
premises. Deposits in the case of rented premises were
recorded but are not discussed seperately (though
included in total investment figures) because the practice
of collecting deposits for rental premises was not found
to be much prevelant in the district.
Table 5.4 shows Allopath specialists made the
largest investment while ayurveda practitioners made
the least. This is easy to explain and understand.
Allopath specialists by the very nature of the services
they offered required to have more facilities and
equipment and hence needed to invest more in setting up
their practice. Interestingly, except the ayurveda practitioners,
in urban areas the investment of all categories of practitioner
was in the same range of (330-390) whereas for rural areas
the investment range was almost same for all categories
of doctors (210-270). Rural practitioners spent less than their
urban counterparts. The services extended by rural
practitioners are limited, more over cost of land and
construction is less in rural areas than in urban.
Another important factor playing a role in
determining the volume of investment required by
health providers in urban areas as against those in the
rural areas is competition. Given the concentration
private medical practitioners in the urban areas the
competition forced by urban practitioners may make
them invest and spend substantial amount of money
for interior designing of their units. This investment and
Table 5.4
Average investment of each category according to social geography (in Rs. ’000)
Social
Geography
Allopath-GPs
Allopath
Specialists
Ayurveda
Doctors
Homeopath
Doctors
All
categories
Average
Urban
Rural
338 (3)
226 (12)
388 (14)
263 (3)
192 (8)
207 (14)
344 (1)
276 (17)
320 (26)
219 (46)
Average
248 (15)
366 (17)
201 (22)
223 (18)
255 (72)
( Figures in parenthesis indicate the number of practitioners)
34
i
Table 5.5
Average Investment of each category according to bed facilities (in Rs.’OOO)
Bed
Facilities
Allopath-GPs
Allopath
Specialists
Ayurveda
Doctors
Homeopath
Doctors
All categories
Average
Without beds
With Beds
199 (12)
446 (3)
359 (12)
384 (5)
207 (21)
(1)
202 (15)
327 (3)
234 (60)
360 (12)
Average
322 (15)
371 (17)
144 (22)
264 (18)
255 (72)
81
(Figures in paranthesis indicate the number of practitioners)
Allopathy specialists made the highest
investment (3,71,000). Their average investment worked
out to 3.6 lakhs (for the no-beds category) which rose
to 3.8 lakhs for those with beds. In contrast, allopathy
GPs made the lowest average investment (approximately
2 lakhs), but allopathy GPs with beds led all others in
terms of investment (4.5 lakh). This appeared to be the
case because allopath non-specialists to meet the
competition did not restrict their practice to general
practice but provided modem services, or ran maternity
homes.
after 1985 was noted. Investments made by these two
categories of doctors between 1976-1985 was more. This
can be explained for by the size of the unit and other
facilities provided.
Investment in building construction furniture
and equipment are the two major components of the
total investment made. Table 5.7 shows a high difference
in the investment for building construction in urban and
in rural areas for each of medical practitioner category.
The difference is obvious because of the higher cost
of construction including the prices of the land in urban
areas than in rural areas. As far as furniture is concerned
there is no particular pattern.
Specialists without beds and with beds made
nearly the same amount of investment, as seen in
Table 5.5. In all cases except the Ayurveda practitioner,
the investment was directly related to the availability
of bed facility. [The single Ayurveda practitioner with
beds had only one bed and hence was not considered
for a comparative analysis.]
Most of the investment in furniture was on such
common items as tables, chairs and cupboards except
in the case of individual practitioners who had bed
facilities or major/minor OT where the investment was
on beds and furniture required in the OT.
There was a general increase in investments
made by allopath and homoeopath general practitioners
in the years between 1976-1985 and 1986-1992 (Table
5.6). Some decrease in the investments of allopath
specialists and Ayurveda doctors who had set up practice
Of the total of 96 only 48 gave information
on investment in equipment of which 36 were from the
rural areas and 12 were urban based.
Table 5.6
Average investment of each category according to the period of establishment (in Rs.’OOO)
Establishment
Decade
Allopath-GPs
Allopath
specialists
Ayurveda
Doctors
Before 1975
1976 - 1985
1985 - 1992
213 (4)
224 (7)
325 (4)
237 (4)
454 (8)
350 (5)
248 (15)
366 (17)
175 (8)
229 (9)
193 (5)
201 (22)
(Figures in paranthesis indicate the number of practitioners)
35
Homoeopath
Doctors
All
Categories
Average
166 (1)
198 (17)
213 (4)
231 (13)
240 (28)
256 (27)
223 (18)
255 (72)
Table 5.7
Average investment in various heads for each category (in Rs. ’000)
Heads
Allopath
GP
Building
Furniture
Equipment
Allopath
Specialist
Ayurveda
Doctor
Urb.
Rur
Urb.
Rur.
Urb.
Rur.
525 (1)
89 (10)
225 (2)
95 (2)
85 (2)
47(4)
6 (3)
14 (11)
49 (18)
36 (2)
13 (8)
8 (13)
40 (1)
10 (8)
161 (2)
12 (3)
12 (8)
Homoeopath
Doctor
Urb.
All
Categories
Rur.
7 (1)
125
(1)
5 (12)
122 (5)
10 (15)
7 (13)
116 (26)
21 (71)
17 (48)
(Figures in parenthesis indicate the number of practitioners)
Investment in equipment was on four types
a) imaging equipment, b) diagnostic c) surgical, and
d) therapentic. Only 4 of the urban allopath GPs spent
on equipment whereas 8 of the 13 rural practitioners
spent on equipment. Of the 26 specialists in the urban
area only 2 stated they had invested in equipment
whereas all the three rural based specialists stated they
had spent on buying equipment. Interestingly a majority
of both Ayurveda and homoeopath practitioners had
invested in equipment as against specialists. The real
explanation for this is that majority of the respondents
from amongst the specialists did not provide information
on the investment made in equipment. Thus, it merely
means that specialists did invest in equipment but
declined to give information. The higher investment in
equipments by the urban allopath general practitioners
and specialists owes to the high-tech modem nature of
the system. The lone homoeopath, who has invested
more than Rs. 1,00,000 in equipments owns a computer.
Almost those who had invested in building were those
with large bed facilities. They essentiality owned and
ran nursing homes. The number of doctors investing in
equipment was half of the total respondents. But 71 of
the total practitioners stated their major investment was
in furniture.
Sources of Investment
An important and interesting area to examine
was the sources of finances. The study shows institutional
loans, were the single most important source of finance.
Table 5.8 shows the number of loans taken by the
practitioners of each category for the purpose of setting
up and expanding their practice.
Of the 96 practitioners studied, 33 (34.4%) did
not go in for loans, they had either invested money they
had inherited or their own earnings/savings from earlier
jobs or practice. Of the total 96 respondents, 33 did not
take any loans, 39 took one loan each, 16 took 3 loans
each, 7 took loans each and only one an urban specialists
took 4 loans. Sixty six of the total respondents took
loans. Of these 35 were from rural areas and 28 from
Since nearly half of the individual practitioners
operate from rented premises, and still a few others from
premises which were part of intented property, the
number of doctors investing in building was small.
Table 5.«
Frequency table for the number of loans
Loan no.
Allo-GPs
AIlo-SPs
U
U
R
U
4
3
6
4
7
11
13
26
0
1
2
R
3
4
Total
4
1
6
1
Ayurved
Homoeo
RMPs
U
R
U
R
2
5
1
33
39
16
7
1
2
6
96
U
if
1
6
1
2
5
2
1
5
4
1
5
10
2
3
9
15
1
17
R
36
Total
Table 5.9
Average monthly expenditure of each category according to social geography (in Rs.)
Social
Geography
Allopath-GPs
Allopath
Specialists
Ayurveda
Doctors
Homoeopath
Doctors
All
Categories
Total
Urban
Rural
3613 (4)
5920 (11)
10369 (22)
8984 (3)
3519 (9)
3124 (15)
5940 (1)
3330 (16)
23441 (36)
21358 (45)
Total
9533 (15)
19353 (25)
6645 (24)
9270 (17)
44,799 (81)
(Figures in parenthesis indicate the number of practitioners)
The procedures for borrowing are well defined.
Since these doctors mainly borrowed under these
schemes, they faced no difficulties as long as they
followed procedures and met basic requirements. The
lending agencies themselves also appeared to have an
open mind and willingness to entertain the loan
applications from doctors. Doctors were good customers.
In our informal discussion with bank officials and MSFC
officials, we were informed that doctors were least likely
to default on repayment. Indeed records showed that
doctors hardly defaulted on repayment of loans. In the
case of co-operative banks, as a few doctors told us,
local contacts were usefill. Co-operative banks being
local banks, friends and relations in cooperative banks,
especially at the Board of Directors or management level
were important and useful contacts.
the urban areas. None of the urban allopath GP, took
a loan while 10 of the 13 allopath GPs did. Of the total
29 specialists 22 had borrowed money of which 19 were
from the urban area and three from the rural. Eight urban
Ayurveda practitioners borrowed money while nine rural
practitioner went in for loan. The lone urban homeopath
took a loan against 12 out of 17 of the rural homeopaths.
Interestingly only one RMP took a loan. Most loans
were taken by specialists and the homeopaths.
Nationalized banks are the major source for
borrowing finances. Of a total of 63 loans taken 55 (87%)
were from nationalzed banks, 7(11%) from co-operative
banks, 5(7.9%) were from Maharashtra State Finance
Corporation (MSFC), 15 (23.8%) were from other
institutions like LIC etc. Of all the loans 8 (12.7%) were
taken from informal sources.
Expenditure Patterns
Most of the respondents said that the general
experience of raising loans was good. The hassle free
experience doctors had in raising loans meant primarily
that they faced no red tapism or bureaucratic hurdles
in their efforts. Part of the explanation may be found
on the fact that both nationalised banks and MSFC had
special loan schems for medical practitioners.
The monthly expenditure figures were recorded
for broad heads such as supplies (included expenditure
on drugs, medical supplies, equipments and maintenance
of equipments), maintenance for running a unit (includes
telephone and electricity bills, taxes, fuel, stationary and
other maintenance), salaries, rent, vehicles - fuel and
Table 5.10
Average monthly expenditure of each category according to bed facilities (in Rs.)
Bed
Allopath-GPs
Allopath
Specialists
Ayurveda
Doctors
Homoeopath
Doctors
All
Categories
Total
Without Beds
With Beds
5178 (12)
5812 (3)
7953 (18)
16410 (7)
3249 (23)
3815 (1)
2861 (14)
6387 (3)
19241 (67)
32424 (14)
Total
10990 (15)
24363 (25)
7064 (24)
9248 (17)
51665 (81)
Facilities
(Figures in parenthesis indicate the number of practitioners)
37
repairs, and other (included premises repair, newspaper,
magazines and other if any).
all categories of doctors. But it is salaries and supplies
which takes up the larger share. There is a greater degree
of difference between urban and rural for all categories
suggesting that there is co-relation between social
geography and expenditures. The allopath GP and
specialist spent more on salaries than the Ayurveda
doctor or the homeopath. This may have been so
because amongst Ayurveda doctor and homoeopaths
there were few who offered indoor care. They were
general practitioners with outdoor services and hence
did not requisition the service of the paramedical staff.
More of the allopath GPs and specialists offered indoor
service which required employing paramedical staff and
even doctors. This would be true more of those offering
specialised services.
Rural practitioners of all categories except
allopath general practitioners spent less than those in
the urban area (Table 5.9). Higher expenditure of
allopath general practitioner in rural areas may be
explained by the break-up in various expenditure heads.
The monthly expenditure of allopath specialists in both
urban and rural area was high suggesting that urban and
rural location made little difference.
Expenditure may be directly related to the
availablity of bed facility. Table 5.10 shows that those
with beds spent more than those without beds. Allopath
specialists and homeopaths with beds spent far more
than those without beds. These two categories of
practitioners also spent more than allopath general
practitioners and ayurveda practitioners with bed
facilities spend. This is so because amongst Allopath
GPs and Ayurveda doctors, most of them have fewer
than 5 beds, used more for the purpose of day-care facility
rather than long term stay. The substantially high
expenditure of allopath specialists can be explained in
relation to number of beds as seven of the allopath
specialists had up to 10 beds and 1 had 16 beds. Allopath
specialists did not merely offer out door services but
ran nursing homes and hospitals. The number of beds
they had in their units was higher than those in units
run by non-allopaths practitioners. Specialised services
being technology oriented specialists spent substantially
high to maintain and operate their practice.
Interestingly rural allopath GPs spent more on
supplies than those in urban areas. Rural practitioners
tended to store more supplies especially medicine
because access to medicines is difficult in rural areas.
Urban specialists spent more on supplies than rural
specialists and the urban homoeopath spent more on
supplies than the rural. In the last case it needs to be
emphasised that this homeopath practised his own
system of medicine namely homeopathy and hence
needed to spend on medicines. Rural homeopaths
engaged in allopathy treatment rather than homeopathy.
Urban practitioners spent more on maintenance than the
rural practitioners.
Concluding Remarks
The study was exploratory. It is possible on the
basis of the present study to identify newer areas of
research for generating further and finer data to get a
better picture of investment and expenditure in the health
Table 5.11 shows that supplies, maintenance
and salaries are the major expenditure components for
Table 5.11
Average monthly expenditure in various heads for each category (in Rs.)
Heads
Supplies
Maintenance
Rent
Salary
Other
Allopath
GP
Allopath
Specialist
Ayurveda
Doctor
Homoeopath
Doctor
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
1250(2)
987(3)
210(2)
1512(4)
290(3)
3266(12)
385(12)
250(1)
597(7)
415(11)
7128(15)
2112(20)
934(14)
4462(21)
2208(17)
4460(3)
399(3)
212(2)
2633(3)
294(3)
1610(8)
557(9)
371(6)
622(9)
153(7)
1809(15)
205(14)
210(10)
380(12)
206(13)
5000(1)
410(1)
400(1)
2306(16)
158(17)
175(10)
544(8)
185(11)
(Figures in parenthesis indicate the number of practitioners)
38
90(1)
system especially health providers in the private sector.
make requisition of space for a clinic or dispensary.
Space did not appear to be a major constraint. Those
who opted to spend money on buildings were those
running nursing homes rather than mere outdoor service.
But where money is spent on construction, it is high.
Equipment purchase was the other area of major
investment. In the case of specialists this was common
given that the services they offered were technology
oriented. But for the majority furniture was the main
area of investment.
The study shows there was not wide disparity
between urban and rural practitioners except in the case
of allopath specialists, in the area of investment and
expenditure. But as far as practitioners with beds and
without beds was concerned, a disparity was noticed,
thus indicating a link between number of beds and
investment and expenditure. The study has shown that
premises except in the case of practitioners with bed
facilities did not invite much investment. This suggested
that since rented premises were still easily available,
rents were low and deposits still not demanded, doctors
found it convenient and easy to conduct practice from
rented premises and did not feel the need to invest in
building and construction. Moreover, there was the other
factor of family property from where it was possible to
Expenditure study showed that salaries and
supplies took up the greater share. Salaries was high
with urban practitioner especially allopath GPs and
specialists. Supplies was high with rural practitioners
who needed to maintain a stock.
□□
39
6
Health Institutions - Investment and Expenditure
health establishments ? What factors influence the
nature and volume of investments? The chapter further
analyses the expenditure incurred by the health units
in running their services. Actual data collection and
the subsequent analysis highlighted the various
difficulties in conducting a study of this nature. The
most apparent aspect of this study was that organized
and disaggregated data on investment in particular in
the public and voluntary sub-sectors was difficult to
come by. This was partly due to a refusal to disclose
information and partly due to the system in which
The present chapter examines investment and
expenditure incurred by health establishments offering
in-patient or specialised health care. The units offered
either general or specialised services or both and
belonged to both the Public and Private sectors. The
latter includes the voluntary sub-sector. Geographically
these were distributed over both urban and rural areas.
One of the questions the chapter seeks to answer is
whether a pattern can be discerned in this investment
and expenditure. Are there any preferential areas of
investment while setting up and developing in-patient
Table 6.1
Public health units / Health establishments
Staff
Municipal Dispensary
Municipal Maternity Hospital
I
General Information
Type of Units
3 doctors
4 paramedics
3 non-med.
3 doctors
12 visiting doctors
4 paramedics
Gen/Special
Special
Special
2 doctors
11 paramedics
2 non-med.
General
30 paramedics
3 non - med.
Special
Primary Health Centre
3 paramedics
1 non - med.
General
Rural Hospital /
Mother Primary Health Centre
11 paramedics
11 non - med.
General
Primary Health Centre
Municipal Hospital
General
Cottage Hospital
40
accounts were maintained. Data for investment and
expenditure were available from individual private
proprietors of nursing and maternity homes. The study
throws up several issues concerning investment and
expenditure which will also be discussed.
such as municipal councils. The initial investment in
both cases was made for construction of the building
and part of it was spent to buy equipment and
instruments. The exact division between amount spent
on construction and equipment was not available. All
additional capital expenditure in subsequent years was
incurred mainly on equipment and instruments.
Public Sector
Seven public sector units were selected for
study which included muncipal dispensaries, maternity
homes and hospitals. Cottage and Rural hospitals and
Primary Health Centres. (See Table 6.1) Out of these
seven, information on investment was available for only
two units, namely a Municipal Dispensary which offered
only X-ray services and the Municipal Maternity
Hospital. This indicates the difficulties in conducting
such a study. Moreover, this information was available
for only a few investment heads. Recurrent monthly
expenditure was available for only five units. Hence
only the expenditure of these units has been examined.
Once the physical area/ premises of the
establishment were defined and the structure
constructed, in subsequent years no extension of the
structure was undertaken. It appears that the major
constraint was finance. The available information on
investment suggests that most of the additional capital
expenditure was incurred in extending or creating new
facilities and making available technology based medical
care such as X-ray. Thus, most additional capital/
development expenditure went into the purchase of
medical equipment and at times fumiture-mostly of
everyday use such as tables and chairs. Although new
medical technology was introduced in the form of
various instruments and equipment, it was also apparent
that expenses in this area were constrained by the lack
of finance as seen by the long and gradual process of
acquiring this equipment. The establishment of modem
health units providing technology based medical care
indicates the growing need for health services which
would meet the new health needs of the urban population
increasingly exposed to and victim of urban and modern
diseases as of the heart and lungs; respiratory diseases,
cancer etc. Urbanisation and industrialisation created
new health needs and problems.
Investment in the Public Institutions
As already stated, this information was virtually
not available for public sector units. Limited
information was available for two municipal units. The
two municipal units were set up in Ahmednagar town
in 1959 when the initial capital investment was made.
Additional investments were made over the years to
expand and extend services. Capital investment in the
municipal dispensary appears to be have been made till
the year 1980 after which there was no new investment
In the case of the maternity home the last known
additional investments appear to have been made in 1993.
The initial investment made for the erection of the
municipal dispensary was Rs. 12,300 (in 1959 value) and
in the subsequent years Rs 33,640 were invested, 1980
being the last year. This money was spent on purchasing
or replacing imaging equipment, like a X-ray unit.
Expenditure in the Public Sector
The DHO’s office provided information on
expenditure of the 81 PHCs in the district for the year
1992-93. This amounted to a total of Rs.2,92,24,469
which on calculating worked out to Rs.3,60,796 per
annum per PHC. Disaggreated expenditure was shown
for only three heads, - establishment costs, medicine
and vehicles. Establishment costs included salaries,
maintenance and purchase of stationery and other
miscellaneous expenditure. Available separately were
expenditure figures for medicine and expenses incurred
on official vehicles during the year 1992-93. The
establishment expenditure for all the 81 PHCs in 199293 was Rs. 24,845,581; for medicines Rs.37,76,685
and for vehicles Rs.6,02,203. Calculations show that
In the case of the maternity home, the initial
capital investment made in 1959 was Rs. 1,05,000 and
in the subsequent years upto 1993, the capital
expenditure was Rs.64,300. Land for the maternity
home was donated to the Municipality by a prominent
citizen of the city. This has been a common feature
since pre-independence days when government run units
were initiated by private charity or those set up by
charity were later handed over to government agencies
41
Type of unit
Drugs
Primary Health
Centre
2,500
Muncipal Hospital
12,500
Primary Health
Centre
2,500
Mother Primary
Health Centre
30,000
Cottage
26,120
Table 6.2
Monthly Expenditure of Public Sector Units ( 1991 - 1992)
(Actuals in Rs.)
Rmp.
Rme.
S.S.
W.T.
Elec.
Tele.
E.S.
4,170
300
200
25,000
300
1,670
1,50,000
330
2390
Equipment and Supplies (including repairs and maintainance)
Tele. - Telephone
Elec. - Electricity
W.T. - Water Taxes
S.S.-
Staff Salaries
Rme. - Repairs and Maintainance of Equipments
Rmp. - Repairs and Maintainance of Premises
Rmv - Repairs and Maintainance of Vehicles
Pet/Oil - Petrol, Oil etc.
OF -
Fuel
Other - (Laundry, misc. expenses)
49,000
170
O.F.
Other
400
1,500
330
500
170
Pet/Oil
2,080
1,000
170
170
90,000
Drugs - Drugs
E.S. -
200
Rmv.
56,600
170
700
establishment expenditure consumed 85% of the total
expenditure, while 12% was spent on medicine and a
mere 3% on vehicles. Information on expenditure was
sought from three PHCs one of which was a mother
PHC, being upgraded to a rural hospital, hence receiving
funds from both the civil surgeon (state government)
and the District Health Office. During the course of
our data gathering. Medical Officers at the PHCs did
not always appear to be in a position to give us
information on expenditure incurred under most
subheads. In the case of medicine, since all PHCs get
a standard Rs.2500 per month or Rs.30000 per annum
this figure was common. The mother PHC, however,
received Rs.30,000/- per month for medicines.
on maintaining the staff leaving a smaller share for those
heads concerned with actual delivery and facilities
essential to provide basic medical care. The oft made
criticism that public services suffer from shortages of
medicine and supplies in relation to the population they
cover, or that shortage of funds immobilizes the staff
and disrupts transportation was seen from the amount
available for the maintenance of vehicles. In rural areas
where transport facilities are either lacking or are poor,
the break down of PHC vehicles or the non-availability
of these hampers the provision of medical care.
The need is to better distribute financial
resources to areas which would ensure the delivery of
health care, the improving of PHC functioning, and
increasing its efficiency. Given that it is a widely
acknowledged fact that rural health services suffer from
shortage of paramedical and professional resources and
that the proportion of doctor /nurse to population ratio
is low, we cannot call for a reduction of staff whose
salaries and allowances take up a sizeable portion of
the expenditure. The whole issue of how much salaries
take up at the local level where the setup is least
bureaucratic and forms the immediate and first level
contact in the 3 tier health service structure needs to
be examined in the context of the non-availability or
shortage of essential health human power.
Other heads showed low expenditure, for
example, repairs Rs. 1000/. The diesel expenditure for
the jeep of the Centre used for Subcentre visits and
Family Planning Programme from April 1992 to Dec.
1992 was a mere Rs. 9947/- and for repairs Rs. 2355.
The low expenditure on fuel and repairs on the jeep
confirms the information given to us that the jeep was
left unused for long periods for want of necessary funds.
Table 6.2 shows that staff salaries took up the bigger
share of monthly expenditure for PHC. The figure varied
from PHC to PHC depending upon the actual numbers
of incumbants on the various posts. One thing which
was noticeable was the low expenditure incurred on
maintainance and upkeep of the establishments. This
was due to deficiency of funds for this purpose.
It would be in order to discuss some of the
difficulties encountered in calculating expenditure,
especially disaggregated expenditure, for each type of
health unit. A major difficulty is that expenditure
accounting is centralised with Government departments.
Moreover, more than one Government department may
be responsible for allocation of funds or expenditure.
For example, the Rural Hospital/ Mother PHC was
supplied drugs from both the District Health Office
and the office of the Assistant Surgeon from time to
time as per the demand. The same is true of equipment.
Equipment is provided again either by the office of
the Asst. Surgeon or the Dy. Director of Health
Services. The Civil Surgeon gave Rs. 1000/- for the
purchase of stationary and a contingency amount of
Rs. 1,296/- to the Mother PHC. These figures are not
constant and would differ from time to time and unit
to unit. There was, thus, no one common source of
finance. The above discussion brings out some of the
difficulties in studying expenditure incurred by
government health units in the provision of health care.
There does not appear to be much difference
between PHCs and Municipal and Cottage Hospitals
with regard to expenditure as Table 6.2 shows. Salaries
and drugs consume the larger shares. But of interest
is that in the case of this particular Municipal Hospital
listed here, information on expenditure for almost all
heads was available. These figures were made available
by the Chief Medical Officer of the Hospital who
maintained these detailed records. The Municipal
Council of this town ran, apart from this Hospital, only
one more dispensary. Other municipal bodies of large
towns operating a numbers of units do not seem to
keep unit wise expenditure data. It is difficult to explain
the difference in accounting procedures.
The above stated disaggregated expenditure
reinforces the most common criticism of public health
services, that the establishment consumes the largest
share of the expenditure. Thus, more money was spent
43
units a mere five were located in rural areas while
twelve were urban based. The number of beds in a
hospital / nursing home is an important indicator of
size, the nature and type of facilities available and
services offered. This too impinges on expenditure
involved in running the unit. The units being studied
here have been split into three categories according
to bed strength. A total of eleven units belonged to
the bed range of 3-16. There were six units in the bed
Profile of Private Institutions
Before examining investment and expenditure
of health establishments in the private sector, it is
essential to have a profile of the units being studied
with regard to social geography, bed strength, staff
employed, faculties and services offered. In all twenty
private health units were examined for their investment
and expenditure. Private institutions fell into two main
Table 6.3
Staff in private health establishments - according to social geography
No.
of units
Doctors
Nurses
ANMs
Para
medics
Lab
Tech.
Other
U.
12
12
4
3
9
4
6
R.
5
5
2
4
1
3
Total
17
17
6
13
5
9
Social
Geog.
3
Table 6.4
Staff in private health establishments - according to bed strength
No.
of units
Doctors
Nurses
ANMs
Para
medics
Lab
Tech.
Other
16
11
11
2
1
8
2
6
20 - 40
6
6
4
2
5
3
3
Total
17
17
6
3
13
5
9
Bed
Strength
3
range 20-40. Three trust run hospitals had a bed range
between 80-110 which suggests that the financial
capacity of voluntary sector units was strong.
categories defined by ownerships/management, wherein
seventeen had individual proprietors while three were
run by Trusts or in other words belonged to the
voluntary subsector. Ownership/Management can
determine the capacity to spend and hence make a
difference to expenditure incurred. Ownership/
Management can also determine the size of the unit
and types of services/facilities offered. The Trust
managed hospitals, were all, located in towns. As for
social geography of the seventeen individual owned
Staff salaries are a very important component
of expenditure. The category of staff employed their
qualifications and skills determines the salaries paid
and the expenditure made. The type of staff besides
profiles the nature and type of services / facilities
offered by the health unit. Our information revealed
44
that in the urban institutions eight had visiting doctors,
while only two rural units had visiting doctors. Going
by bed strength in the 20 - 40 capacity 4 had visiting
doctors while the two had 3 and 2 full time resident
doctors mainly a husband and wife team.
theatre for minor surgeries. This suggests that urban
units have set up medical equipment required for
diagnostic purposes while in the rural areas such
facilities are far less available. This tells us something
about the kind of investment in rural units made
especially with respect to medical equipment.
4
The table also shows employment of paramedic
and non-paramedic staff. Most units, especially those
Facilities seen in the context of bed strength
represent a similar picture where maternity, routine
Table 6.5
Facilities / services in private health establishment according to social geography
!
Social
Geography
I
U. (12)
ICU
1
■
R (5)
Total 17
1
Lab/
Path
Major
OT
OT
8
4
1
7
8
2
2
3
5
2
10
6
4
12
10
Minor
Maternity
Labour Room
Radiology*
Table 6.6
Facilities / services in private health establishment according to bed strength
Bed
Strength
ICU
3 - 16 (11)
Lab/
Path
Major
OT
Minor
OT
5
1
2
7
6
Maternity
Labour Room
Radiology*
20 - 40 (6)
1
5
5
2
5
4
Total 17
1
10
6
4
12
10
Foot Note :
*
Includes X-ray, Ultra Sound, Sonography
in rural areas are not known to employ trained
paramedic staff. Indeed not much staff is employed.
This is mainly due to dearth of skilled and qualified
staff. Also at times doctors are known to be not
inclined to appoint the essential supporting staff so
as to cut costs. This is well reflected in Tables 6.3
and 6.4
pathology and radiology facilities are most common
to both categories. Although major OT is found, mainly
in the second category which has a bed strength of
20 - 40. Units with a lower bed strength show that
just one has a major OT while two have a minor OT,
maternity being more common.
The facilities extended reveal the type of services
offered. In addition it can tell us about the investment
in equipment. Equipment is mainly of five types,
diagnostic, imaging, pathological, therapeutic and
surgical. Investment made for buying any of the above
mentioned types of equipment helps to explain the size/
volume of investment made.
Tables 6-5 and 6-6 show facilities with respect
to social geography and bed strength. The most common
facilities in urban areas were lab / routine pathology,
radiology and maternity. In the rural units, maternity
services were offered by all the five, other facilities
being offered by two each. These units had operation
45
No. of
Units
Doctors
3
2
Table 6. 7
Staff - voluntary sector hospitals
Paramedics
ANMs
Nurses
Of the three voluntary sector hospitals all were
urban based with a bed strength between 80-110. Hence,
staff according to social geography and bed strength
is not being analysed separately. Table 6-7 shows that
of the three only two had employed regular staff from
the various categories. The leprosy hospital had only
one visiting doctors and three administrative staff. Rest
of the medical relief work was carried out by volunteers.
Patients in this hospital were sent to the Government
Hospital for any other major illness afflicting them
or for any surgeries required. The other two hospitals had
a regular staff but also had a few visiting doctors. The largest
of the three had 17 Resident doctors, two visiting doctors,
34 Qualified Nurses, 6 ANMs, 2 pharmacists, 6 technicians,
50 paramedics and 15 administrative staff. The other followed
the pattern but with slightly less numbers.
2
2
2
2
Lab.
Tech.
Others
3_______
health units which came up between 1971-1980 and
1981-1991. In terms of percentage share of total
investment the order remained the same. However, what
was noticeable was that the difference between money
invested in construction and medical equipment was
wider during the decade 1981-91. During 1981-91, the
investment going into construction was very high at
56.76% against 21.74% spent on medical equipment
whereas during 1971-1980, the same investment heads
took up 39.02 and 28.86 respectively. This can be
explained by the feet that construction costs in the 1980s
suddenly shot up, especially in the early 1980s when a
shortage of such construction material as cement was greatly
felt. A few of the doctors reported having to buy cement
in the black market. The other factor which explains this
rise in construction costs, as stated earlier, was due to the
Table 6.8
Facilities offered by voluntary sector hospitals
No. of
Units
ICU
Lab/Path
Major OT
Minor OT
Maternity
Labours
3
2
2
2
2
2
Excluding the leprasy hospital the other hospitals
had facilities offering services common to large
hospital as seen in Table. Both the hospitals stressed
that they catered to the poor and needy patients.
Radiology
2
feet that the same building formed both the health unit and
the residential premises of the proprietor practitioner.
However, individual units showed a few cases where the
investment into medical equipment for exceeded
construction. This may be explained as done earlier - that
Investment by Private Health Providers *
Investment according to years of establishment
Of the 17 private health establishments studied, one
was set up in 1957, 5 in the decade 1971-1980 and the remaining
11 between 1981-1991. Given that there was just one unit for
the decade 1951-1960, only those cases from the decade 197180 and 1981-1991 were examined for purpose of comparing
and contrasting investment patterns. See Table 6.10
Here too the pattern was similar to the
observations made earlier. Construction, equipment and
land in this order took up the larger share of total
investment. The situation was not very different for the
once the physical stucture of the unit came up, doctors
invested in medical equipment to build up, develop and expand
medical practice by offering more facilities and better
medical care i.e. technology based care.
If health units which came up between 198191 were taken separately according to social geography
(see Table 6.9) then it was noticed that the gap between
investment in construction, on land, and medical
equipment was far less in urban unit as compared in
the rural units. The reasons for this has been fairly
well explained in the previous sections.
* This excludes the voluntary sub-sector hospitals for want of data.
46
Unit
u.
R.
Table 6.9
Investment made in 1981-91 by establishments according to social geography
Aetna s and as percentage of Total (in Rs.)
Total
Equi.
Turn.
Depo.
Reno.
year
Land
Buil.
228800
12.27%
680000
60000
170000
(6)
36.48%
3.21%
9.12%
1981-91
(5)
107000
5.48%
1485000
76.15%
1981-91
5000
025%
168000
9.00%
557000
29.88%
1863800
80500
272500
13.97%
1950000
4.12%
Investment according to Social Geography
cases even money spent on land. This happened where
once the health unit premises were in place, doctors
offering specialised medical care gradually made additional
investment for in procuring medical equipment. More and
more medical technology has been coming into the market
in the last two decades. New developments are taking place
in the creation or updating of medical technology. In the
increasingly competitive profession and with harder
marketing by manufacturers, doctors acquire more of the
latest medical equipment.
Examination of investment according to Social Geography
showed that both in the urban and rural areas individually
construction took up the largest percentage share of total
investment. But the difference in the investment share going
into construction between urban and rural was large. The
explanation can be found in that, urban health units invested
heavily into equipment. Most urban units were offering
specialised medical care. They invested in buying up the latest
medical technology. These health units offered services, that
rural health units did not. Although in the rural areas too
investment in medical equipment followed that of building
construction as with the case of urban health units, the proportion
of total investment was less. Rural health units while offering
indoor care offered general or maternity service, rather than
specialised care. Hence, these units needed to invest less in
medical technology. As seen in the previous chapters doctors
trained in allopathy and with specialisation tended to be urban
concentrated and were hardly rural based.
With urban units offering specialised medical care,
they tended to spend on medical technology. Moreover,
urban land prices were higher than in the rural areas.
As a result the proportion of investment going into
construction of building as part of the total investment
was less. Investment into land and medical equipment
competed with construction. In the rural areas while
construction costs were certainly less than in urban areas
unlike in the urban areas construction took up the largest
share of total investment. The other reason why construction
takes such a large share was that both in urban and rural,
but particularly so in the latter, the constructed building apart
from the area built for the health unit, consisted of the
residential premises of the individual doctor proprietor. Loans
taken for the construction units were also used to construct
residence of the doctors as a part of the entire premises.
Table 6.11 does, however, show that in individual
cases, money spent on construction was far less than
money spent on buying medical equipment and in a few
As for average investment per unit is concerned the
difference between the urban and rural units was very wide
with urban units investing far more than rural units.
Disaggregated investment showed that, however, when it came
to land, the urban unit paid far more than the rural unit.
It was a very high and noticable difference so too with medical
equipment though not so much with construction.
Hospitals/ nursing units in rural areas had not opted for very
high tech equipment. Most of those who had bought medical
equipment, surgical equipments required for minor surgeries
or such basic imaging equipment as X-ray machine or equipment
required for routine pathology tests. Some of these can be said
to have become a part of the essential paraphernalia of a doctor’s
practice. The poor quality of public health services turns the
population to private practitioners who offer these facilities which
are absent or inadequate in public services. But in the rural market
doctors can afford just this type of equipment not anything
expensive. Another reason is virtually all doctors offering indoor
patient care are general practitioners and not specialists. For
socialised services they offered rural nursing unit proprietors
were dependent on the service of visiting specialists. Given this
situation of having to depend on outside help may also explain
why the majority do not opt for very high tech equipment. Another
reason is inadequate infrastructural support. Electricity failures
are common and transport faolities are poor. Getting repair
and back up service for expensive and high tech medical
equipment is difficult for the rural nursing units.
47
Table 6.10
Investment according to years of establishment
Actuals and as percentage of Total (in Rs.)
Total
Fum.
Equi.
130000
81.50%
2500
0.63%
27000
16.92%
159500
2100000
41%
1500000
29.41%
500000
9.80%
1000000
19.60%
5100000
73
30000
6%
70000
14%
50000
10%
350000
70%
500000
74
40000
2.95%
560000
70000
1355000
41.32%
5.16%
685000
50.53%
40000
4%
980000
50000
3%
684000
42%
1624000
670000
7.00%
2759000 9559000
28.86%
Unit
Year
1
57
1
71
2
3
Land
Bull.
Depo.
Reno.
40000
4%
4
79
150000
15%
750000
76.53%
5
79
40000
2.46%
850000
52.34%
Total f
1971-80
2360000
24.68%
3730000
39.02%
13800
150000
30000
100000
4.69%
51%
10.21%
34%
25000
8.77%
60000
50000
32.67
18000
11.76%
85000
55.55%
153000
1
2
81
40000
0.41%
30000
83
10.32%
170000
59.64
293800
285000
21%
3
85
4
85
90000
21.68%
80000
19%
20000
4.81%
225000
54.21%
415000
5
86
125000
400000
15000
27000
567000
2.65%
4.70%
60000
40%
60000
40%
500000
5000
33.33%
5000
33.33%
15000
22%
70%
30000
20%
6
91
7
80
8
85
30000
29.70
70000
69.30
500
0.49%
500
0.49%
101000
9
86
7000
1.03%
440000
64.80%
40000
5.89%
192000
28.27%
679000
10
87
20000
1.99%
900000
89.82%
20000
1.99%
62000
1002000
89
50000
32.67%
75000
49%
15000
9.80%
13000
8.49%
153000
1981- 91
335800
8,80%
2165000
56.76%
248500
829500
21,74%
3813800
11
Total 11
5000
33.33%
60000
1.57%
48
175000
4.58%
6.18%
f
Table 6.11
Investment according to social geography
Actuals and as percentage of total (in Rs.)
Soc. Geo
Land
Buil.
Depo.
Reno.
Fum.
Equi.
Total
15000
2.65%
27000
4.76%
567000
40000
40%
980000
1.
U.
125000
22%
400000
70%
2.
U.
150000
15%
750000
76.53%
3.
U.
90000
21.68%
80000
19%
20000
4.81%
225000
54.21%
415000
4.
U.
40000
2.46%
850000
52.34%
50000
30%
684000
42%
1624000
5.
U.
25000
8.77%
60000
21%
285000
6.
U.
1500000
29%
500000
9.80%
1000000
19.60%
510000
7.
U.
130000
81.50%
2500
0.63%
27000
16.92%
159500
8.
U.
60000
40%
60000
40%
150000
9.
U.
70000
14%
50000
10%
350000
70%
500000
10.
U.
50000
32.67
18000
11.76%
85000
55.55%
153000
11.
U.
40000
2.95%
560000
41.32%
70000
4.81%
685000
5431%
1355000
12.
U.
13800
4.69%
150000
51%
30000
100000
34%
293800
10.21%
2588800
2235%
4540000
39.13%
840500
735%
3343000
28.86%
11582300
Total (12)
Percentage
40000
4%
30000
10.52%
2100000
41%
170000
59.64%
30000
20%
30000
6%
60000
031%
210000
1.81%
1.
R.
7000
1.03%
440000
64.80%
40000
5.89%
192000
28.27%
679000
2.
R.
50000
32.67%
75000
49.00%
150000
9.80%
13000
8.49%
153000
3.
R.
5000
33.33%
5000
33.33%
15000
4.
R.
500
5000
33.33%
30000
29.70%
700000
69.30%
500
0.49%
101000
0.49%
R.
20000
1.99%
900000
89.82%
20000
1.99%
62000
6.18%
1002000
Total (5)
Percentage
107000
5.48%
1485000
76.15%
80500
4.12%
272500
13.97%
1950000
5.
5000
035%
49
Table 6.12
Investment according to bed strength
Actuals and as percentage of total (in Rs.)
Unit
No. of Beds
1
3
2
4
3
6
4
7
5
9
6
10
7
10
8
10
9
14
Fum.
Equi.
Total
60,000
40%
60,000
40%
1,50,000
5,000
33%
5,000
33%
15000
75,000
49.00%
15000
9.80%
13000
8.49%
153000
50000
32.67%
18000
11.76%
85000
153000
55.55%
25000
8.77%
60000
21%
285000
80000
19%
20000
4.81%
225000
54.21%
415000
130000
81.50%
2500
0.63%
27000
16.92%
159500
13800
150000
51%
100000
34%
293800
4.69%
30000
10.21%
7000
40000
5.89%
192000
28.27%
679000
1.03%
440000
64.80%
Land
Buil.
Pepo.
Reno.
30000
20%
5,000
33%
50,000
32.67%
30000
10.52%
90000
21.68%
170000
59.64%
10
15
30000
29.70%
70000
69.30%
500
0.49%
500
0.49%
101000
11
16
30000
6.0%
70000
14%
50000
10%
350000
70%
500000
220800
7.60%
1065000
36.66%
266000
9.15%
1117500
38.47%
2904300
Total 3-16
(11)
60000
2.06%
175000
6.02%
1
20
40000
2.95%
560000
41.32%
70000
5.16%
685000
50.53%
1355000
2
20
20000
1.99%
900000
89.82%
20000
1.99%
62000
6.18%
1002000
3
23
125000
22%
400000
70%
15000
2.65%
27000
4.76%
567000
4
24
150000
40000
4%
980000
15%
750000
76.53%
40000
2.46%
850000
52.33%
50000
1624000
3%
684000
42%
2100000
41%
1500000
29%
500000
9.80%
1000000
19.60%
5100000
2475000
23.28%
4960000
46,66%
655000
6.16%
2498000 10628000
23.50%
5
6
Total 20-40
(6)
24
40
40000
4%
40000
0.37%
50
Investment according to Bed Strength
Although doctors were asked about deposit paid
by them for rented premises and expenditure incurred
on renovation this is not being discussed in detail sence
the number of units incurring this investment was
negligible. The discussion pertains to other heads listed
in the table. Investment information was available for
only 11 out of the total 12 individually owned health
units.
Bed strength could indicate type of facilities
available and services offered. It could also indicate
physical size of the health unit. Here two categories
were made - one category consisted of health units
with a bed range of 3-16 and the other 20 - 40. (see
Table 6.12). In these cases too investment in
construction and medical equipment took up the larger
share of total investment. Thus, in the first category,
36.66 per cent of the total investment went into
construction and 38.47 per cent into buying medical
equipment. In the second category it is 46.66 per cent
and 23.50 per cent respectively. This is because there
is a strong desire among individual proprietors to have
their own premises which meet their requirements in
terms of area, size and locality rather than go for rented
premises. There is also the practice of combining
professional and residential premises. One floor of the
constructed building is used a residence. While units
seek to offer competitive services and create facilities
with available modern technology, — however, an
extremely miniscale number of specialists have opted
for highly developed medical technology. Most
technology falls in the diagnostic, imaging, pathology
or therapeutic categories which though high priced is
not very expensive. Investment in high-tech diagnostic
and therapeutic is made in the larger units which had
larger bed strength because these were the ones who
did and who could after specialised care. Units with
smaller beds strength, apart from the occassional
X-ray machine or routine pathology equipment, invest
mainly in surgical equipment. Partly due to perceived
needs of its clientele or the patients it expects to serve
and partly due to affordability.
Moreover, the first had inherited the premises where
the unit was located, thereby making no investment in
premises and making barely any as far as furniture and
equipment is considered. The unit with 14 beds had
its own premises and had spent more on furniture and
equipment though not the highest. A 16 bedded unit
had spent Rs. 3,50,000 on equipment. It was however
difficult to link up investment in equipment with bed
strength as Table 6.12 shows where a fifteen bedded
unit reported less investment in equipment than a 3
or 4 bedded unit. It can partly be explained by the fact
that investment was related to facilities and services
offered rather than number of beds and partly by the
fact that the respondent may not have been entirely
honest in disclosing and stating the information.
In the bed range 20 - 40, the difference between
the lowest and highest was noticeble. The difference
between the bed strength was wide - virtually double.
The difference in investment made in medical equipment
between one 20 bedded unit and the 40 bedded is wide
but on the other hand is a second 20 bedded unit which
had made a huge investment in medical equipment.
Although within the two categories may be found wide
gaps between the lowest and highest investment it is
difficult to link it up with the lowest and highest bed
numbers. Even with respect to the two categories of
units it is difficult to discern a very wide gap as far
as investment is concerned, whether total or in medical
equipment.
A matter of special notice was that the
difference in investment into land buying between the
two categories was very high. This could , however,
be explained by the fact that in the second category
just one unit had made a very large investment in buying
land, spending a sum of Rs. 21,00,000 as seen from
Table 6.10. All other units had spent far less on land.
The reason furniture took up only a small part
of the total investment was because except the number
of beds, all other furniture pieces were restricted to
the bare necessary items such as tables, chairs, small
cupboards etc.
The lowest investment made in 3-16 category
was Rs. 15,000 while the highest is Rs. 6,79,000. This
was so because of the difference in bed strength, the
first had a more 4 beds while the other had 14 - bj
Ff
nOC'
k'? a
! •
Vie ioo
05607
Sources of Finance
Table 6.13
Investment sources according to bed strength
Personal Contribution
Institutional Loans
Units
Bed Strength
Nationalised Banks
Coop. Bank
MSFC
6
20-40
5 (12)
1
n"
3-16
9 (16)
1 (1)
4 (7)
14
5
2
17
6
T
9
(Figures in parenthesis denote number of loans)
fact that nationalised bank have developed a wide
network of branches covering not just urban areas but
also rural areas. Local branches of nationalised banks
also extended loans. MSFC has its offices only in the
Oistrict head quarters. Cooperative banks may be area
specific not having a network of branches. Moreover,
in Maharashtra where Cooperative Banks, as with Sugar
Cooperatives or other Cooperative societies are closely
linked with local political leadership, it may be difficult
for individuals to get loans from these bank unless they
have the necessary influence for the Cooperative banks
are known to service the political leadership or parties
concerned more, than the general category. Indeed, our
field study shows that more often than not those doctors
who were able to avail of loans from Cooperative banks
were those who in variably had close family members
or relatives associated with the management of these
banks. Doctors not having those connections turned to
nationalised banks. In rural areas the doctor is a valued
customer of nationalised banks and the doctor and bank
manager may be persons having regular social contact.
These interaction could facilitate loans from the banks.
An important aspect in understanding
investments being made by private sole proprietory units
would be to examine their source of investment. Two
broad sources may be identified : 1) Institutional loans
and personal contributions. The former consists of
nationalised banks. Cooperative banks and State owned
institutions such as the Maharashtra State Finance
Corporation. Personal source consists of inherited
money intented, personal savings and loans taken from
close relatives as father, brother etc. (in our study there
was just one such case). The most interesting aspect
here was that five out of six units with bed strength
20-40 made investments which were sourced as
institutional loans as well as personal contributions.
Only one doctor informed that his investment was made
entirely out of his own personal contribution which
amounted to Rs. 5,67,000. A large part was pitched
in by family members with more than 93% of it going
into land purchase and building construction. However,
again this was so because the building also housed the
residential premises of the joint family. A mere seven
per cent was invested in furniture and equipment.
Table 6.14
Investment sources according to social geography
Personal Contribution
Institutional Loans
Unit
Social Geography Nationalised Banks
12
U
10 (20)
5
R
4 (8)
17
14
Self
Coop. Bank
MSFC
5 (8)
1(1)
7
2
5
1 (1)
2
9
(Figures in parenthesis denote number of loans)
MSFC was seen as too distant and bureaucratic on the
other hand.
The above table shows that units from both
urban and rural areas took more loans and more often
from nationalised bank. This can be explained by the
52
Expenditure of Private Health Providers*
the last was in the 80-110 bed range. This last category
was also the one consisting of units falling in the
voluntary subsector. It was obvious that the Trusts had
access to larger and better resources than individual
proprietors and hence ran large establishment.
Expenditure according to Ownership/Management
Table 6.15 shows average monthly expenditure incurred
by health units classified by ownership/management. An
examination of the table reveals the major heads identified
as staff salary, drugs, and equipment and supplies did not
display much difference as far as expenditure was
concerned between the two categories. The above
mentioned heads took up major portion of the monthly
expenditure while the difference as far as the minor heads
such as telephones, electricity, taxes etc. was notable.
Hospitals in the voluntary sector offered
services to specific groups such as leprosy patients,
as was the case of one hospital studied here. Or they
offered specialised services, attempting to offer
services that were lacking in the area, services which
were non-available or to which various sections of the
population have no access. Since the basic idea was
to cater to the needs of as large groups as possible,
establishments were also large. Hence, running costs
were also high.
The average monthly expenditure for each individual
managed unit was calculated at Rs. 16,788. The Trust
managed hospitals incurred an average monthly
expenditure of Rs.2,21,044. In terms of percentage
share of the monthly expenditure, staff salary took up
38 per cent and 43 per cent for individual units and
trust units respectively. For drugs it was 25.76 percent
and 23.42 per cent respectively.
The monthly average expenditure for units with
bed strength between 3-16 was Rs.8462, for those with
a bed strength range of 20-40 Rs.32054, and with those
with bed range 80-110 Rs.221044. The average monthly
expenditure on staff salary for the first category was
Rs.2213, for the second category Rs. 13809 and the
last categoiy Rs.95261. The average expenditure on drugs
was Rs.3447, Rs.5858 and Rs.51782 respectively. For
equipment/supplies it was Rs. 1025, Rs. 4441 and
Rs.36668 respectively. The figures are revealing in that
greater the bed strength, greater the expenditure. But
of interest was the percentage share in monthly
expenditure. Thus staff salary took 26 per cent for the
3-16 category, 43 per cent in case of both for the 2040 and 80-110 categories. The per centage share of
drug expenditure for the twice categories was 40.73
per cent, 18 per cent and 23.42 per cent. In the case
of equipment supplies it was 12 per cent, 13.85 per
cent and 16.58 per cent. Of interest is the fact that
units with bed strength 3-16 incurred less expenditure
on staff salary as compared to drugs. This was because
smaller hospitals were often one doctor units with few skilled
paramedical staff Often, outside professional help came in
the form of visiting or consulting doctors. These units did
not normally employ other doctors and depended on the
services of the individual proprietors (See Tables 6.3 and
6.4). These unit also did not employ trained nurses or
paramedics. Rather they employed the services of less
educated personnel who received on the job training. Hence,
salaries paid out were far too low. This is not the case with
the laiger units where dependence on professional services
and trained staff was greater owing more often to the nature
and extent of services or facilities offered.
For equipment/supplies including repair and
maintenance of equipment, expenditure was 13 per cent
and 16.58 per cent. Telephone, electricity, water taxes,
other taxes (those paid to local bodies by way of property
taxes etc.) repairs and maintenance, fuel, stationery and
other expenditure individually took up a smaller percentage
of the monthly expenditure. If anything, what it reveals
is that for both categories, staff salary, drugs and
equipments remain the major heads of expenditure. The
monthly average expenditure by each individual owned unit
on staff-salary was Rs.6306 and by the trust hospital
Rs. 95261; on drugs it was Rs.4298 and Rs. 51782
respectively. On equipment/supplies it was Rs.2230 and
Rs.36668. These were the major heads, for the other heads
the Table may be examined. The wide difference in the
expenditure between the two categories was apparent.
However, what ownership really denotes here is the size
and types of services ofiered. The Trusts managed and ran
larger establishments as compared to those owned by individual
proprietor. And this was most apparent in bed strength.
Expenditure according to Bed Strength
Table 6.16 gives average expenditure according
to bed strength. Three categories were determined by
bed strength. Thus there was one category of units in
the 3-16 bed range, the second which was 20-40 and
* Includes the Voluntary Sub-sector
53
Table 6. 15
Average Monthly Expenditure according to Ownership/Management
(in Rs.)
Tele.
Elec.
W.T.
O.T.
S3.
Rmp
O.F.
StatN.P.
Other
Total
2230
507'
986
126
329
6306
505
150
393
958
16788
25.76
13
3
6
0.75
2
38
3
0.9
2
5.74
Trust
(3)
Average
51782
36668
2082
3563
1913
1667
95261
11241
2707
3998
10162
23.42
16.58
.94
1.61
0.86
0.75
43
5.08
1.22
1.80
4.59
Percentage
Drugs
E.S.
Average
4298
Percentage
Heads
Own.
Man
Individual Prop.
(17)
Notes:
Drugs- Drugs
Equipment and Supplies (including repairs and maintainance)
E.S-
Tele. -
Telephone
Elec-
Electricity
W.T.-
Water Taxes
O.T.-
Other Taxes (local bodies)
Staff Salaries
S.S.Rmp. - Repairs and Maintainance of Premises
OF. -
Fuel
Stat. N.P. - Stationary and News paper
Other- (Laundry, misc. expenses)
221044
Table 6.16
Average Monthly Expenditure according to Bed Strength
(in Rs.)
Bed-Heads
Drugs
EJS.
Tele.
Elec.
W.T.
O.T.
S.S.
Rmp
O.F.
Stat N.P.
Other
Total
3-16 Average
3447
1025
447
482
45
135
2213
212
135
356
13.63
8462
11
Percentage
40.73
12
5
5
0.63
0.62
26
2.50
1.60
4.21
0.16
100
20-40
Average
5858
4441
616
2003
275
685
13809
1043.66
177
460
2689
32059
6
Percentage
18
13.85
2
6.24
0.85
2
43
3.25
0.55
1.43
8.38
100
80-110
Average
51782
36668
2082
3563
1913
1667
95261
11241
2707
3998
10162
221044
3
Percentage
23.42
16.58
.94
1.61
0.86
0.75
43
5.08
1.22
1.80
4.59
100
Strength
th
Notes:
Drugs- Drugs
E.S.-
Equipment and Supplies (including repairs and maintainance)
Tele. -
Telephone
Elec. -
Electricity
W.T. -
Water Taxes
O.T. -
Other Taxes (local bodies)
S.S. -
Staff Salaries
Rmp. - Repairs and Maintainance of Premises
OF.-
Fuel
Stat. N.P. - Stationary and News paper
Other- (Laundry, misc. expenses)
Tabie 6.17
Average Monthly Expenditure according to Social
(in Rs.)
Geography*
Drugs
E.S.
Tele.
Elec.
W.T.
O.T.
SJS.
Rmp
O.F.
Stat N.P.
Other
Total
Average
5366
2729
582
1233
159
436
8454
651
131
373
1345
21302
Percentage
25
12.81
2.731
5.78
0.74
2
39.68
3
0.6
1.75
6.31
Average
1734
1034
327
395
46.5
72.4
1150
156.8
195
441
30
Percentage
31
18
5.87
7
0.83
1.29
20
2.80
3.49
7,90
0.53
Social
Geog.
Urban
(12)
Rural
(5)
Notes:
Drugs- Drugs
E.S.-
Equipment and Supplies (including repairs and maintainance)
Tele. -
Telephone
Elec. -
Electricity
W.T.-
Water Taxes
O.T.-
Other Taxes (local bodies)
S.S.-
Staff Salaries
Rmp. - Repairs and Maintainance of Premises
O.F.-
Fuel
Stat. N.P. - Stationary and News paper
Other- (Laundry, misc. expenses)
* Table excludes hospitals from the voluntary sector
5582
o
Expenditure according to Social Geography
Social geography is an important factor
determining expenditure. Table 6.17 shows the average
monthly expenditure of two categories of units, one
urban based and the other rural located. Here the units
studied include only individual proprietors and exclude
the Trust run units which were all urban based. There
were 12 urban based units and five rural located. The
average monthly expenditure of each urban unit was
Rs.21302 while that of the rural units was Rs.5582.
Monthly expenditure on staff salary for the urban units
was Rs. 8454 and for the rural Rs. 1150. Monthly
average drug expenditure was Rs.5366 for urban and
Rs. 1734 for the rural. Expenditure on equipment/
supplies was Rs.2729 and Rs. 1034 for urban and rural
respectively.
witnessed a steady expansion over the years. It is well
entrenched and the period after 1980 saw a rapid
expansion of the private sector. What helped the private
sector was that the government formulated policies that
favoured its growth. This was substantiated by the
scheme created by the government or other public
agencies to assist the setting up private practice. A
primary hurdle in the establishment of private practice
in India has been finance. The difficulty was relatively
eased as a result of these schemes. The study of
investment by medical care professionals had shown the
various channels available to both rural and urban
practitioners to raise loans with relative ease. They are
utilized to finance permanent capital expenditure heads
such as land, building, furniture and equipment. These
heads especially land and building construction take up
the bulk of the investment. Medical equipment in several
instances followed taking up a fairly large share. This
in a way corresponds to Sukanya’s study (1996) in
Madras wherein medical equipment was seen as
consuming the largest share of total investment.
Examination of expenditure showed that medicine,
supplies and staff salaries took up much of the
expenditure. Staff salaries would be expected to take
up the largest share of the monthly expenditure. While
it was true of the public sector and the voluntary sub
sector, it did not always apply to the private sector.
This was so because individual doctor proprietors,
choose not to employ paramedics, and if they did,
depend less on them. These were not necessarily
qualified and fully trained paramedics. Sometimes
trained paramedics were not simply available. Individual
doctor proprietors thus saved on salaries.
As for the share in percentage terms was
concerned in the case of urban units, 39.60 per cent
went into staff salaries while for the rural units this
share was 20 per cent. In case of drugs expenditure,
the percentage share was 25 for urban and 31 for the
rural. Equipment/supplies expenditure was 12.81 per
cent for urban and 18 per cent for rural area. These
figures reveal that rural units employed less staff or
lower paid staff (see Table 6.3). Very often the only
professional services available were of the doctor
owner and occassionally visiting doctors. Rural units
also found it difficult to get trained paramedics due
to their rural location although the other possible
reason may also be that these units did not always offer
specialized services. Indeed mdst indoor services
offered were overnight stay, or minor surgeries
requiring one or two day stay but most likely were
those offering maternity services rather than surgical
or other indoor treatment. Given the nature of services
there was less dependence on trained staff.
□□
Concluding Remarks
The present chapter examines the pattern and
nature of investment and expenditure incurred by
private individual proprietor in setting up practice and
in the delivery of medical care. It is by now a well
acknowledged fact that the private health sector
57
7
Conclusion
inequitable public health services infrastructure in
India. Easy and convenient access to health care
services is an important determinant in the use of
services. Under-utilisation or non-utilisation of existing
public facilities suggests inaccessibility. Any attempt
to remedy the situation and to ensure equitable
distribution requires a reliable database. The survey
conducted in Ahmednagar attempted to create such
a database at the district level. The objective of
determining the volume of health resources was meant
to overcome the flaws in official sources where the
number of health providers was grossly underestimated.
The study on health resources, investment and
expenditure carried out in Ahmednagar was primarily
exploratory in nature. The objectives were to determine
the volume of health providers in the district and to
examine the nature and pattern of investment and
expenditure by the health providers. The study identifies
and brings out the main characteristics of the health care
delivery services in the district.
The district level census of health providers is
an important contribution of this study. It shows that the
problem of non-availability and inaccessibility to health
care is as much due to unequal distribution of health
services as shortage of health resources. The factors
responsible for this maldistribution of health resources
in the district have also been examined.
The exercise described in the previous
chapters aimed at bridging the gap between grossly
underestimated figures of health providers from official
sources and the actual number of health providers
operating in the district. This objective was fairly well
met when the census showed the number of health
providers as double the officially known figure. These
health providers included all individual practitioners
representing all systems of medicine, qualification,
specialisation, trained and untrained, private and public
sector and urban and rural based. These also included
all kinds of health establishments providing medical
care from both public / private sectors, urban / rural
location. The difference between the two revealed the
inadequacies of official resources and highlighted the
drawbacks of depending on the same.
The study brought out the lacunae and
inadequacies of official data and data collection. The data
generated through the study is a more reliable
representation of the size of available health care services
in the district. Such an exercise at the district level is
not known to have been attempted elsewhere. The second
part of the study covered investment made and
expenditure incurred by the health providers in the
provision of medicine. The study examined the areas in
which investment was made, the amount of money
invested in each; the preferences and factors influencing
decisions regarding investment. The sources from where
investment money was raised were identified and
examined as an important factor in the growth of the
private sector. Items on which expenditure incurred were
analysed and the reason why spending was more on some
and less on the other.
The final results justified the exercise,
demonstrating the extent to which health resources were
numerically underestimated. This census exercise was
able to highlight the limitations of official sources,
namely lacunae in registration in Medical Councils;
the inadequacies arising from the lack of definite
official policies; ambiguity in registration procedures
of local self-government bodies; lack of knowledge
/ information amongst Government officials. Medical
Councils and health providers themselves about
registration and government rules and regulations; and,
non-implementation of these regulations.
Health Resources
In India inaccessibility to health care is not always
and necessarily a matter of lack of resources but of their
distribution. Maldistribution of health resources is an
important factor in the inaccessibility and non
availability of health care. Centralised planning
contributed to the development of a nation-wide but
58
practice became easily available. The overproduction
of medical professionals and constraints of the
government sector (inhibited) employment in that
sector. The low attraction for government employment
meant doctors turned to setting up private practice, if
they did not migrate abroad. Migration abroad, however,
is possible only for those trained in allopathy and again
mainly specialists. Those trained in the other systems
besides having extremely limited openings in
government employment have virtually no opportunity
for migration. As the study shows, the proliferation in
private colleges has also meant an increasing and large
turnout of doctors trained in the non-allopathic systems.
These medical personnel set up individual practice
contributing to the burgeoning private medical system
in the district. The various available sources of finance
facilitated the establishing of independent individual
practice.
The main features of the health services in the
district as they emerged from the survey were : unequal
distribution of health resource reflected in geographical
imbalance-urban/ rural and developed/ undeveloped
differentials; geographical imbalance in population
served by doctor; low doctor to paramedic ratio; low
paramedic to population ratio; shortage of medical
professionals in government health services co-existing
with underemployment or unemployment of doctors;
decline of general practitioners amongst allopaths;
rampant cross-practice arising out of the great demand
for allopathy and under-utilisation of the traditional
systems of medicine; the imbalance between promotive/
preventive health care and curative health care (medical
care) in rural public health services; the lack of both
specialised medical care and basic health care to
underprivileged sections, for instance, women; the
growth of the private sector in the last two decades;
the dominance of the unregulated private sector in health
care delivery; relatively limited growth of the
government health delivery system; and,tendency of
private health providers to set up medical practice where
public facilities already exist.
If the availability of investment funds helped
the expansion of private medical practice and medical
units, financial constraints limited the growth and
expansion of health services. This suggests that much
of the investment in health care was in the private sector
rather than the government sector. This is evident in
the volume of and dominance of the private sector in
health care. Individual practitioners have better access
to institutional loans. Nationalised banks, co-operative
banks and societies. State run institutions such as the
Maharashtra State Finance Corporation offer loans at
reasonable rates of interest. Procedures for loans are easy
and client friendly. Government policy has been to
encourage institutional loans and thus support the
privatisation of health care.
All of these in composite may be considered
responsible for the lack of accessibility and availability
of health care to the various sections of the district’s
population wherever this situation exists. The unequal
distribution in the health system can be attributed to
the absence of proper priorities with regard to
development of health care, medical human power,
medical education and indigenous systems of medicine;
the growing support for the ideology of privatisation
of medical care; the bias in favour of medical health
professionals; the low priority given to training of para
medical staff; bias in favour of specialised, technology
oriented, hospital based medical care; a shift away from
general practice to specialisation amongst allopaths;
and, a decline in the concept of the family physician.
A large proportion of the investment goes into
land purchase, construction and buying of medical
equipment. The study has shown that the latter consumes,
when not the largest share of investment, at least second
to land and building. This suggests growing
specialisation of medical care and dependence on
medical technology. But it also implies that medical
care has grown more competitive. Setting up practice
is expensive requiring large investment. In order to
recover this money spent, doctors conduct medical
practice where the ‘market’ is i.e. where the purchasing
power is. This is available only in urban areas or the
developed rural regions. It is this that leads to unequal
distribution of medical facilities making health non-
Investment and Expenditure
'J
The years after independence in India witnessed
an expansion and extension in the health care services.
Centralised planning ensured growth of government run
health services but this development was gradual and
slow. In contrast the private subsector grew rapidly. The
impetus for rapid expansion of private health care came
from the late 1970s onwards as finance for setting up
59
professionals. In this manner salary expenditure was kept
low.
available.
High investment can also make medical care
inaccessible. Medical care becomes expensive putting
up a financial barrier to accessibility to health care. In
other words, large investments by health providers can
make medical care unaffordable and hence inaccessible
to many who need it.
This was not true of the larger hospitals
especially those with bed strength of 80 to 110. Hospitals
belonging to the voluntary sector, as stated earlier had
better access to financial resources which ensured
employment of medical and semi-medical professionals.
In some health units, expenditure on medicines
and medical supplies was kept at the minimum by
having patients buy the required drugs and materials
from outside. Patients would be asked to replace the
medicines used. By passing on the burden to the
patients, doctors often kept their own expenditure low.
Hospitals in the voluntary sector, especially the
mission run or those managed by religious trusts are
better placed in their capacity to raise funds for
investment. These hospitals, even when spending on
providing specialised care or departments with high
technology, being motivated by charity, offer subsidised
or free health care. Hence, large investment in the setting
up or expansion of trust run hospitals may not
neccessarily invite high cost medical care for the
patients.
Several difficulties and problems were faced
while studying investment and expenditure. These are
difficulties that any researcher wishing to conduct
research in this area will encounter. These relate to nature
of data, reliability of data, collection of data, the
accounting systems of the agencies concerned,
attributing financial value to land or building donated
or inherited and used for establishing a health unit or
medical practice. A sector wise and period wise
comparative study can be difficult. This could as well
apply to units geographically distributed between urban/
rural and developed/underdeveloped regions.
Of late even hospitals in the voluntary sector
are beginning to charge user fees. This is a new trend
as privatisation of health care is increasing and being
encouraged. Although it has been said earlier that the
voluntary sector has less difficulties with raising money
more recent developments such as the globalisation of
the economy has affected the funding of these health
units. Foreign funding is becoming increasingly difficult
to come by.
In the government, historical information on
health units was difficult to access, often because of
disorganised records keeping. None of the mission
hospitals approached were willing to divulge any
financial information whether it be investment,
expenditure or fees. Ahmednagar has a more than century
old history of missionary activity. It has several mission
run hospitals. But information on these was limited and
sketchy, while financial data was simply not available.
Even those units from the voluntary sector who gave
expenditure data were unable to give information on
investment.
Examination of the expenditure shows salaries,
supplies and medicines consume the larger share of
total expenditure. These are essentials in health care
delivery. The share of other expenditure heads such as
rent, maintenance, taxes was too small or negligible to
consider for detailed analysis. In several cases, salary
was a relatively smaller component of total expenditure.
This was because no paramedic staff or other staff was
employed and where it was employed, the staff had no
formal training, receiving on the job training. Hence,
they tended to be paid lower salaries than those paid
to trained and skilled staff. The employment of untrained
staff may have been due to non-availability of trained
paramedics or may have been a deliberate act to save
on salaries. Small units with bed facilities often did not
employ doctors, but depended on visiting doctors or
the services of the doctor proprietor. Sometimes the
proprietors were husband-wife doctor couples who then
dispensed with the services of additional medical
In the case of individual private practitioners,
some refused to give information. There were others who
did. But the question remains as to how reliable could
some of this information be. Investment in several cases
was spread over several years. This information was
based on personal recollection. In empirical research
there have always been questions relating to recall period.
60
i1
4
and the reliability of data thus recollected. Moreover,
it was difficult to get disaggregated information. Often
the exact break up between expenditure incurred on
renovation of premise and furnishing could not be given.
Medical equipment would be clubbed together with
furniture. Getting the respondent to recollect information
on the disaggregrated investment would require repeated
probing, cajoling and coaxing by the researcher. In the
private sector there is no access to documentary
evidence since the papers are personal and confidential.
There are also cases where no documents are maintained
about transactions especially in rural areas.
have the right and duty to participate individually and
collectively in the planning and implementation of their
health care”. The report of the WHO Expert Committee
further stated “Health can never be adequately protected
by health services without the active understanding and
involvement of the individuals and communities where
health is at stake.” It meant involving all individuals
and institutions providing health care in the district
whether governmental, social security, non
governmental, private and traditional. In India the ICMR
/ ICSSR Report Health for AH’ of 1982 and the 1983
National Health policy emphasised decentralised health
care. But nothing much happened by way of
implementation.
How does one analyse investment in cases
where medical practice is inherited or carried out from
inherited premises? How and what financial value does
the researcher attach to these premises ? Or does the
researcher disregard the premises from the study of
investment ? There are cases of doctors who have
inherited practice from their parents or spouses. There
are cases of doctor couples operating from the same
premises. The value of land and building differs from
locality to locality, region to region within the same
territory. The same is true of cost of construction.
The World Health Assembly meeting at Harare
(Zimbabwe) in 1988, brought out a Declaration on
strengthening Distict Health Systems based on Primary
Health Care. Here, district health system was defined
as a more or less self contained segment of the national
health system which comprises a well defined
population living within a clearly defined administrative
and geographical area, either rural or urban and all
instituting and sectors whose activities constructed to
improve health. In India panchayati administrative and
geographical units match well the requirements outlined
in the above definition.
All of the above issues and questions apply to
expenditure. In the government sector, the difficulty is
getting disaggregated data where several agencies are
involved. Thus both the State Government and Zilla
Parishads contribute to rural health services. Municipal
bodies may not keep disaggregated data for the different
health units they run. These may vary from being a fifty
bedded maternity home to a Radiology Clinic to an
Ayurveda dispensary
Database for Decentralised Planning
Recent years have seen a renewed interest in
strengthing Panchayati Raj institutions. The 73rd
Constitutional Amendment relating to Panchayati Raj
seeks to ensure decentralised planning and community
participation. With a decentralised administrative
structure more or less in place, this could facilitate a
decentralised health system. Health in India has
constitutionaly been a state (provincial) subject. The
73rd Amendment has identified 29 subjects to be handed
over to Panchayati Institutions. Health is one of these
29 subjects. The Indian Constitution has thus attempted
to empower Panchayats to plan for health care. The need
is to seriously work towards this goal.
Preparing a database as outlined in this study
has utility for decentralised health care planning
especially as discussed in the context of Panchayati Raj
in India. A corollary to the primary health care approach
enunciated at Alma Ata was decentralising of health care
planning. The Declaration of Alma Ata outlining the
primary health care approach had stated, “The people
In recent years, there is a growing realisation
and recognition that the goal of Health for All is
unattainable by the year 2000. Moreover, with the crisis
in the public health system , as reflected in the outbreak
of Plague in Surat, Cholera in the North East, Malaria
in various regions, and regular reporting of the
breakdown of government health services, there is a
All these issues will have to be addressed by
researchers. Well defined techniques and methodology will
have to be worked out for more detailed and indepth
analysis of investment and expenditure in the health sector.
61
Community based planning is emphasised thus
favouring a shift towards decentralised planning.
growing realisation that national centralised planning
has its limitations. Centralised planning overlooked and
ignored local and regional factors resulting in skewed
planning. Lopsided development and maldistribution of
resources were the consequences of this planning process
over the years.
To achieve community participation the action
programme should aim to generate informed and
knowledgeable participation. It is essential to build up
the capability of the people and their local institutions
to respond to local needs and situation. Developing this
capability means above all to equip people and their
institutions with the requisite knowledge and skills. Only
then will existing health care delivery systems become
more responsible and responsive to people’s needs.
There is now a greater awareness of the
dynamics of regional and local forces and recognition
of the wide diversity in situations at the regional and
rural levels. The need for a more concerted efforts at
decentralised planning with a flexible framework that
responds to regional needs and disparities in the health
care situation is recognised. Regional disparities are so
wide and the development process including health
service development so diverse that planning at regional
level, and at district level particularly, is not only
necessary but also relevant.
The study carried out by FRCH in Ahmednagar
district shows how a database of health providers can
be created, the techniques and methods that can be used.
Moreover the study addresses the issues of geographic
distribution of health provides, systems of medicine,
volume of health providers, type of services offered,
investment and expenditure incurred to establish and
run medical practice all of which are important from
the point of view of planning.
The 73rd Constitutional Amendment on
Panchayati Raj is a recognisation of this urgent need.
It provides us with the opportunity for institutionalising
a localised planning process involving the community.
□□
62
Appendix A
District Profile
Selection of the District
1
u
lowest (120). The concentration pattern for population,
shows that the 5 developed talukas are densely populated
(346 persons/sq. km.) while the remaining 8
underdeveloped talukas have a population density of
only 152 persons/sq. km.
The district of Ahmednagar was selected for the
study as representive of Indian district with average
socio-economic development. The selection was based
on the CMIE indices for levels of economic
developments of 1980. The development index for
Ahmednagar was 132 and for Maharashtra it was 164,
the All India index being constant 100. Although the
development index for Ahmednagar was higher than
the all India index, it fell between the all India index
and that of Maharashtra and hence was considered
average for socio-economic development. Moreover the
district is representative of the disparate economy and
unequal levels of underdevelopment in the country. [See
Table A.l]. It is this disparity within the district which
does not present a correct picture of the level of socio
economic development. The high development index
is more due to the pockets of high level development
in the district.
The sex ratio for the district 949 : 1000 is
slightly better than that for Maharashtra 933 : 1000.
Shrirampur has the lowest proportion of females (941)
to males and Pamer has the highest (1020). This can
be explained by the disparity in development levels
between the Northern and Southern regions of the
district. The latter constitutes the labour reserve areas
for the former and also for the other industrially
developed areas of the state.
The present Ahmednagar district was formed in
1869. Ahmednagar district has to its west Thane and
Pune districts, to the South and South-east are Solapur
and Osmanabad. to the East is Beed, to the North and
North-east is Aurangabad and to the North and North
west is Nashik.
About 84% of total population of Ahmednagar
district lives in rural areas while 16% in urban areas.
Of the total population of Ahmednagar district 76%
is engaged in agriculture. Of the total geographic area
78% land is cultivable and only 68% land is actually
cultivated. Only 25% of total cultivable land is irrigated.
Out of the total cultivable land only 6% is irrigated
by canal water. This canal irrigated land lies mainly
in the developed talukas (61%) and the underdeveloped
talukas depend on the low rainfall or on wells wherever
available.
The district has thirteen talukas, five of which
- Nagar, Kopargaon, Rahuri, Sangamner and
Shrirampur - are relatively developed talukas having
better infrastructure facilities with sugar dominated
industry and trade. The remaining eight talukas, Akola,
Jamkhed, Kaijat, Newasa, Pamer, Pathardi, Shevgaon
and Shrigonda are underdeveloped. Akola taluka has
a pre-dominantly tribal population. Local selfgovernment bodies in the district consist of ten
Municipal Councils, one Cantonment board and 1175
grampanchayats.
The cooperative movement in Western
Maharashtra has a long history contributing to the
social development and economic prosperity of the
region. The cooperative movement encompasses Milk
and sugar cooperatives, weavers cooperatives, banks and
credit societies. But it is sugar cooperatives above all
that have brought around most visible economic
prosperity in Western Maharashtra and Ahmednagar
district. The Ahmednagar District Cooperative Bank
is said to be one of the largest cooperative banking
enterprises in south Asia.
The 1991 census recorded a population of
3,372,935 which is 4.3% of total population of
Maharashtra and is spread across 5.54% of geographic
area of the state. The average population density (198
persons/sq km.) for Ahmednagar district is lower than
the average for Maharashtra (256). Shrirampur taluka
has the highest density (420) and Pamer taluka the
The first sugar cooperative in India was
established at Pravaranagar in Ahmednagar in 1950
which by the 1980s had gone up to 18. In 1991-92
Ahmednagar produced 17% of total sugar output in
Maharashtra which was the highest in Maharashtra which
produces 40% of total sugar output of India (Sudhakar
Joshi, 1992). The sugar industry has helped in the overall
63
Table A.l
Ahmednagar : Some Selected Economic Indicators
Indicator and Year
Ahmednagar
Maharashtra
India
1) CMIE Index of Levels
of Economic development
1980
132
163
100
1981
1981
324
158
203
63
245
61
848
855
1468
386
250
307
1979-80
184
149
166
June 1981
61
86
45
June 1981
96
430
168
December 1983
5.6
6.8
6.5
8) Per capita bank deposits
(Rs.)
December 1983
361
1731
897
9) Per capita bank advances
(Rs.) :
December 1983
363
1605
603
2) Bank Credits for
agriculture (Rs.)
a) Per hectare of
cropped area
b) Per capita
3) Value of output of
major crops (Rs.)
a) Per hectare:Avg.of
five yrs ending 1979-80
b) Per Capita Avg.of
five yrs ending 1979-80
4) Per Capita production
of food grains (kg.)
Avg. of five yrs ending
5) Per Capita bank credit to
small-scale industry
(Rs.) :
6) Per Capita bank credit to
all industries (Rs.) :
7) No. of bank offices per
lakh population :
[Source : Centre for Monitoring Indian Economy, : Profile of Districts, Mumbai 1985].
sugar-cane,factional politics within the cooperatives,
corruption and some impractical policies have had
adverse effects on both the sugar industry and the
cooperative movement As a result by 1988 out of 18
sugar co-operative factories seven had closed down and
a majority of the remaining units, were running in
loss. (DSA 1988-89).
development of the district but the development and
wealth is mainly concentrated in 5 developed talukas,
where 65% of total sugarcane growing land lies and
which gives 71% of total sugar output in the district.
In recent years, however, the sugar cooperatives
have not been able to assure a sustained economic
growth. Inadequate supply of sugar-cane, low-rates for
64
Agro-industries constitute the major section of
the industrial sector in Ahmednagar district with 76%
of the industrial employment and 64% of the total
industrial value production. (Ahmednagar, DSA, 198889). The district has, however, witnessed an industrial
spurt in the 1980s. A few major corporate industrial
concerns have manufacturing units in diverse fields,
polyester filament yarn, nylon filament, paints, cinema
carbon, basic drugs, metal tubes and pumps.
Density (Population/sq.km)
Notwithstanding the presence of these industrial
units the district as a whole lacks a strong industrial
base and agriculture remains the mainstay for a majority
of the population. However, agriculture dependent on
a scanty rainfall has not contributed much to the
economic growth and development of the district. An
excessive emphasis on the cultivation of sugar-cane, has
had negative impact for agriculture in the district.
Sugar-cane is known to require more water than
subsistence crops and it adversely effects availability
of water for the latter. It is primarily the small and
marginal farmers who are engaged in the cultivation
of subsistence crops, which are mainly jowar, bajra and
wheat. The area under jowar cultivation was 48,64% of
the total district area under cultivation, for bajra 26.97%
for wheat 4.61%. It is clear that these subsistence crops
occupied far more land than sugar-cane did. But seen
in terms of production value as percentage of the district
total, sugar-cane scores much higher than the other three.
The percentage value for sugar-cane is 40.86%, for jowar
19.49, for bajra 5.69 and wheat 5.49.
Literacy Rate
Total
Rural
Urban
Sex Ratio Females/1000 males
949
956
915
Total
Males
Females
50 %
62 %
38 %
Electrified Villages
(as on 31.3.1992)
1497
Percentage
of Total
99.5%
Villages where drinking
water is available
(as on 1.4.1991)
1436
95.4%
Villages connected by Road
(as on 31.3.92)
1087
72.2%
Total Primary Schools
2613 (as on 30.9.1990)
Total Primary Students
427000
Total Secondary Schools
386
Total Secondary Students
249000
Total Colleges
19
Total College Students
36000
Birth Rate
28.1%
Death Rate
6.3%
Infant Mortality Rate
5.4%
Sources :
The District at a Glance
1)
1991 Census Maharashtra Primary Census
Abstract (Final) Census Directorate,
Maharashtra.
2)
Ahmednagar District, 1991- 92, Economic
and Statistical Bureau, Government of
Maharashtra, Bombay.
3)
Provisional Vital Rates, Survey of Cause of
Death (Rural).
4)
Sudhakar Joshi, “Sahkar Samriddhi Pudhil
Awhane” Saptahik Sakai, Pune.
Area in Sq.Km.
17048.00
16702.26
345.74
Population
Total
Rural
Urban
Total
Rural
Urban
Number
Sugar cooperatives dependent upon sugar-cane
cultivation prevail upon government to divert limited
irrigated water supply to sugar-cane cultivation to the
exclusion of subsistence crops. Thus the developed
northern region with 71% of the total sugar-cane
cultivation receives a greater share of irrigation. Of
the total irrigated land 63% belongs to the north.
Total
Rural
Urban
197198
170170
15431543
3372935
2839454
533481
□□
65
Appendix B
Health Investment and
Expenditure in a District
(For Preliminary Investigation into PHC Services through Medical Officers)
Objective of present survey . To map out all the existing health resources in Ahmednagar district covering both public and private
sectors with a view to study investment and expenditure pattern in health care.
To make this possible we request you to kindly fill up the following questionnaire. Information provided by you
will be kept in strict confidence and used only for research purposes.
This study is being conducted by the Foundation for Research in Community Health, Mumbai.
1.
Ahmednagar
Location :
1.3 District
1.2 Taluka
1.1 PHC village
under the PHC.
and villages
2.
No. of subcentres
3.
Population covered by PHC
3.2 (population)
3.1 (latest year)
4.
Biographical Profile
4.1 Personal Information
Sex
Salary Rs.
Designation
Name
Marital Status
Age
4.2 Educational Qualifications
College/University
, Year of Passing
Highest Degree
4.3 Family Information
Native Place :
Village/Town
District
Taluka
4.4 Educational Qualifications : Parents/ Spouse
Spouse
4.5
5.
Father
Mother
Spouse
Father
Occupation :
Mother
Work Experience :
5.1 Did you join government service immediately after graduation ? Yes / No
,
5.2 If no, what did you do ?
66
p.m.
5.3 Which year did you join government service ?
5.4 Since when have you been working in the present PHC ?
5.5 What are the major health problems in your area ?
5.6 What is the average daily OPD attendance in your PHC ?
5.7 What are the factors that hinder your day to day functioning in providing health services to the people ?
5.8 What are the advantages you see in government service as a contrast to private practice ?
6.
We also seek the following information from you on the private health services in your PHC area.
Name of Doctor/Hospital/Disp.
Qualifications
Village / Town
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
If you need to use extra space to record the above information, please use a separate sheet. We thank you for your
participation in this study. Please put the filled up questionnaire in the self addressed and stamped envelope and
post it.
67
Appendix C
Health Investment and
Expenditure in a District
(Sample Survey of Private Services through Private doctors)
Objective of Present Survey : To map out all the existing health resources in Ahmednagar district covering both
public and private sectors with a view to study investment and expenditure pattern in health care.
To make this possible, we request you to kindly respond to the following questionnaire. Information provided
by you will be kept in strict confidence and used only for research purposes.
This study is being conducted by the Foundation for Research in Community Health, Mumbai.
1.
Name :
Sex :
2.
3.
Age :
Address :
Locality
Village
Taluka
Qualification :
System :
University :
Year of Passing :
Year of Registration :
4.
Native Place :
Village *
Taluka
District
5.
Family Background
Educational Qualifications
Occupation
Father
Mother
Spouse
6.
Whether any of your brothers and sisters are in the medical professions ? Deliberate - why ?
68
7.
Please give an overview of the status of people in this village
a)
Main Occupations
b)
Economic Class
c)
Caste / Religion
d)
Education
e)
Living conditions / Drinking water / Sanitation
8.
What are the prevalent diseases in this area ?
9.
With what frequency ?
With what intensity ?
10.
How many patients did you treat last weak ?
a) How many from the same village ?
b) How many from the neighbouring villages ?
11.
Do you visit other villages ?
Which ones ?
12.
Do you make home visits ?
13.
How do you deal with emergency cases ?
14.
Where and to whom do you refer patients ?
15.
What are the facilities do you offer to the patients ?
16.
Do you have any other staff to help you ? Give details.
17.
Whether you dispense medicines or prescribe them ?
18
From where do you by drugs ?
19.
How far is the nearest medical store ?
20.
Have you seen any medical representative visiting this area ?
21.
How long you have been practising in the village ?
22.
Did you start your private practice immediately after your graduation / post - graduation ?
23.
Did you practice somewhere else before you started practising in this village ?
24.
Are there beds in your clinic ?
25.
Do you offer indoor facility ?
26.
Identify other medical practitioners in this area.
27.
How much do you charge per consultation ?
69
Appendix D
A Study of Investment and Expenditure
in Health Services
(Sample Survey of PHC services thruough PHC paramedics)
The FRCH, Mumbai has undertaken a research project on the Investment and Expenditure by those providing
Health Services in Ahmednagar District.
Initially, as a part of the project, we are preparing a list of persons and governmental / semi governmental/
non-governmental / private organisations which provide health services.
We request you to fill - in the following questionnaire.
We assure that the information will be kept confidential and use only for the research project.
1.
2.
Information about the following where you work
Primary Health Centre
Subcentre
Taluka
District
Information about the following in the jurisdiction of the PHC where you work
Total number of subcentres
Total number of villages
Total population
3.
Information about the following in your jurisdiction (if you work at a subcentre)
Total Villages (number)
Total population
4.
Information about yourself
4.1
Name
Sex
Married / Unmarried
Salary : Rs.
4.2
Were you given any training before you joined government service ?
Year
Place
Duration
4.3
About the Family
Place of origin
Taluka
District
70
4.4
Educational Background of the family
Husband / Wife
Father
Mother
4.5
Experience of Work
Did you immediately join the government service
after completing your education ?
Yes / No
If no, other details
5.
Year of joining government service
5.1
Since when have you been working in the present subcentre ?
5.2
What is the nature of your work ?
5.3
What are the difficulties encountered while making available government medical service
and facilities to the general public ?
5.4
Amenities re . water supply in the settlements under your jurisdiction
closed pipes / river / canal / wells / handpumps / other
6.
Information regarding medical services and facilities under your jurisdiction
6.1
Name of the doctor
Degree
Address
6.2
Vaidya / Hakim
Degree
Address
6.3
Dais / Godmen / Others
Name
Category (As above)
Address
Please attach separate sheet if you wish to provide additional information
Thank you for your co-operation !
71
Appendix E
A Study of Investment and Expenditure
in Health Services
(Sample Survey through indigeneous practioners)
The FRCH, Mumbai has undertaken a research project on the Investment and Expenditure by those providing
Health Services in Ahmednagar District.
We seek your help in finding out the problems faced while providing health services.
We assure that the information will be kept confidential and used only for the research project.
Name :
Sex :
Age :
Education :
Address :
Name of the village :
Taluka :
Business :
1.
2.
3.
4.
5.
6.
7.
8.
You wish to use your knowledge about diseases and their treatment for the service of the people.
However, do you encounter any problems while reaching the people ? Do government officers,
private doctors or any one else obstruct you ?
What problems do you face in obtaining means (medicines etc.) essential to treat people ?
Since when have you been providing service to people ?
How did you obtain knowledge about the same ?
What steps will you be taking to train the next generation in your knowledge ? Do you contemplate
any difficulties in it ?
Which are the main diseases round the year in the village ?
For which particular disease, do people visit you for treatment ?
How may people called on you for treatment ?
last Year
last month
last week
9.
What is the fee given by people for the services provided by you ?
10.
Do you feel that it is adequate ?
11.
While treating a patient, do you face any problem while seeking health during an emergency ?
12.
Can you name other persons who offer services in this context ?
12.1
Vaidya / Hakim
Address
12.2
Dais / B/M / DR (Folk healers) / Others
Degree
Category (as above)
Name
72
Address
Appendix F
Profile of Practising Doctors
in Ahmednagar District
(Through Postal Survey - I)
1
(The information provided will be used only for research purposes and the confidentiality of the individual will
be strictly maintained.)
1)
Name :
Sex
2)
Age
Address :
Locality
Village :
Taluka
3)
Qualification :
Degree
Diploma
Certificate
4)
5)
System of qualification : (Please
appropriate one)
Allopathy
Homeopathy
Ayurved / Unani
System of practice : (Please
appropriate one)
Allopathy
Homeopathy
Ayurved / Unani
University / Board :
Year of Passing :
Year of Registration :
6)
Do you practice at present ?
7)
Native Place : Village
District
8)
How many patients did you treat last week ?
Taluka
a)
How many from the same village ?
b)
How many from the neighbouring villages ?
73
RMPs
Other (Specify)
RMPs
Other (Specify)
9)
Do you visit other villages ?
How many ?
10)
Do you make home visits ?
H)
Do you have any other staff to help you ? Give details.
12)
Whether you dispense medicines or prescribe them ?
13)
From where do you by drugs ?
14)
How far is the nearest medical store ?
15)
Do medical representatives visit you ?
16)
How long have you been practicing at this place ?
17)
Did you start your private practice immediately after your graduation / post-graduation ?
18)
Did you practice somewhere else before you started practising at this place ? Where ?
Village / town
*
km
Taluka
District
How many ?
19)
Are there beds in your clinic ?
20)
Please list names and qualifications of other medical practitioners in a 5 km. radius from your place.
Kindly indicate your interest in participating in a trilingual seminar on Economics of Health Care
Provision : Dynamics and Problem’ to be organised by us.
I am interested / not interested in attending the seminar.
If interested.
Name of Representative :
Convenient Day of the week :
Thank you for participating in this study.
74
Appendix G
Profile of Practising Doctors
in Ahmednagar District
(Through Postal Survey - II)
This questionnaire is a supplement to the earlier one you had responded to. We request you to kindly fill - in
the additional information needed by us in the following proforma. As assured earlier all information provided
will be treated in strict confidence and used for research purpose only.
1.
Name :
2.
Address :
3.
Family Background : (including those members presently not residing with you)
Education
(highest level)
Occupation
(present)
Location
(rural / urban)
Father
Mother
Wife / Husband
Brother
Brother
Sister
Sister
Any other (specify)
4.
Is your present family nucleus (husband, wife, unmarried children) or joint / How many persons?
Male
Female
5.
Do you or the family own any agricultural land ? If Yes how many acres ?
Professional Background
6.
Which medical college / institute did you study in ?
Name of College :
Place (City and district) :
75
7.
How did you pay for your medical education ?
Scholarship / parents / loan / other (specify)
8.
Are you a member of any professional bodies ? If Yes, which ones ?
9.
Have you attended any refresher courses after you basic medical qualification ? If Yes, specify where
and how ?
______________
10.
Do you subscribe / read any professional (medical) journal / magazine ? If Yes, give names.
II.
Please list the equipment (for medical practice) owned by you.
12.
How many hours daily do you practice ? ------How many days in a week is your clinic open ?
13.
Cost of Practice : Please indicate the monthly expenditure for the following or any other items to
run your clinic :
(a) Rent
(b) Fuel / Transport expenses for practice ------------(c) Any salary paid to helper/asst./Compounder etc.
(d) Drug purchases
(e) Any other expenses of clinic or practice (specify)
14.
What do you normally charge a patient ? -----------How many days medicine is included in this charge ?
What do you charge for giving an injection ?
with vial
without vial
15.
Do patients pay in kind (grain, etc) ? If Yes, how many of your patients pay in such manner ?
16.
We are aware that a few patients may not pay / or be able to pay for your services. In this case
(a) What do you do ?
(b) How many such patients have you encountered during the last one year ?
Thank you for participating in this study.
76
Appendix H
Sample Survey
Health Personnel Data
Card for Community
Sample Survey
(Through non-qualified practitioners)
Name of the Interviewer :
Name
Type/
Qualification
Type of
treatment
♦
*
Dispensary
Own/Rental
None
Type / Qualification :
Local/
Outstation
(From
which
place)
If outstation,
how many
days in
the town
Time
Since how
long do you
have the
dispensary ?
Do you
visit other
towns ?
Where ?
Type of Treatment :
Medicines / Tablets
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
H)
12)
13)
Allopathic
Ayurvedic
Unani
Homeopathic
Employees in PHC / SC
Trained Dai
Traditional Dai
Vaidya
Herbal
Godman
Bhagat
Spiritualist
Others
1)
2)
3)
4)
5)
6)
7)
8)
Allopath
Ayurved / Unani
Homeopath
Herbal
Massage
Incantation
Angara
Others
Remuneration
Nature ?
Amount ?
Appendix I
Questionnaire for Information on Health
Establishments in Ahmednagar District
(Postal Survey for Hospitals)
(The information given will be used only for research purposes and the confidentiality of the individual institution
will be strictly maintained)
1)
Name of Hospital / Nursing Home
and Address :
2)
Name of Person incharge
3)
Type of Institution :
(Please xz' appropriate one)
Public
Sector
4)
5)
NGO or
Voluntary
Type of Management ( Please
Private
Sector
appropriate one) :
Government
Municipality
Partnership
Trust
Panchayat
Body
Society
Year of Establishment :
78
Individual
Proprietor
Co-operative
Other (Specify)
6)
Ownership of Premises : ( Please
Owned
7)
8)
\/
appropriate one)
Long term lease from
Govt, or local body
Rented
Staff Strength :
(a)
Full time / Resident Doctors :
(b)
Visiting / Attached Doctors :
(c)
Qualified Staff Nurses :
(d)
Auxiliary Nurse Midwives :
(e)
Pharmacist and other technicians and paramedics :
(f)
Other employees :
Names, qualifications and specialisation of doctors
(if you need more space, use separate sheet)
(a)
Resident Doctors
Name
Qualifications
Specialisations
Visiting / attached Doctors
Name
Qualifications
Specialisations
1.
2.
3.
4.
(b)
I
2.
3.
4.
79
9)
Number of Beds :
W)
Total floor space
(area in square feet)
ID
Main types of indoor cases handled (Please
12)
those applicable)
General
Medical
General
Surgery
Maternity
MTP
Cardiac
Orthopaedic
Pediatric
Intensive
Care
ENT
Infectious
Diseases
Opthalmic
Other
(Specify)
Special facilities offered : Minor operation theatre / Major Operation (Please \/those applicable)
Minor Operation
Theatre
Routine
Pathology
Major Operation
Theatre
Special Pathological
Tests (Please specify)
Labour
Room
X-Ray
Fluoroscopy
Anaesthesia
Equipment
ICU
Ultra
Sonography
Any other
(please specify)
Special diagnostic or Therapeatic
Procedures (please specify)
13)
Average number of admissions in a month :
14)
Average length of stay of patients :
15)
Average occupancy rate
16)
Do you have an out-patient department ?
days.
per cent.
If yes, average number of OPD cases in a month :
80
YES/NO
17)
Any other information you would like to give.
18)
Kindly indicate your interest in participating in a seminar on Economics of Health Car
Provision : Dynamics and Problems' to be organised by us.
I am interested / not interested in attending the seminar
If interested.
Note :
(a)
Name of Representative :
(b)
Convenient Day of the week :
Please look at the list enclosed of hospital and nursing homes in your taluka and indicau
any missing hospital / nursing homes as well as those which have closed down.
Thank you for participating in this study !
81
Appendix J
Study of Health Care Providers
with reference to Investment and Expenditure
in Ahmednagar District
(For Individual Practitioners)
Note : The present task is an important link in series of studies on the "Economic Dimensions of Medical
Care Provision". The present concern is aimed at analytically understanding and recording the processes
and experiences of setting up health care establishments (clinic, nursing home, hospital, diagnostic
services), their growth and their place in the overall economy.
The establishments included in the study have been selected randomly (through well known statistical
principles) and in no way are a reflection of an individual establishment and / or providers achievements
or shortcomings. The identity of individual establishments and providers will be kept confidential
and the data obtained used only as aggregates for research purposes.
Name of interviewer :
Place :
Date :
82
A. Biographical Sketch
I)
Name of the respondent :
Age :
Sex :
2)
Address :
Locality :
Village / Town :
Taluka :
Dist :
3)
Ahmednagar
Pin :
Individuals : Qualifications
Premedical Qualifications :
Basic Medical Qualifications :
Additional Medical Qualifications :
Specialization :
4)
Year of passing :
5)
Year of registration with council :
Other system :
Name of the council :
Registration No. :
Address of registration :
6)
What did you do after completion of your medical education ?
Jobs : Where ?
Period :
7)
When did you start your own practice ?
8)
Awareness about legal registration ( NH Act / Shop & Establishment Act etc.)
9)
If registered, where
When
No. of other units associated with
Visiting
Attached :
Where :
83
Reg. No.
B. Historical Information on Private Practice
Year
Place
Floor
Space
(Sq.ft.)
Ownership of
Premises
Services
Provided
Type of
Mgmt.
Staff
Position
Notes : (Include all other current units).
C. Historical Information on Private Practice
1) Investment and Sources
Year
Place
Land/Build.
Deposit
Furnish.
Renovatn.
Equip.
Vehicle & Other
(if any)
Note : (Ask for the amount and its break-up into following sources
Self
Contributory/inherited
Deviations / Funds / Grants
Loans (Institutional)
Loans (informal)
Other (specify) )
1)
2)
3)
4)
5)
6)
2) Loan repayment pattern .
Source
Amount
Year
Interest
3)
Experience in raising finances :
4)
Decision Making Process in Setting-up Practice
Monthly
Current
Did factors such as family and financial background, market availability etc. determine your decision
with regards to
i)
a)
b)
c)
d)
ii)
Repayment
Type of services : (Facilities / Staff)
Location of your unit :
Initial pattern of fees (Did financial background like investment, loans, competition, market
availability or any other factors decide your charging system ?)
Other decisions regarding practice :
Efforts taken to establish and develop practice :
84
D. Current Provision Profile
Reference Period
1)
Total no. of admissions
2)
Indoor cases
according to each type
0
2)
3)
Current OPD attendance
4)
OPD attendance during
rainy season
5)
No. of home visits
6)
No. of cases to which
each facility is
offered
1)
2)
3)
85
E. Current Expenditure Profile
1)
Current Expenditure :
Exp. Head
Amount (Rs.)
1)
2)
3)
4)
5)
6)
7)
8)
Drugs
Equipments/Suppliers
Rent
Medical Indeminity
Telephone
Electricity
Water taxes
Other taxes
Local bodies
1)
2)
9)
10)
H)
12)
Staff Salary
Repairs & Maintenance & Insurance of equipments
Repairs & maintenance & insurance of equipments
Repair & maintenance of vehicle
Petrol / Oil / Diesel
for vehicle
Other fuels for
clinical purposes
Stationary
Newspapers (Magazines)
Other (specify)
13)
14)
15)
16)
17)
Reference
Period
F. Revenue Resources for Running Present Medical Units
1)
Sources other than income by
patient charges :
Sources
Amount
Period
Patient Charges Profile :
2)
1)
Only Medicines
2)
Only Consultation
3)
Medicine with Injection
4)
Only Injection
5)
Saline
6)
Home Visits within Village / Town
7)
Home Visits outside Village / Town
8)
Other Available Facilities
Amount
1) ---------------------------------------------
2) ________________ __________
G. Future Plans
86
Cases
Ref.
Period
Appendix K
Study of Health Care Providers
with reference to Investment and Expenditure
in Ahmednagar District
(For Health Establishments)
Note : The present task is an important link in
series of studies on the "Economic Dimensions of Medical
Care Provision". The present concern is aimed at analytically understanding and recording the processes
and experiences of setting up health care establishments (clinic, nursing home, hospital, diagnostic
services), their growth and their place in the overall economy.
The establishments included in the study have been selected randomly ( through well known statistical
principles) and in no way are a reflection of an individual establishment and / or providers achievements
or shortcomings. The identity of individual establishments and providers will be kept confidential
and the data obtained used only as aggregate for research purposes.
Name of interviewer .
Place :
Date :
87
A. Biographical Sketch
1)
Name of the respondent :
Sex :
Age_^
Designation of the Respondent
(Owner / doctor in-charge/chief administrator/ other specify)
If the respondent is not owner.
Name of the Owner :
Qualifications :
2)
Address :
Locality :
Village / Town :
Taluka .
Dist :
Ahmednagar
Pin :
3)
Sector : Public / Private / Voluntary - NGO
4)
Year of Establishment :
5)
Awareness about legal registration ( NH Act / Shop & Establishment Act etc.)
If registered, where
When
88
Reg. No.
B. Historical Information on Private Practice
Year
Floor
Space
(Sq.ft)
Ownership of
Premises
Services
Provided
Type of
Mgmt.
Place
Staff
Position
Notes : (Include all other current units).
C. Historical Information on Private Practice
1) Investment and Sources
Year
Land/Build.
Place
Deposit
Furnish.
Renovatn.
Equip.
Vehicle & Other
(if any)
Note : (Ask for the amount and its break-up into following sources
Self
Contributory/inherited
Deviations / Funds / Grants
Loans (Institutional)
Loans (informal)
Other (specify) )
1)
2)
3)
4)
5)
6)
2) Loan repayment pattern :
Source
Amount
Year
Interest
3)
Experience in raising finances :
4)
Decision Making Process in Setting-up Practice
a)
b)
c)
d)
ii)
Monthly
Current
Did factors such as family and financial background, market availability etc. determine your decision
with regards to
i)
v
Repayment
Type of services : (Facilities / Staff)
Location of your unit :
Initial pattern of fees (Did financial background like investment, loans, competition, market
availability or any other factors decide your charging system ?)
Other decisions regarding practice :
Efforts taken to establish and develop practice :
89
D. Current Provision Profile
Reference Period
1)
Total no. of admissions
2)
Indoor cases
according to each type
I)
2)
3)
Current OPD attendance
4)
OPD attendance during
rainy season
5)
No. of home visits
6)
No. of cases to which
each facility is
offered
I)
2)
3)
1
90
E. Current Expenditure Profile
1)
Current Expenditure :
Exp. Head
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
M)
15)
16)
17)
Amount (Rs.)
Reference
Period
Drugs
Equipments/Suppliers
Rent
Medical Indeminity
Telephone
Electricity
Water taxes
Other taxes
Local bodies
1)
2)
Staff Salary
Repairs & Maintenance & Insurance of equipments
Repairs & maintenance & insurance of equipments
Repair & maintenance of vehicle
Petrol / Oil / Diesel
for vehicle
Other fuels for
clinical purposes
Stationary
Newspapers (Magazines)
Other (specify)
4
F. Revenue Resources for Running Present Medical Units
1)
Sources other than income by
patient charges :
Sources
Period
Patient Charges Profile :
2)
>
Amount
1)
Only Medicines
2)
Only Consultation
3)
Medicine with Injection
4)
Only Injection
5)
Saline
6)
Home Visits within Village / Town
7)
8)
Home Visits outside Village / Town
Amount
Other Available Facilities
1) ---------------------------------------------
2)
G. Future Plans
91
Cases
Ref.
Period
References
Annual Vital Statistics of India, Central Bureau
for Health Information (CBHI), Pune
(Unpublished) 1992
Government of Maharashtra, Census of India
1981, District Census Hand-Book, Ahmednagar,
Bombay, 1986
Banerjee D, Health and Family Planning
Services in India, New Delhi, I^okpaksh, 1985
Government of Maharashtra, Census of India
1981, Occasional Paper 1, 'Study of distribution
of infrastructure facilities in different regions and
levels of urbanisation,’ 1986
Bang R., 'Prejudices in Medical System against
Female Health Functionaries’, background
paper MFC, unpublished.
Government of India, Central Bureau for Health
Information, various years. Health Information
of India, New Delhi.
Baru R.V. (1993) 'Inter-Regional Variations in
Health Services in Andhra Pradesh’,
Economic and Political Weekly, May 15,
1993 : 1963-1967
Government ofJndia, Central Bureau for Health
Information,^wth Information of India,
New Delhi, 1992
Centre for Monitoring Indian Economy,
Profiles of District, CMIE, Bombay. 1985
Government of Maharashtra, District SocioEconomic Review, District Ahmednagar,(1991-92)
Bombay
Crawford, D. G., A History of the Indian
Medical Service 1600-1913, Vol 11, W.
Thacker & Co., Calcutta, 1914
Government of Maharashtra, Gazetter of India,
Maharashtra State, Ahmednagar District
(Revised Edition) Bombay, 1976
A
Department of Statistics, Government Of
India, New Delhi., National Sample Survey
Organization (NSSO), Morbidity and Utilization
of Medical Services, 42nd Round, July 1986-June
1987, Report No. 364
Government of Maharashtra, Law and Judiciary
Department, The Bombay Nursing Home
Registration Act, 1949, Government Publications
and Printing Press, Bombay
Duggal R, State Health Financing and Health
Care Services in India, undated (Unpublished)
Government of Maharashtra, Socio-Economic
Review and District Statistical Abstract Ahmednagar 1988-89, Bombay
George A., Nandraj S., State of Health Care in
Maharashtra, A Comparative Analysis, Economic
& Political Weekly, Vol XXVIII, Nos 32 & 33,
Aug 7-14, 1993
Government of Maharashtra, Socio-Economic
Review and District Statistical, Abstract Ahmednagar 1991-92, Bombay
Government of Bombay, Hospital and
Dispensaries, Report of Bombay 1954-56,
Bombay 1959
Government of Maharashtra. Census,
Maharashtra Primary Census Abstract (Final),
Census Directorate, Maharashtra, 1991
Government of India, Report of the Health
Survey and Development Committee (4 Vols),
1946, New Delhi
Government of India, Report of the Health
Survey and Development Committee, New Delhi,
1946
Government of India, Directory of Hospitals in
India, 1988, New Delhi
92
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